1. The Human Factor The Quality Colloquium
August 19, 2008
Patient Safety Lessons from Other Industries
Jim Bouey
Boeing Commercial Aircraft
Retired

2. Commercial Aviation Long History of Safety Performance Improvements
North American accident rate
(accidents per million departures)

3. Primary Causes of Hull Losses
flight crew
airplane
weather
maintenance
miscellaneous
airport, ATC
4.933
Hull Loss Rate (x10-6 Flights)
0.749
From Boeing Statistical Summary of Commercial Jet Airplane Accidents – Worldwide Operations

4. How the mind likes to work
Short cuts!

5. Short-Cut Trap

6. Federal Aviation Regulations
Title 14: Aeronautics and Space PART 25—AIRWORTHINESS STANDARDS: TRANSPORT CATEGORY AIRPLANES Subpart D—Design and Construction Personnel and Cargo Accommodations
§ 25.781   Cockpit control knob shape.
Cockpit control knobs must conform to the general shapes (but not necessarily the exact sizes or specific proportions) in the following figure:

7. Commercial Aviation Overarching Safety Philosophy
FAIL-SAFE
Assume that no matter what you do, something or someone will fail.
Now, what do you have to do to make sure that everyone stays safe?

8. Fail-Safe Designs

9. Safety Precedence in Design
Eliminate the hazard
If it cannot be eliminated, minimize it through design selection
If it cannot be eliminated or minimized, control it through the use of protective safety design features or devices
When neither design not safety devices can effectively eliminate, minimize or control a hazard, detect the condition and provide a warning
Resolution of hazards by the above methods can be supplemented with appropriate procedures and training, but these are not to be the sole means of hazard resolution

10. In commercial aviation, everyone involved believes that safety is their job #1 and improvements have come about because everyone knows that the pilot is the last person you want to depend on for a safe flight.