Complacency: A Silent Killer

Just in Fiscal Year 2012 (FY12)1, complacency as a causal or contributory human factor accounted for only one percent of the total reportable safety mishaps, but represented 30 percent of the total Class A mishaps, 41 percent of the total cost, 50 percent of the aircraft destroyed, and 56 percent of the fatalities. That gives "complacency" a price tag of $236.7 million and five service members that paid the price in blood ... and that doesn't even include the near misses!

When assessing risk or employing Risk Management (RM) principles, every commander, operations officer, planner, and aircraft commander reviews the tasked mission, whether training or actual, and tries their best to identify the top risks and mitigate them. For some of our more routine activities, identifying risk can be difficult and sometimes ignored. In these instances, "complacency" can sometimes become the RM form's scapegoat when the Aircraft Commander "pencil whips" it in as a high risk item without giving it much thought. Challenging this as a valid high risk for a particular mission's RM is easy and justified, but more often than not complacency is in fact the highest risk for the mission and if left unchecked, the source of the next mishap.

Almost every mishap can trace its origins in human factors. "Complacency is a factor when the individual's state of reduced conscious attention due to an attitude of overconfidence, undermotivation or the sense that others "have the situation under control" leads to an unsafe situation."2 Unaware of actual danger, the victim of complacency may even feel a sense of self-satisfaction. This can affect aircrew or maintainers as both professions look toward proficiency in certain tasks. As the individual develops proficiency, overconfidence may mask their awareness of danger.3

The Federal Aviation Administration (FAA) lumps "complacency" into a top 12 list of common causes of human factors errors, affectionately known as "The Dirty Dozen."4 In fact, "complacency" sits in the #2 seat behind "Lack of Communication." This is a common problem for both aircrew and maintainers alike.

Some symptoms of complacency that we all should be wary of include:5

1) Accepting lower standards of performance,

2) Erosion of desire to remain proficient,

3) Boredom and inattention,

4) Satisfied with the status quo,

5) Increased feeling of well being, and

6) Neglecting personal safety items.

There are five major types of complacency that can result from these symptoms:6

1) Task Induced:

Task induced complacency can be found in task saturated environments or events. Examples can be seen during high operations tempo periods such as readiness exercises, or even during brief periods where multiple external influences are bearing down such as heavy traffic in the visual pattern at night.

2) Organization Induced:

Organization induced complacency is where supervisors and leaders play a role. By accepting shortcuts or not holding subordinates accountable, an organizational culture of complacency can be promoted.

3) Fatigue/Stress Induced:

Fatigue and stress induced complacency is almost self explanatory. After multiple visual approaches to touchn-go's, a checklist item or the entire checklist may be missed as the training events become mundane. At best, the crew catches the deviation in time and executes a goaround.

4) Dependency:

Dependency complacency focuses in on co-workers that you recognize as being proficient and dependable. Not only do you assume they will catch your mistakes, but you misplace confidence in them when they may be victim to the same type of complacency in yourself. Two experienced maintainers may rely on each other to accomplish all the steps on a given technical order checklist, only to later find out that the other assumed the same and did not accomplish all the steps.

5) Automation:

Automation is simply a reliance on technology. The catch with this one is that it's the same technology that is designed to improve your situational awareness and promote safety. It breaks down to the individual being an operator rather than a supervisor of the technology. Not properly monitoring instrumentation in the cockpit because you assume the technology is always right might leave a computer malfunction unchecked.

Understanding the types of complacency and the symptoms that lead to them is the first step at mitigating complacency. In addition to recognizing these symptoms, the FAA suggests that aircrew and maintainers take a cautious approach. They suggest mitigating the risk of complacency by:7

1) Avoiding the tendency to see what you expect to see,

2) Expecting to find errors,

3) Not signing it if you didn't do it,

4) Using checklists, and

5) Learning from the mistakes of others.

Consider two scenarios: 1) a highly complex night tactical training sortie with multiple students and training objectives, or 2) a simple basic preflight (BPO) of a line flying aircraft in a permissive environment. Which scenario would you consider complacency to be a top risk for the mission? Would you think both? An obvious answer may be the BPO with its ample opportunity for repetitive, monotonous, robotic, automation and fatigue induced complacency. But how about the high workload training line full of repetitive, monotonous, robotic, and fatigue/stress inducing checklists and training requirements compounded by repetitive tasks such as multiple approaches, landings, threat engagements, or extended low level? Add a little task induced complacency and you have equal opportunity for disaster caused by complacency on both accounts.

Complacency is not just an RM worksheet "scapegoat." It's a silent killer that directly caused or contributed to 44 percent of our safety mishaps in FY12 alone.8 It's insidious and clandestine, either sneaking into your active risk mitigation where you catch it just in time for a "near miss," or you miss it completely and fail to accomplish a checklist item on a repair or during a critical phase of flight. Now you have our next safety mishap.'lp

References:

1 Air Force Safety Center. (2013). Data Extraction Tool. Retrieved from the AFSAS Database on 6 Aug 2013. https://afsas. kirtland.af.mil/.

2 Air Force Instruction 91-204. (2014). Safety Investigations and Reports, http:// www.e-publishing.af.mil, Attachment 5.

3 FAA (2008). Aviation Maintenance Technician Handbook. Retrieved from the World Wide Web on 6 Aug 2013. http://www.faa.gov/regulations_policies/ handbooks_manuals/aircraft/amt_ handbook, figure 14-17.

4 FAA. (2013). Avoid the Dirty Dozen, 12 Common Causes of Human Factors Errors. FAASTeam, FAA Safety Team Circular.

5 Grey Owl Aviation Consultants INC. (1997). Complacency. Retrieved from the World Wide Web on 6 Aug 2013. http:// www.greyowl.com/articles/complac_ article.pdf

6 Jensen, R.S. (1995). Pilot Judgment and Crew Resource Management. Retrieved from the World Wide Web on 5 Aug 2013.

7 FAA. (2013). Op Cit.

8 Air Force Safety Center. (2013). Op Cit.

BY MAJ. HECTOR L. COLLAZO III