Navigated to PAPod 574 - Margin for Safety: Lessons from 50 Years in the Cockpit - Transcript

PAPod 574 - Margin for Safety: Lessons from 50 Years in the Cockpit

Episode Transcript

Yeah, so I guess you understand, you know, where my audience is.

Yeah, your audience sounds rather amazing.

I mean, you're quite successful.

Good on you.

Yeah, it's all pilots just trying to keep them safe.

And, oh, my God, it's a challenge.

Yeah, yeah, yeah, yeah.

Because it is a diverse group of human beings.

Yeah, and with diverse training is the real problem.

Yeah.

They don't all get the same training, so sail of gear.

Oh, shit.

Oh, shit.

Oh, shit.

Welcome to the Pre-Accident Investigation Podcast.

I'm Todd.

How are you?

I hope you're doing great.

I hope you had the best week ever.

I really do.

I genuinely hope that for you.

I bear no ill will upon any man.

Can you tell I've been watching Ken Burns' Revolution?

It's really made me think about the word despot and the word whilst.

Those are words they use a lot.

There's another one too, but I can't think what it is.

Anyway, I'm so glad to have you on the podcast today.

Today's interesting, I think.

I mean, I think you'll find it interesting.

I definitely found it interesting.

I met a new friend, and his name is Max.

I can't even talk.

Max.

That's not that hard to say.

Max Trescott.

Maybe it is that hard to say.

I think it's just me.

And he has a show called the Aviation News Talk.

And he also writes a lot for flight safety.

And he is a pilot and he specializes really in general aviation.

So that's like not the airline pilots or the military pilots, but everybody else.

And that is, in fact, the vast majority of pilot fatalities.

So he has quite a little media empire.

I mean, I don't know if you'd actually call it a media empire, but that sounds good.

And he has a column in Flying Magazine.

And he contacted me and said, hey, would you do a pod?

And I said, well, sure.

And so we did.

And you know the rule.

If I'm on your podcast, you're on my podcast.

That's how it works.

But this was really interesting because we were talking a lot about.

Stability, the stability trap, because he was experiencing that book that I just finished that's available now.

And he was talking about sort of the pressure of economics on general aviation safety.

It's pretty interesting.

You're going to like it.

Let's jump into it because it's a good conversation.

I think you're going to enjoy it immensely.

So welcome, Max.

You're a new friend of the pod, and I'm glad you're here.

Sit back and relax, and you'll hear all about it.

This is the discussion I had with Max Trescott.

Todd, welcome to the show.

So great to have you here today.

It's a treat to be here.

Thank you.

Well, likewise, I've been a big fan.

I've been listening to your podcast for more than a year.

I was driving all the way to Southern California to take courses at USC on aviation safety, and I found your podcast at that point in time, Pre-Accident Investigations, and I just loved it.

So great work that you're doing.

Well, thank you.

So you just accidentally bumped into it?

I was searching for safety related topics and found it that way.

So anyway, what I love about what you're doing is that you are looking at safety in general for a lot of different industries.

And I found in general that one industry can borrow, you know, techniques and ideas and adapt them to their particular industry.

Absolutely.

Absolutely.

Looking to see what expertise you can bring from all the many different industries that you've worked with.

Now, our listeners are probably divided into two categories.

We've got those that work for a company or government organization and fly for a living, and then we've got the majority of them who just fly for fun.

So let's kind of talk about the first group.

If you would, would talk about HOP be a good place to start?

Just talk about HOP principles.

Sure.

Yeah.

So there's a couple of things that I think are always really important to think about.

One is that I think we've seen safety traditionally as kind of a game we can win.

You know, that at some point, well, we'll have safety taken care of and then we can move on to, I don't know, salary management or something exciting like that.

And what we've done in the human performance world over the last 30 years or so is really struggle to change the paradigm around safety.

So safety is not something you have.

It's something you do.

So it's an active action to create non-events.

I mean, you're actively creating non-events.

You don't want things to happen.

And so it's been really an important journey to help sort of create this new definition that safety is a capacity, kind of like fuel.

I mean, you manage safety as a capacity.

And so that's been a really important fundamental shift.

And out of that came a really important piece of knowledge, but it took us a while to get there.

And that is that the workers who do the work aren't the problem, they're the solution.

And as odd as this sounds, Max, and it does sound a little odd when you say it out loud, we've really taken safety on as if the worker was the problem, as if the pilot's the problem.

The pilot's not the problem.

The pilot's actively involved in creating dynamic non-events.

They're doing that.

I mean, that's what you do for a living is you kind of keep everything from wrecking, right?

I mean, that's kind of a part of the goal.

And that switch changes the way you look at and manage safety programs throughout institutions kind of globally.

And it's been a really interesting journey because it's taken a while because, you know, people really want to say the problem is the person.

Because if the problem is the person, well, that's pretty cheap and quick to fix.

You just fix the person.

But in fact, what we've learned, and you must know this as well, I'd be so curious to see what you say.

is that the problem is almost never the person.

In fact, the person's actively trying to hold this together.

The problem are the systems and processes and practices in which we place workers.

And that in and of itself is interesting because the world is filled with variability.

And so you have all these crazy things that happen because I probably don't have to tell you or the people that listen to your podcast this, but things that never happen happen all the time.

And the funny thing is, I can't tell you how many times I'm surprised when I've been flying for 50 years.

I'll tell somebody, wow, that's the first time I've ever seen that.

Yeah.

You know, new stuff keeps happening all the time.

And it just, it's constantly a surprise to me.

I would think that I've seen it all and I haven't.

Yeah.

Yeah.

Because, because everything that can happen will happen.

I mean, it's just, and the longer you live on earth, the grayer your mustache gets, the more you realize, yeah, every day is kind of a new adventure.

Let's see what happens today.

I think you summed it up well in your book.

You wrote that aviation accidents are the unexpected combination of normal aviation variability.

Yeah.

And I like that because I think that really catches, captures how dynamic the field is and how we have to constantly be on our toes.

You know, we just can't relax and kind of go, oh, well, I got this handled.

Yeah.

And just because it didn't lead to a bad outcome yesterday doesn't mean that it might not be the set of conditions that could potentially lead to a bad outcome today.

And so we're constantly monitoring not failure.

We're constantly having to monitor normal.

And that's a really interesting challenge, but you guys are quite good at it.

I mean, not to butter you up, but it's quite impressive how remarkable it is.

And so that's true in one area of aviation, not so true in another.

And that is that in the airline world, yes, they have really figured this out and they are doing incredibly well to the point where we see an accident that results in fatalities once every 10 years, which is phenomenal.

When you consider the millions and millions of flights that occur every year.

And the area where we're not doing so well is in general aviation, where we have on the order of a few hundred fatal accidents per year that kill several hundred people.

Big, big differences.

Now, I know that you have done some work with airlines in the past, or at least one airline in particular.

What have you learned about that?

What did you take away from that consulting experience?

So it's a super interesting business.

It's really pressure filled and super time constrained.

And there's a huge drive for efficiency.

I mean, just everything needs to be better, faster, quicker.

Let's turn this around.

Let's make this happen.

And so that production pressure dramatically eats into capacity for people to actually manage normal variation.

Because the way I got it figured, and I know nothing, I mean, you'll have to correct me, but it looks like that you have time to act and time to think differently.

And those are kind of separate things, like pre-planning is kind of thinking time and then actually operating is kind of acting time.

And what's interesting is that the acting time is relatively important, is seen as pretty significant.

But the time to think, the preparation, planning that time, it's being kind of dramatically truncated a little bit every single year.

And so what happens is you have organizations that are really interested in making money and producing profit and being a business, which those are all really reasonable things.

That's what companies do.

Sort of eating the capacity that they've built over years.

To do things really reliably.

And that's a really interesting trap to be in.

Like I've thought a lot about your industry, at least on the commercial side, in the last couple of years, just because a lot of things have happened.

And one of the things that I think is really interesting is that.

There's kind of a stability trap that because the system is so stable, the belief is we can erode some of the margins on that system and still be stable.

And what happens when we erode margins is that we lose that excess capacity for variability.

And now we have much quicker responses necessary.

We have to move faster in our planning preparation and in the way we process and practice the work we do.

It's a really interesting business because it's filled with super smart people who are passionate about their work.

I mean, incredibly passionate about their work.

And genuinely, I mean, the thing that I think kind of makes me laugh is I'm not sure how you would ask a pilot to be more careful.

I mean, the assumption that they're not careful is just goofy.

I mean, that's just a dumb assumption.

And so asking them to be better isn't really fixing the problem.

Yeah, nobody plans to have an accident and yet people have accidents all the time.

And so, yeah, I think you bring up an interesting thing about the think versus act.

I never really thought about it that way.

The think part is really, as you described it, kind of the pre-flight planning part, all the stuff that goes ahead of time prior to jumping into the cockpit.

The act is, you know, manipulating the controls and pushing all the buttons and doing those kinds of things.

And I think the problem with shrinking, you know, what you call the thinking time is that now you've got to be really good with the act part.

Right.

You've got to recognize problems sooner.

You've got to come up with solutions sooner.

You're really just kind of making it up on the fly.

Whereas if you dumb the planning part correctly, the act part becomes relatively simple with relatively few kind of fix it on the fly kinds of problems.

Yeah, because you have more margin built in.

You've micro-simulated, you know, what could happen.

And you guys are really good at that.

And, I mean, these aren't my ideas.

Kahneman talks about thinking fast and thinking slow.

But what made me really think about it was the fact that you'd look at some of your checklists and the first thing on the checklist would be first fly the plane.

So don't stop acting in lieu of thinking, right?

But they're very different activities.

And it's a really interesting way to look at it.

And it's been quite successful.

My guess is, and I'd have to sort of beg you to answer this question.

My guess is because we've consciously built in time capacity is a word I like to use because it's time resources, knowledge, training, skill.

We've built in capacity so that people who operate high-risk businesses, Highly critical, highly reliable jobs, like flying a plane full of people, oftentimes I'm one of those people, really have had the appropriate margin to think through and micro-stimulate what's going to happen on the flight from, you know, Santa Fe to Denver.

Which is one I fly a lot.

That's why I picked that one.

Yeah, of course.

Yeah, I like the concept of capacity.

I've heard you talk a lot about it on your show.

and it equates with what I've always talked about, a safety margin.

Yeah.

And I'm constantly telling pilots that we want to build in extra margin to every little activity.

I'll give you just a couple silly little examples.

But for example, we have to avoid different kinds of airspace.

So where I'm located, we have Class Bravo airspace around San Francisco.

And there's some people that'll fly right up next to the line on their little map.

Whereas I'll tell them, well, gee, why don't you stay at least a half mile away?

Because if the radar on the ground is slightly different than the map in your airplane, they're going to say, you went into that airspace and you'll think, no, I didn't.

And if you build in that extra margin, then you don't even have to worry about having that conversation with the FAA later.

And so I'm always looking at how can we build in extra margin in every aspect of how we're flying so that if things don't go quite exactly the way that we thought they were going to go, we're still going to be fine.

Yeah, and that extra margin.

And I'm not in love with the word capacity, right?

And I'm constantly seeking a better word than capacity, but capacity is general enough that it covers lots of things.

But that extra margin, that room for recoverability, that resilience, that's what keeps critical high-risk operations safe.

And what's so interesting about that is when you look at things that have to go, because we have limited time, limited money, limited resources, and we're trying to do more with less, all those things, and complexity is increasing, technology is increasing.

I mean, we can have a really long conversation.

It'd be boring as hell, but we could have a long conversation on this.

One of the things that's easy to cleave away is that margin.

And expert performers, he says to a pilot of 50 years, looking him right in the eye, expert performers will often move closer to the margin, usually without transgressing the margin.

I mean, I'm not saying they're going to break the margin, but they'll move closer to the margin because they have a certain amount of comfort in their operation because of their experience, training, ability.

You know, they've seen a lot of things.

What gets us into trouble is when that margin goes away.

So it's not so much the presence of risk that I think about in aviation It's the absence of control.

Risk seems kind of normal to me.

I mean, I'm not even sure risk is terribly interesting.

It's dynamic.

It's ever-present.

It's sort of fundamentally why you're a pilot.

I mean, it's kind of, that's the exciting part.

What matters is not the presence of risk.

It's the matching presence of control or the absence of control.

That's what scares me.

And I think that's when we get into trouble.

So let's talk about control from a couple different perspectives.

I think that the airlines probably are at one extreme of that.

They've done a really great job of proceduralizing everything to the point where they're exercising a lot of control.

Pilots know what the rules are.

They know that they have to follow the rules.

If they follow the rules, generally they're going to be exceptionally safe.

We go to the opposite extreme, and we're talking about recreational pilots, people who don't fly for a living.

They fly for fun.

they've had a wide variability in training some got really excellent training some got training that was just barely enough to pass the check ride that they had met the minimum standards for being a pilot there the control is really self-imposed and yet if they lack the knowledge they don't really know what controls to self-impose right talk about the individual worker or the individual pilot who's in that kind of situation, what kinds of things do they need to be thinking about or doing to bring more control to their flying environment?

Well, so there's kind of a paradox.

I mean, you bring it up pretty beautifully.

And that is that the less formal training, the less experience you have, the.

The more you need proceduralization and control, uniformity, some kind of expectation management.

Whereas the more experience you have, the less you probably need procedures, but the more you understand procedures.

So procedures make sense to you because they provide really a frame.

And safety operationally itself doesn't live in procedures because procedures are incredibly important.

I mean, they're incredibly valuable.

But they're also relatively incomplete.

And so what I think of, whether we're talking about a professional pilot or somebody who flies for fun, is their job is to sort of complete the procedure.

They provide sort of the candy coating, if I can use a food analogy, or the donut icing.

I'm thinking of that this morning.

They provide that additional completion of procedure that's going It's going to be imprecise.

It's going to be carefully written, but imprecise.

Why I think that matters so much in your world is something that you said, which is remarkable, and that is you don't know what you don't know.

And so part of what I would suggest is one of the conversations we should have really with pilots at every level is the relationship between control and recoverability or robustness and resilience.

You can sort of pick the words you want, is that you can do whatever you need to do in order to accomplish whatever you need to accomplish.

As long as you've built in enough recoverability that if something fails, you can, in fact, bring it back to center.

And the example I think of all the time is if I said, we're going to go on a trip.

We're going to drive from the Bay Area to Yosemite.

Okay.

And it's going to be fun.

We're going to have a great time.

It's, we are going to have the best trip ever.

It's going to be a super fun road trip, except that I guarantee you we're going to have car problems.

I guarantee it.

In fact, I'm so psychic.

I know we're going to have car problems.

Well, so before we leave for our trip to Yosemite, we're going to really do some stuff.

Like we're going to make sure we have our cell phones and we're going to make sure we have the phone number for AAA.

And we're going to make sure that we, you know, people know our route and we're going to have extra snacks.

And, you know, we're going to have warm clothes.

And we're going to really prepare for the fact that the inevitable car problem is going to happen.

Now, that really is interesting because we should probably do that every time we travel, but the tendency to believe that we won't have car problems dramatically outweighs the need to prepare margin, your word, I love that word, or prepare recoverability into that system.

And so one of the things I would tell somebody who's less experienced is because you're less experienced, you should be more prepared.

So you need to change your language from if this fails to the much more accurate when this fails.

Because the only way I've got it figured out And I'm the world's expert on this Because I've just been through a pandemic And a bunch of other crap that's going on I don't know if you've gone through that, Max But I did over here on my side.

When met with an uncertain future, You can only manage uncertainty with certain controls, which is why procedures make sense.

Because we don't really know what's going to happen.

And because we don't know what's going to happen, we want to build in as much recoverability that we can measure, touch, monitor, validate, and verify before we go on that trip.

And whatever type of pilot you are, that seems relatively important.

I don't know.

What do you think?

I love it.

I love the analogy of the trip to Yosemite.

And it's part of why, for example, when I'm on trips going across the country, moving an airplane with a new owner, for example, they'll typically try and find airports that we're going to land at where the fuel price is the cheapest.

Yeah, yeah, yeah.

That's kind of their single goal for picking out an airport.

By contrast, I'm usually looking for larger airports because we have more resources.

Because as my wife has said, something always happens on these trips.

It's not quite 100% true, but it's true enough that it just makes sense to choose the big airports because we have more resources.

We have longer runways.

We have places where we get things repaired.

We have places where we can eat.

There are hotels nearby as opposed to being stuck in one little tiny town in the middle of nowhere where you don't have any of those resources.

So, yeah, I think if you apply those kinds of techniques, it's not if something is going to happen, it's something is going to happen.

You just don't know what it is.

And that's, I think, probably the biggest thing that pilots don't look at is, yeah.

Some point in time, something's going to happen.

So you need preparation in terms of training.

You need to have practiced what it is you're going to do when that something eventually happens.

And it's tough because, for example, engine failures.

Yeah, people practice engine failures, but not very often.

And I look at my experience of flying for 50 years.

Have I had an engine failure?

No.

I've had two times where the engine didn't quite put out as much power it was supposed to.

So it was relatively easy to deal with.

So I think that's part of the problem as well is we've got to prepare and anticipate for events that rarely happen.

And yet something's going to happen.

Maybe it's not as dramatic as an engine failure, but maybe, for example, when I remember a recent trip where we were assigned a runway where the crosswind was right at the limits of what the aircraft could do, pilot was all prepared to land.

And I said, I had to say it twice.

Why don't we just ask for that other runway that's right straight into the wind, take an extremely difficult landing to a non-event.

It was like, oh, okay, well, that makes sense.

So I think we're constantly evaluating alternatives and trying to find the most conservative alternative so that we don't have to use all of our skills.

You know, why not make it easy, right?

Why push yourself right up to the edge to test and see, well, how good really am I?

Because that kind of results in bent airplanes.

I think that's such a great example you just gave, too, because you added beautifully the economic pressure with the fuel price thing.

Because that's really – and what's interesting, and again, this isn't the world I live in, but I've thought about this, that pressure economically is becoming more palpable.

It's definitely more important.

People aren't perfect.

People make mistakes.

And that blame fixes nothing.

Those are really important foundational premises to set the stage for how we will move into understanding operations, both success and failure.

Yeah, and blame is certainly important.

I know that a lot of our aviation reporting systems are anonymous so that you can't blame a particular pilot for reporting something.

And that reporting would all go away if, frankly, there was being blame attached to it.

Yeah.

I found it kind of interesting that one of my clients, somebody who I talked to fly, had a bad landing when he was in the airplane by himself years after I taught him how to fly.

And he collapsed the nose gear, a lot of damage to the airplane.

And I was talking with the club about it.

And at the very end of the conversation, they said, and what percentage of the blame do we assign to the instructor?

I thought for a moment and i i said you know anytime i've made a mistake i've never thought that my instructor was in any way responsible for that particular mistake and that ended the the meeting but yeah i think it's really easy to latch on to blame yeah i think people are constantly looking for who do we assign this to because now we can be done with this issue we can And they'll say, yeah, we can move on to something else because we just figured out who to blame.

Well, yeah, and it's psychologically sound because the belief that something bad can just happen is really hard to accept.

And so it's much easier to say this bad thing happened because this pilot was a bad pilot.

A better pilot would not have done this, which is quite true.

But it's also really oversimplified and super incomplete.

I mean, we want to know what happened.

And we want to know what conditions led to getting to the place where this outcome was possible.

Because a lot of things in our worlds have to fail simultaneously for us to have a catastrophic outcome.

I mean, a lot of things have to fail.

Not one thing.

It's many, many, many things.

And the seeds for the next big aviation event are being planted systemically now.

Yeah.

Yeah, this goes back to what I said about every flight having mistakes.

If a single mistake would create a crash or failure, then we'd have every flight would be a crash or a failure.

Yeah.

But in fact, we have to have multiple mistakes, usually at least three or more.

Yeah, yeah.

And certainly with a Baltimore ship accident, you're probably saying essentially the same thing.

Yeah, yeah, yeah.

Yeah, that wire was part of it, but there were all these other things that were part of it as well, too.

So principle number three.

Learning is vital.

So the ability to learn is key.

And the great thing, I don't know if you feel this as well, but the great thing about maturing in your profession is you become, even though you're very experienced and you've seen many things and you really are quite good at what you do.

There's a humility around the fact that you can always learn more I mean to me The biggest enemy of the question is the answer And believing you already know Puts you in a position where you no longer ask how did this take place?

And so building a system that is consistent And really effective at learning from itself Is is kind of the definition of mature, effective, and reliable systems.

Really, really reliable people don't think they're reliable.

They're constantly saying, I could have done that differently.

I wonder why I did this.

I wonder what motivated me to do that.

I mean, the organizations that I get to work with, and I'm really lucky because I work with lots of really super interesting organizations.

Like, for instance, the National Park Service search and rescue team at the Grand Canyon.

I worked with them for a long time.

They are incredibly good at what they do.

And yet, at the end of every mission, they do a really strong hot wash, and they don't believe that they know all the answers.

In fact, it's quite the opposite.

it, they're certain they don't know all the answers and they're constantly questing for more information.

So learning's really vital.

It's everything.

And that kind of goes to the second part of the audience that we talked about, which is the individual pilots.

Right.

And I suspect that some pilots who have accidents are just not as driven.

They may feel like, oh, it's kind of like a driver license.

You know, I went to DMV and I passed my license and now I can fly.

And, you know, it's no big deal.

And yet I think there are others that strive to constantly be learning everything they can possibly learn about their airplane, about the environment they're flying in and developing rich procedures.

And that's probably the case of those who aren't curious and aren't trying to find out all this stuff.

Wow.

I would imagine that they're more likely to have an accident.

You're exactly right.

I think that's curiosity is really an important safety tool and it makes a huge difference.

Understanding the how.

Is really vital, but probably more important than understanding the why.

Why accidents happen, I don't know, that's probably emotionally satisfying.

How the accident happened, that's technically enlightening.

You talked about your work with Admiral John Meyer in the past.

Talk a little bit about what pilots might want to take away from what he did in the Navy as running those naval operations.

So he is.

I mean, he's still around.

He's an incredible human being.

But, I mean, that's how you get to be a really high-up admiral.

And he was in charge of, I mean, he was the air boss, big air boss.

I mean, he was an important dude.

And one of the things that I'll never forget is he had me come and speak at a meeting that he had every year.

And there were 900 flight command personnel in the room.

Have you ever been to one of those meetings?

No, afraid not.

So, and everybody's dressed the same.

They all have on their flight suit.

And I just, I was blabbing away about something.

And I said the words, write this down.

And 900 people reached into their pant leg and grabbed a notebook and a pen at the same time.

It was like, it was freaking.

One of the things that Admiral Meyer did that was remarkable.

So the big challenge we had was not really flight safety.

It was ground incursions or bumps, they call them.

Right.

So one of the things he did was, was he had us look at that from more of a how humans perform, because these are 18 year old kids.

Moving around, you know, $60 million planes with great regularity on the deck of an aircraft carrier, which by definition has limited space.

It's the deck of an aircraft carrier.

And it's constantly moving.

Oh, and it's super complex.

I mean, it's caught many, many systems operating at the same times.

And seriously, most of the people are 18, 19 years old.

I mean, so you don't have this high level of experience to lean on.

So they have to formalize operations and make it happen.

One of the things we realized, and this was really an interesting question, and Admiral Meyer let us ask this, is when I went out to observe this operation, I asked one little question.

I said, where do you not bump planes into each other?

I'd be really curious where it doesn't happen.

And the guy who's in charge of the little model thing with sticks and he moves planes around, he was a pretty high up, dude.

He said, that's a really good question.

He says, we never, ever, ever have incursions on the elevator.

When we bring them from the hangar up to the flight deck.

And I said, why don't you fail there?

And he said, well, one thing is that we have a limited amount of planes that can be on that elevator, and we have additional personnel because the elevator is high risk.

And I said, well, it seems like that.

And the problem is, is when you're not on the elevator, you need to have additional personnel and a limited amount of planes.

And so what Admiral Meyer did, which was so interesting, is he took a place in Norfolk and he drew with highway painting machine.

He drew the flight deck of aircraft carrier on asphalt in a big parking lot.

And then he brought out old planes that didn't work anymore and old tuggers and all the stuff they needed.

And they went out and practiced moving planes in a easy to learn low risk environment and then he did the most amazing thing max he had the tugger drivers turn into the coordinator people and the coordinator people had to been then do the tugger and the signaling guys had to become the coordinator and he had other people do each other's roles, and they dramatically decreased, dramatically, almost to zero.

Decreased the number of incursions they had on the flight deck.

Now, that's a great little story about kind of how the world allows us the opportunity to practice.

And when we practice, We don't practice to be perfect We practice because we are imperfect.

I love it.

One of the things he said was that when we have a near miss, we refer to it as a gift.

Yeah.

Talk about that.

Well, it is, right?

It's the accident without the mess.

So the thing about a near miss is you can look at a near miss as if it were the accident, but it's not the accident.

I mean, the accident didn't happen.

It's a near miss.

So then you have to think, well, what it is, It's really almost the near-perfect combination of everything necessary to fail.

It's not perfect because it would have failed.

And then we went on to help the Navy understand that not every near-miss is the same.

That in near-miss learning, you sort of have two categories.

You have near-miss good.

The margin was there so that when variation happened we were able to recover regain control and land safely or you have near miss lucky and that is there but by the grace of god go i i mean this could have gone so badly i just lucked out and didn't have a bad thing happen and what's amazing is both forms of those near misses are really valuable every near miss you guys have in your world should be categorized almost immediately, right out of the chute, either near-miss good or near-miss lucky.

Because if it's near-miss good, then it helps you understand your systems are working and it really allows you to reinforce things.

I mean, you can look at processes and procedures and practices and reward them.

It's a great gift.

If it's near-miss lucky, you've just identified a relatively significant risk component that is not in control.

And what gets you into trouble is when you're not in control.

I love it.

That's probably one of the most important things we've just talked about.

We should put that back at the beginning.

You can.

You can do anything.

We can edit the crap out of this.

What do you think?

I told you.

It's a super interesting conversation.

I think I talk too much.

Let's just put that out there.

I think I blabbed on too much.

But it was such a pleasure to meet Max.

Thanks for doing that, Max.

And thanks for listening to the pod.

Until then, learn something new every single day.

Bet you did today.

Have as much fun as you possibly can.

Be good to each other.

Be kind to each other.

And for goodness sakes, you guys, be safe.

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