Unexpected Rough Air

Added on May 15, 2015

When I first joined the HPI Team, I was a novice flyer. I believed, based on the handful of flights I had taken prior, that I had experienced turbulence, or what is now referred to as “unexpected rough air”.

Patient Safety

Anyone who has flown has heard the flight crew announce, “When seated, please keep your seatbelt fastened in case we experience any unexpected rough air”. And, I’m sure that there have been more than a few that have half-heartedly listened, or worse yet, practiced non-compliance.

It was a recent flight that caused me to reevaluate my level of commitment to seatbelt usage during flight. We were just starting our descent into Atlanta after a very smooth flight when we experienced an unexpected period of moderate/severe turbulence. Phones, glasses, iPads and laptops went flying, passengers flew up out of their seats- testing the compliance of their seat belt usage, and flight attendants were thrown while standing in the galley. The cabin passengers audibly gasped and then fell silent during the rest of the flight. While my seatbelt had been on, it was not as tight as it should have been. I rose at least 6 inches out of my seat before abruptly reconnecting with gravity.

The Federal Aviation Administration (FAA) states that approximately 58 people are injured every year from turbulence events. Most commonly, these injuries occur when passengers are not wearing their seatbelts or are thrown while up in the cabin. So, why do people practice non-compliance in regards to seatbelt usage on planes? Here are a few thoughts:

  • • They’ve never experienced a true turbulence event (knowledge-based)
  • • They forget to put their seatbelt back on when returning from the restroom (skill-based)
  • • They figure a seatbelt is of little use if the plane is going to crash (rule-based)
  • • They don’t like feeling “restricted” while sitting in an already uncomfortable space (rule-based)


Human behavior shapes everything around us. Take a moment to review the drivers of non-compliance:

Choosing to not follow a rule occurs for a variety of reasons: We don’t think that something bad will happen to us (risk), the rule seems silly or time-consuming to follow (burden) or the culture may not support the compliance to the rule (coaching).

In my experience, it was more of the knowledge-based error. The turbulence I experienced prior to this event didn’t compare and I didn’t really understand the implications of wearing a loose seat belt.

hospital safety

In our safety and reliability work, we really do need to consider the non-compliance equation when asking our people to create and sustain safe working habits as individuals and as teams. We need to get to the “why” (be willing to share our failures so others can learn), and we must reduce burden so that our error prevention techniques and/or safe practices seem more like tools and less like rules. Lastly, peer checking and coaching cannot be a “nice to have,” it has to be a “must”.



Consider these questions:

  • 1) Do our people know why we have selected our safety practices and error prevention techniques (EPT’s) for our toolbox? Have we talked about them as more than theory? Do we share the lessons learned in our organizations so others can understand the perceived risk of not practicing and avoid having to experience the error or bad outcome themselves?
  • 2) As leaders, are we managing our expectations for EPT’s to be performed as individual and team habits tightly or loosely? Do we reduce the burden for our people to practice them? Do we not only encourage peer checking and coaching but insist that it must happen for our success?