Transcript Document
Using Information Proactively to Address Human Performance Issues Federal Aviation Administration Presentation to: International Helicopter Safety Symposium 2005 Name: Christopher A. Hart Date: September 28, 2005 International Helicopter Safety Symposium 2005 September 28, 2005 Federal Aviation Administration 0 0 The Context: More Complexity • Increasing System Interdependencies – Large, complex, interactive, tightly coupled system – Highly redundant – Hi-tech components – Continuous innovation • Safety Issues More Likely to Involve Interactions Between Parts of the System International Helicopter Safety Symposium 2005 September 28, 2005 PEOPLE MATERIALS SOFTWARE TOOLS PROCEDURES EQUIPMENT FACILITIES Federal Aviation Administration 1 Effects of More Complexity: More “Human Error” Because • System More Likely to be Error Prone • Operators More Likely to Encounter Unanticipated Situations • Operators More Likely to Encounter Situations in Which Operating “By the Book” May Not be Optimal International Helicopter Safety Symposium 2005 September 28, 2005 Federal Aviation Administration 2 The Result: Operators Who Are - Highly Trained - Competent - Experienced, -Trying to Do the Right Thing, and - Proud of Doing It Well . . . Yet They Still Commit Inadvertent Human Errors International Helicopter Safety Symposium 2005 September 28, 2005 Federal Aviation Administration 3 When Things Go Wrong . . . How It Is Now . . . How It Should Be . . . You are highly trained You are human and and If you did as trained, you would not make mistakes Humans make mistakes so You weren’t careful enough so You should be PUNISHED! International Helicopter Safety Symposium 2005 September 28, 2005 so Let’s also explore why the system allowed, or failed to accommodate, your mistake and Let’s IMPROVE THE SYSTEM! Federal Aviation Administration 4 Fix the Person or the System? Is the Person Clumsy? Or Is the Problem . . . The Step??? International Helicopter Safety Symposium 2005 September 28, 2005 Federal Aviation Administration 5 Enhance Understanding of Person/System Interactions By: - Collecting, - Analyzing, and - Sharing Information International Helicopter Safety Symposium 2005 September 28, 2005 Federal Aviation Administration 6 Objectives: Make the System (a) Less Error Prone and (b) More Error Tolerant International Helicopter Safety Symposium 2005 September 28, 2005 Federal Aviation Administration 7 Heinrich Pyramid ACCIDENTS Mandatory Reporting INCIDENTS Voluntary Reporting (NEAR MISSES) UNREPORTED OCCURRENCES International Helicopter Safety Symposium 2005 September 28, 2005 Federal Aviation Administration 8 Benefits of Routine FDR Use Hull Losses as a Percent of Total Turbine Fleet Flight Data Recorder Users v s. U.S. v s. W orld Percent 0.3 0.2 Worldwide FDR Use <7Years 0.1 Total U.S. FDR Use 7-14 Years FDR Use >14 Years 0 76-82 83-89 90-96 Y ears Sources: Total U.S. - FAA NASDAC Other - Skandia Insurance Co. Ltd. International Helicopter Safety Symposium 2005 September 28, 2005 Federal Aviation Administration 9 Other Major Source of Information: Hands-On “Front-Line” Employees “We All Knew About That Problem” (and we knew it might hurt someone sooner or later) International Helicopter Safety Symposium 2005 September 28, 2005 Federal Aviation Administration 10 Legal Concerns That Discourage Voluntary Collection, Analysis, and Sharing • Public Disclosure • Job Sanctions and/or Enforcement • Criminal Sanctions • Civil Litigation International Helicopter Safety Symposium 2005 September 28, 2005 Federal Aviation Administration 11 Typical Cultural Barrier Middle Management CEO Front-Line Employees “Safety First” “Production First” “Please the Boss First… THEN Consider Safety?” International Helicopter Safety Symposium 2005 September 28, 2005 Federal Aviation Administration 12 12 Next Steps Improved Analytical Tools Legal/Cultural Issues As we begin to get over the first hurdle, we must start working on the second . . . International Helicopter Safety Symposium 2005 September 28, 2005 Federal Aviation Administration 13 Information Overload International Helicopter Safety Symposium 2005 September 28, 2005 Federal Aviation Administration 14 Immediate Benefit: International Helicopter Safety Symposium 2005 September 28, 2005 $avings Federal Aviation Administration 15 Other Potential Benefits: More Robust Communications Process -• Helps Labor and Management Become Partners Improving Safety, Rather Than Adversaries, and • Can Also Improve: - Productivity, - Quality, - Reliability, and - Efficiency International Helicopter Safety Symposium 2005 September 28, 2005 Federal Aviation Administration 16 Others Who Are Interested • Other Transportation Modes • Nuclear Power • Chemical Manufacturing • Public Utilities • Firefighters • Health Care Industry International Helicopter Safety Symposium 2005 September 28, 2005 Federal Aviation Administration 17 The Health Care Industry To Err Is Human: Building a Safer Health System “The focus must shift from blaming individuals for past errors to a focus on preventing future errors by designing safety into the system.” Institute of Medicine, Committee on Quality of Health Care in America, 1999 International Helicopter Safety Symposium 2005 September 28, 2005 Federal Aviation Administration 18 Thank You!!! Questions? International Helicopter Safety Symposium 2005 September 28, 2005 Federal Aviation Administration 19