Target The Gremlin – A Fundamental Attribute Accidents typically happen when danger is close at hand ... but is not appreciated. Some people are more prone to this syndrome than others. Insofar as ability to sense danger – or its sibling, unwillingness to acknowledge proximate hazard – is the product of learning, then learning offers an antidote to the alarm blind syndrome. Originally published: September 26, 2003. KnovaWave Weekly Review as: Crowd behavior in markets Part ten: Obedience Air Force experience enables "carriers" of The Gremlin to be identified. Certain aspects of personality provide clues, though profiling is a crude instrument. Learning can produce behaviour modification. You’re not stuck with your personality; you can effect changes – though it’s hard going! The Red Flag System (RFS) analyses The Gremlin Syndrome in depth and sets out compelling arguments that it is not an irreversible condition. Training supplies a powerful antidote (if you need it).

Your Red Flag engagement challenges you daily (well, 4-5 times a week should do), weekly and monthly, in different ways. The quest to maintain critical skill fitness can rightly be seen as a continuing work-in-progress. So, too, is this website. To keep you posted, changes and news reports will be inserted, from time to time, on this Notice Board.

Current Notice: Wednesday 7 June 2006

To remind: The Basic Red Flag Program can be accessed for free. If there is something new to be said about safety, if the potential to reduce harm can be activated, then it should be spread as far and wide as possible. That's the reason for the "open access" policy. Cost-recovery items are limited to the reference text, the Checklist and the monthly Test (The Professional Program). Options for self-test using freely available mechanisms are described in the diary.

The next website update is scheduled for Saturday 1 July 2006.

Previous Notices:

Open Access

I would hope that everyone in a position to do it will spread the open access message. (The intention is to make the hard copy materials available to bona fide secondary and tertiary students at minimum cost, though the mechanism for doing that is yet to be worked out.)

No Easy Ride

On the face of things, adopting Red Flag presents daunting challenges - daily, weekly and monthly exercises - year after year? From one point of view, accident causes are at work 24/7. Not only that, just like bacteria and viruses, they get to know our defences (antibiotics) and adapt so as to defeat them. So our protections against the "accident bugs" must be continuous - and continually evolving.

Check Yourself Out

And many people already live their lives that way: For them, Red Flag will merely be an exercise in codifying things they already do. For such folk, the main difference will be the opportunity to record these activities (in the Diary). That formal record should provide the basis for recognition and advantage, and I would hope those effects are eventually realised in every possible way.

A Challenge

Perhaps the toughest problem to come to grips with is the error-prone-type-syndrome. We Queenslanders have for some months been fed a steady daily diet of news on the infamous Dr Patel case. In a relatively short period he caused 13 deaths (that are accounted for) and maimed many others with his terrible surgery. Now unmasked, the staggering thing is how many well-intentioned people regarded him as a consummate professional. I know from experience and research over many years that aviation professionals can also be "carriers" of the syndrome. And they're rarely as obvious as a Patel. It's not so much the case that other people can't pick them - they can and do perform impeccably - but that they do not know themselves. The key criterion is ability to perform under stress. You can go a long way in life without encountering a sufficiently severe stress test. Indeed, you may never face it. Red Flag offers the opportunity to any person to self-evaluate. You can prove you are not of that type.

The Syndrome

If you any doubt about The Syndrome I invite you to read Testing for Error Potential. The charts included are from a very good decision-making-under-stress test. The dramatic last chart shows it. It is from a colleague who is an airline pilot - and who has overcome the bug. A detailed explanation of The Syndrome is in The Tools (Professional version).

Recognition

Accepting the challenge of searching self-evaluation warrants recognition. As people (or organisations) "join the Red Flag club" their names will be placed on the Honour Board. The green "Tick" is placed alongside the name from the time of the first test. It will remain there, unchanged, for as long as the continuing regime is followed. If a monthly test is missed, the colour of the tick changes to amber. (EMSA is notified when a test is completed, but not of the result.)

Zero Tolerance

Finally, Red Flag advocates the philosophy of zero tolerance to risk as a Risk Management (RM) strategy. RM doctrine evolved out of the casinos. (The first known example was an attempt to beat the odds at a heads-or-tails type game.) It travelled by way of places such as Stock Exchanges and Futures Markets, and got a lot of help from insurance companies along the way. Mixing in those circles, it picked up one of its leading characteristics - tolerance to loss. The Red Flag approach disavows - strenuously - passive acceptance that things might go wrong or accidents are inevitable.

And why do we need a different approach to Risk Management?

Risk Management's greatest weakness is acceptance of what you might call "actuarial results" - and the associated induced complacency.

Take the case of surgery. It's been established that 95% of surgeons have an average error rate ("complications" in their terminology) of 3%. So that's become the benchmark. As long as you're at or under 3% you're doing OK. When the Royal Australian College of Surgeons first got wind of the "Patel problem" they checked his stats: under 3% - within limits, and thus acceptable. They even published a report to that effect. (In their defence, I suspect some of the stats were dodgy.)

In short, the surgeons think it's fine if 3 people out of every 100 they operate on become maimed or worse from an error on their part (nerve severed, loss of feeling and movement, inadvertent penetration of bowel, infection, and so on). The equivalent in aviation is to say it's OK to crash the plane 3 times in every 100 flights. (You might walk away form the crash.)

But that's not the real problem. The fact is that sooner or later a benchmark will become the aim point. For the medics, the objective became to do no worse than 3%. They should be striving for 0%. "Ah, unrealistic," you'll say, "Can't be done." (Well, maybe. Some of them can do it so why not the rest?) But that's not the point. The thing you aim for isn't necessarily the place you get to. We all want to be fitter than we are, and most of us work towards the goal. Even when falling short, you keep striving for the objective. The way Risk Management has gone, the goal has become the current standard and therefore there's nothing to try to achieve. Tolerance of error metamorphoses into indulgence of error potential. Red Flag calls this phenomenon Objective Shift - and sets Zero Tolerance as the standard to aim for.