international helicopter safety symposium 2005 september 28, 2005 federal aviation administration 0...
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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
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• 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
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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
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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
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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
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Fix the Person or the System?
Is the Person Clumsy?
Or Is the Problem . . .
The Step???
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Enhance Understanding of Person/System Interactions By:
- Collecting,
- Analyzing, and
- Sharing
Information
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Objectives:
Make the System
(a) LessError Prone
and
(b) MoreError Tolerant
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INCIDENTS
ACCIDENTS
UNREPORTEDOCCURRENCES
Heinrich Pyramid
(NEAR MISSES)
Mandatory Reporting
Voluntary Reporting
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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.
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“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
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Legal Concerns That Discourage Voluntary Collection, Analysis, and
Sharing• Public Disclosure
• Job Sanctions and/or Enforcement
• Criminal Sanctions
• Civil Litigation
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Typical Cultural Barrier
Middle Management
“Production First”
Front-Line Employees
“Please the Boss First…THEN Consider Safety?”
CEO
“Safety First”
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Next Steps
Legal/Cultural Issues
Improved Analytical Tools
As we begin to get over the first hurdle, wemust start working on the second . . .
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Information Overload
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Immediate Benefit: $avings
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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:
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• Other Transportation Modes
• Nuclear Power
• Chemical Manufacturing
• Public Utilities
• Firefighters
• Health Care Industry
Others Who Are Interested
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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
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Thank You!!!
Questions?