International Helicopter Safety Symposium 2005 September 28, 2005 Federal Aviation Administration 0 0 Using Information Proactively to Address Human Performance

1International Helicopter Safety Symposium 2005September 28, 2005

Federal AviationAdministration 1

Using Information Proactively to Address Human Performance Issues

Presentation to: International Helicopter Safety Symposium 2005

Name: Christopher A. Hart

Date: September 28, 2005

Federal AviationAdministration

International Helicopter Safety Symposium 2005September 28, 2005


• 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

The Context: More Complexity

FACILITIES

PEOPLE

MATERIALS

TOOLS

PROCEDURES

SOFTWARE EQUIPMENT



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



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

InadvertentHuman Errors



When Things Go Wrong . . .

How It Is Now . . . How It Should Be . . .

You are humanYou are highly trainedand

If you did as trained, you would not make mistakes

Humans make mistakes

so

You weren’t careful enough

Let’s also explore why the system allowed, or failed to accommodate, your mistake

so

You should be PUNISHED! Let’s IMPROVE THE SYSTEM!

and

so

and



Fix the Person or the System?

Is the Person Clumsy?

Or Is the Problem . . .

The Step???



Enhance Understanding of Person/System Interactions By:

- Collecting,

- Analyzing, and

- Sharing

Information



Objectives:

Make the System

(a) LessError Prone

and

(b) MoreError Tolerant



INCIDENTS

ACCIDENTS

UNREPORTEDOCCURRENCES

Heinrich Pyramid

(NEAR MISSES)

Mandatory Reporting

Voluntary Reporting



Benefits of Routine FDR UseHull Losses as a Percent of Total Turbine FleetFlight Data Recorder Users vs. U.S. vs. World

0

0.1

0.2

0.3

76-82 83-89 90-96

Years

Percent

Worldwide

FDR Use <7Years

Total U.S.FDR Use 7-14 YearsFDR Use >14 Years

Sources: Total U.S. - FAA NASDAC Other - Skandia Insurance Co. Ltd.



“We All Knew About That Problem”

(and we knew it might hurt

someone sooner or later)

Other Major Source of Information:Hands-On “Front-Line” Employees



Legal Concerns That Discourage Voluntary Collection, Analysis, and

Sharing• Public Disclosure

• Job Sanctions and/or Enforcement

• Criminal Sanctions

• Civil Litigation

13International Helicopter Safety Symposium 2005September 28, 2005


Typical Cultural Barrier

Middle Management

“Production First”

Front-Line Employees

“Please the Boss First…THEN Consider Safety?”

CEO

“Safety First”



Next Steps

Legal/Cultural Issues

Improved Analytical Tools

As we begin to get over the first hurdle, wemust start working on the second . . .



Information Overload



Immediate Benefit: $avings



More Robust Communications Process --

• Helps Labor and Management Become Partners Improving Safety, Rather Than Adversaries, and

• Can Also Improve:

- Productivity,

- Quality,

- Reliability, and

- Efficiency

Other Potential Benefits:



• Other Transportation Modes

• Nuclear Power

• Chemical Manufacturing

• Public Utilities

• Firefighters

• Health Care Industry

Others Who Are Interested



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

The Health Care Industry



Thank You!!!

Questions?

Documents

International Helicopter Safety Symposium 2005 September 28, 2005 Federal Aviation Administration 0 0 Using Information Proactively to Address Human Performance