Bias Toward Safety

Added on Sep 17, 2015

Fred Noonan had a bias toward safety. Fred is best known for acting as Amelia Earhardt’s navigator. Both she and Fred were lost in the South Pacific in 1937. On Earhardt’s famous around-the-world flight, neither pilot nor navigator could locate tiny Howland Island and their landing field in the vast Pacific, they ran out of fuel and luck, and were lost.

Say again? Amelia Earhardt was lost? So why would her navigator, Fred Noonan, be cited as an example of doing it right?

Fred Noonan was a great navigator. In fact – in the times before radio beacons and global positioning systems – he was a navigator’s navigator. He was an expert. He taught others, and he advised PanAm on the best methods and practices. Don’t judge people by one event. Bad things will happen to good people working in complex systems.

Fred would plot each leg of the trip precisely – and then intentionally bias his result. He would intentionally bias his work to assure safety.

For example, on the leg of the flight across the South Atlantic from South America to North Africa, they would hit the coast of Africa and then turn to fly along the coast to their destination landing field. If Fred plotted his course exactly, the uncertainty in his measurements of position could leave the landing field either up the coast or down the coast from the spot where they hit land. That would be bad. They would need to turn left or right. And if they guessed wrong – they would be flying the wrong way, low on fuel, and searching for the field. Not safe.

Hospital Safety Rules

Fred put a bias toward safety. He intentionally plotted a course with a known error so that he would know with certainty that the field is on the left. (See inset left.) Once they made landfall, Amelia would turn left and follow the coast to the field. Very safe.

And that is why Fred Noonan is (was) a great navigator – he consistently put a bias toward safety.

Safety does not do well in a tie for first place. Safety is distant and remote – safety events mostly do not happen. In the U.S., the public generally considers safe any activity where the probability of a serious harm event is greater than one out of every thousand attempts (1/1000 or 10-3). Production pressures and customer needs, however, they constantly stare us directly in the face.

As a coping strategy our reaction is to borrow a little from safety to make quality or service or cost work in the moment. And that is why. That is why safety has to be more important in the moment than quality, service, and cost.

Part of high reliability organizing is being more resilient in planning for safety. Like Fred Noonan, we must plan ahead and invest in creating safety in the moment. Sometimes we need to sacrifice a little time and effort to be absolutely certain we assure safety before we attend to other, important needs.

Be like Fred Noonan and have a bias – a bias toward safety.

Questions to consider:

  • 1. Do we in our team have a bias toward safety? Or, do we consider safety, quality, service, and cost to all be of equal importance?

  • 2. Where in our work could we - and should we - invest a little time and effort to be certain that we assure safety before attending to other important needs?

  • 3. Do we have any instances where we allow cost or time or service to trump safety?