I’ve been reading “The Strategy Paradox” by Michael Raynor, a book that Toby Elwin put me on to. The thesis of the book is that “Extreme positions in strategic space create the highest levels of profitability, but also create the highest levels of strategic risk and hence failure.” Although targeted at the commercial world there are also lessons that apply to the regulatory world. A few years ago at a safety workshop at Redondo Beach I had a beer with a safety inspector who shortly thereafter was promoted to be the principal operations inspector of a major airline. He observed that, while selection to become a PI was an important step in an ASI’s career, forever thereafter he would live in hope that his airline would avoid a major accident, because if they did have an accident his life would become one of answering questions as to why he hadn’t done this or that to forestall the event, and perhaps asking himself the same questions.

The FAA comes in for frequent lashings from NTSB , congress, and the press, and while some criticism may be justified, a good deal of it is both unfair and unhelpful to the agency’s safety mission. Although these critics presumably understand that you can’t predict the future, they continue to fall back on ineffective models of accidents being caused by an easily understood chain of events. Leaving aside the questions of what type of accident model you use, one thing is certain, it’s easier to identify the precursors of accidents after they have occurred than before – the question is how well one can reduce future risk given current knowledge. This is precisely Raynor’s point when he makes a distinction between forecasting the future with the future, and with forecasting the future with the “future present” that eventually obtains. In other words, at any given moment of time there exists a range of futures that might occur, and that is how one should evaluate the goodness of forecasting, not with what actually occurs. Given enough forecasts, someone will always turn out to have been accurate, but we don’t know at the time who that will be.

The counterpart of strategic uncertainty in a regulatory agency is the need to organize for robustness against a range of risks and hazards. This robustness comes at a price – less than optimal efficiency. The organization is working to mitigate future risks that are entirely possible but actually never transpire. That does not mean that the effort could have been better directed elsewhere — we are not working in an efficient system. One might conclude therefore that there is nothing one can do to address this issue, but Raynor goes one step further and recognizes that the issue of strategic uncertainty is tied to the time horizon. At the operational level one has a time horizon of days and weeks, while at the strategic level one has a time horizon of several years. The FAA has been labeled the “tombstone agency” but this characterization fails to distinguish its operational and strategic roles. At the operational level, there is nothing wrong, and indeed it is quite appropriate that the agency react to short term priorities and, especially, it must know how to react promptly to accidents, incidents, and other events. At the intermediate level, a process of selecting important problems and fixing them, as espoused by Malcolm Sparrow, is the appropriate course of action. But risks, by definition, are in the future, and it is at the strategic level that the agency can perform hazard identification and risk mitigation. Aviation safety already structures the organization by SMS pillars (policy, assurance, risk management, culture) and aviation system levels (national, organizational, individual), and should also structure itself according to different time horizons.

Like most people, I’ve often wondered what heaven is like – or rather, I wonder what other people think heaven is like. As a child, I suppose I believed that you’d be reunited with people who’d died, but of course, since all the people I knew who’d died seemed to be about the same age (old) I didn’t worry about what stage of life they’d be at. So what is heaven like? Are you reunited with all the people that you’ve loved or just the virtuous ones? What about pets? What about places that you loved and that have been replaced by housing developments and shopping malls?

My mother died this week, and I’m reminded of one of my favorite “old timey” songs that I first heard sung by Mike Seeger.

I am a poor wayfaring stranger
Traveling through this world of woe
But there’s no sorrow, toil, or danger
In that bright world to which I go.
I’m going there to see my mother
I’m going there no more to roam
I’m only going over Jordan
I’m only going over home.

My mother, in the last few years, was not the mother I remembered growing up with. She had developed Frontotemporal Lobe Dementia and no longer had interest in people. She recognized us, her children, but no longer had the same personality. I don’t know if she remembered who she used to be or was aware of what she had lost. Perhaps she did but no longer cared.

Last night I lay awake remembering scenes from our life growing up. Holding baby Katy, my younger sister. Cooking leg of lamb for Sunday dinner. Smoking a cigarette in the front seat of the car on our summer vacation in France. She was intensely interested in people and had a knack for spotting celebrities in the street. She had a remarkable memory for all sorts of trivia and I often wonder what she would have made of her life if she had had the opportunities that we have had. Even as an older person, I remember walking with her to the town center in Saffron Walden and stopping every few feet to talk with a neighbor or to point out where someone lived. All of this disappeared in her later years. Talking to her just seemed to annoy her. I remember calling her one day and a football match was on the telly, and though she didn’t even like football she kept it on while she gave automatic responses to my attempts to engage her in conversation.

A few years ago, when I was laid up in hospital, under the influence of some heavy duty narcotics, I had an experience which I suppose corresponds to the Zen concept of the “eternal now.” I was listening to a Haydn symphony and I heard and understood every note separately, complete in itself, weighing for eternity. I understood that the moment that I observed did not disappear into the unreachable past, but that it existed, and that though my point of view might shift, the note stood for eternity. I think Pete Townshend must have had a similar experience.

There once was a note, pure and easy,
Playing so free, like a breath rippling by.
The note is eternal, I hear it, it sees me,
Forever we blend it, forever we die.

That’s how I remember my mother. Not how she died, but how she lived her life. And that, of course, is the meaning of life

All this week Miranda, my 15 year old daughter, has been riding in with me on the commuter rail from South Acton Station to North Station in Boston, from where we take the Green Line to Government Center and the Blue Line to the Aquarium. For the first time this morning, I got off at the Porter Square stop to go to work in Kendall Square, leaving her to navigate the rest of the journey to her job as a CIT at the New England Aquarium summer camp program. It often strikes me when I ride public transportation, what a diverse set of people are in this world. Today, for example, there were buskers both at the Porter Square stop and the Harvard Square stop playing the cello – students on summer break from one of the colleges, gaining a little public exposure? Sitting on the train in front of me was a 60ish Asian gentleman with short cropped graying hair, dressed in a military jacket bearing a stars and stripes pin and a “Free Tibet” button. He held what might have been a spear, or at least some kind of stick, wrapped in an off-white fabric, and was telling beads on loop of string while softly chanting. A monk at a local temple? Next to him sat a nondescript student exploring his new iTouch – totally unremarkable these days – but what would we have made of this gadget a few years back?

Miranda has been texting me at each jump in her journey telling me where she is. There’ll be a time when I won’t be around. I wonder what she’ll see on her journeys?

The term System in Safety Management System refers to the system of controls applied to the operational processes of a certificate holder, and that produces safety as its output. This system is characterized in the three box model as a protection system, in contrast to the production system that delivers freight and passengers to their intended destinations, and the oversight system exercised by FAA. The use of the term system to describe such an assembly of processes and controls is somewhat of a stretch. To the extent that such an assembly can be called a system, it is an open system, using the terminology described by Gerald Weinberg in the standard textbook on the topic “An Introduction to General Systems Thinking.” There are multiple factors that affect safety that are not under the controls of Flight Standards and the Certificate Holder such as the environment (Canadian Geese, to mention a recent example), Technology (until recently, we did not know how to inert aviation fuel), and economics (certificate holders have to be able to stay in business). Furthermore, the output of an SMS is safety. But safety is not directly observable. To the extent that it is observable, it is as the absence of undesired outcomes. Thus it is difficult to determine whether the system is working, since the absence of events may be due to other causes than the ones under AFS and certificate holder’s control.

Karl Weick talks about mindfulness in his book on HROs. This state of mind is both individual and organizational -– if an organization can be said to have a mind — and is an idea that several other authors describe using different terms. Reason (I think) has called it “perpetual paranoia”. When I was sailing in the BVI last week, my instructor told me much the same thing in the context of avoiding collisions: “The first rule is never to assume that the other guy knows what he’s doing!” Mindfulness, I submit, is something that forms part of expertise. If you know what to expect, and can resist the temptation to be a “yes-man” and look for confirmatory evidence, then you are more likely to notice discrepancies. Looking for movement is one of the things our brain is set up to detect, and a difference from the norm is also a kind of movement, although not in a temporal dimension. Another Karl, Karl Popper, talks about the asymmetry of evidence in proving, versus disproving, a hypothesis. Famously, he talks about how the hypothesis that “all swans are white” cannot be proved by observing white swans, no matter how many white swans you observe, but can be disproved by the observation of a single black swan. This mindfulness, the ability to look for evidence to indicate that the things are not what they should be is, I submit, what regulatory agencies need to embrace; they should drop this silly idea of becoming a proactive organization. Proactive means “Acting in advance to deal with an expected difficulty.” This is a lofty goal and I don’t think it can be achieved. What can be achieved, however, is to improve mindfulness and retain the agility to react more quickly and expertly to deviations from the norm. I may see a deviation but sill not knows what to expect, but have a notion that it’s reducing safety. I don’t need to know how that deviation will play out because there may be other deviations that form part of the safety chain that I haven’t observed. Reacting to such cues may appear to a novice observer as being “proactive” but it isn’t – it’s just that the expert is reacting to cues that are not observable to the novice.