A Desk Is a Dangerous Place From Which to Watch the World

This article is a reproduction of an article published in HindSight magazine issue 28 in February 2019 on the theme of ‘Change’ (all issues available at SKYbrary)

Some years ago, I was part of a major project involving a new ATC unit. This involved several changes – a whole new building in a new location, new technology, new positions, new procedures. I entered the project at a fairly late pre- operational stage. Everything was designed, built and mostly installed. The controllers were training for the change. Safety assessments, including human factors analysis, had already been done and were exhaustive, comprising hundreds of pages of documentation from workshops and analysis.

But after reading the analyses and reports, I could not get a real sense of what was going on. The only way I could get a sense of risk and readiness for the changes was to enter simulator training and hang out – just watch and listen. I had no preconceived scheme of what to look for, except what I had internalised through observing people over the years as a psychologist and ergonomist, especially in simulation and live operation.

So I hung out in the simulator for the week. Being with the controllers, watching them and listening to them, allowed me to develop a moment-by-moment empathic understanding of their experiences. This is called process empathy. It’s understanding people’s experience as it unfolds, cognitively, emotionally, physically, socially. I also tried to develop a ‘near understanding’ of their worlds. This is called person empathy. It’s understanding what it is like to be Michael or Michaela, the air traffic controller.

I was not prepared for what I experienced. And neither were the controllers. What I saw – as an outsider – was that they were not ready for the change, despite what several other senior people believed. The controllers could, by and large, use the equipment. They could see what they needed to see. They understood the procedures. But they couldn’t do the job. Some lost the picture. They didn’t know what was going on. Some had had nightmares about their job. Some broke down crying. I couldn’t believe that it had come to this.

It is like the imaginary car described by systems thinking pioneer Russell Ackoff. Imagine selecting the best tyres available. The best engine. The best chassis. The best transmission. The best of everything. Trouble is, they don’t fit together. It’s not about the parts – the individual skills like using equipment and seeing the airfield. Even I can do that! It’s about the whole. It’s about whether you can do the job. And they couldn’t.

“The controllers could, by and large, use the equipment. They could see what they needed to see. They understood the procedures. But they couldn’t do the job.”

Operational staff had spoken up, but the message wasn’t getting through. Sadly, it is a reality that people on the inside are not always heard. And they speak up less if they feel they won’t be heard. And they stop speaking up if nothing happens when they do speak up.

Nothing in any documented analysis could give me anything like the understanding gained from hanging out, because it was just that – analysis: work-as-imagined, decontextualised, decomposed and detached from the reality of work-as-done.

As I arrived home after the fourth day in the simulator, all I felt I could do, as a safety specialist but moreover as a person with a responsibility to be honest, was write openly about what I saw. Not as a report, but as a letter. So I wrote a letter in the late hours of the night. The next day, I went in to the unit to try to talk to someone about what I had seen, as a newcomer and outsider to the project. When I arrived, I read the letter to the project manager and the unit safety manager. Then, with these managers, I read it to the ops manager. Finally, I summarised the contents to these managers and the general manager, plus several senior project and facility staff, in an impromptu meeting. Despite the unorthodox approach, most listened and agreed to look into it further.

But there was some resistance, and I was challenged about my conclusions. I could only think of one question in reply: “Have you been into the simulator?” It turned out that none of the (non-operational) managers or specialists present at the impromptu meeting had spent any time in the simulator during training.

There are many reasons why sitting with operational staff, especially in their own environment, might not seem like a priority on a major change project. Among these reasons are the pressures of the project itself (especially time pressures), as well as regulations and management systems. The time need to comply with formal requirements may get in the way of spending time in operational environments. Ironically, bureaucratised (office-based) safety can take the focus away from operational safety. Because time and other resources are always limited, there has to be a trade-off. The trade-off often favours an abstracted version of safety over a lived experience of safety.

In the weeks following, it was decided to delay the opening of the new unit to allow for more practice in the simulator and shadowing in the new facility. I was able to sit in the new unit during shadowing, and watch controllers develop confidence and competence – a felt ability to do the whole job. And I was able to develop a trusting relationship with more controllers. This is called empathic report. This helps us to feel more psychologically safe to disclose thoughts and feelings, and to act in a natural way. During this time, new human factors and safety issues were identified from informal discussions and observations.

“Sadly, it is a reality that people on the inside are not always heard. And they speak up less if they feel they won’t be heard. And they stop speaking up if nothing happens when they do speak up.”

The facility opened successfully a few months later. Not only were there no major safety issues, the unit operated with fewer capacity restrictions than would have been the case had it opened ‘on time’.

This was a career-defining time for me, and I know that this was a significant period in the lives people of many at this unit. The lesson was clear: if you want to understand what’s going on, you have to get out from behind your desk. For outsiders, ‘hanging out’ with operational personnel, preferably in operational environments, is critical to effective change. And empathy can be as important as abstract analysis.

In your worlds, how connected are managers and other non-operational specialists with operational staff and the operational environment, where changes ultimately end up? Those who wish to support operational staff through change must take the role of pupil, or apprentice – not master. They must get close to the work to understand how the work works. They must gain an empathic understanding of your world. But for that, they need your welcome.

As John le Carré, a former British MI5 and MI6 agent, wrote in his spy novel The Honourable Schoolboy, “A desk is a dangerous place from which to watch the world.”