1. IT WAS PILOT ERROR OK NOW WHAT? Paul McCarthy IFALPA Rep. to ICAO

2. ERROR Almost ALL identifiable accidents and incidents have a crew error component Most commonly quoted figure is 70% but in reality human error is close to 100 % Aviation is a fallible system operated by humans so this allegation should not be a surprise

3. OBJECTIVE Constantly adjust the system Error proof all aspects of the operation Account for humans acting as humans Fault tolerant system

4. PRECURSORS Not all errors become accidents A series of events which are traced to a particular error become precursors of an accident

5. A PROBLEM The error must be identified The identification must point out the weak link in the system Error proofing requires data How do we categorize the error?

6. POINT What is an error? An act, assertion, or belief that UNINTENTIONALLY deviates from what is correct, right or true American Heritage Dictionary

7. POINT An Intentional [bad] act is NOT an error It is an intentional act

8. POINT Punishment can deter an Intentional act. The actor must consider the consequences of the action to be taken

9. POINT Punishment cannot deter an unintentional deviation (an error) The actor believes the action is correct and so without adverse consequences

10. BAD ACTS ICAO has defined acts for which discipline or punishment is appropriate Annex 13, Attachment E:

11. INTENTIONAL ACTS The International pilot community DEMANDS that intentional bad acts related to aviation be punished with zero tolerance

12. POINT The Public demands that BLAME be placed Blame tends to equal punishment in the mind of the public. So, we punish not necessarily to deter bad acts but to satisfy the public Public must be educated about the consequences of this attitude

13. HUMAN NATURE Errors will not be prevented by threat of prosecution Errors can only be prevented by knowledge, training or system redesign Error prevention requires data

14. HUMAN NATURE BUT …. ( here it comes) The threat of prosecution dramatically impedes the acquisition of data on causal factors leading to an error

15. HUMAN NATURE OR – If you punish, you probably cannot fix Annex 13, para. 5.12 note 1 Landing with the landing gear retracted- we could not prevent until we learned why and we did not learn until we stopped punishing

16. ERROR CATEGORIZATION To prevent an error we must first learn why it occurs We can call the sequence of events causal factors A full catalog of causal factors might be called error categorization

17. ERROR CATEGORIZATION Categorization involves determining why an individual acted in a particular way Categorization cannot be performed in a vacuum

18. ERROR CATEGORIZATION Each error (accident, incident or event) must be reported and investigated This can be a simple or complicated task depending on the circumstances It will result in the data needed to prevent future occurrences

19. HOW DO WE DO THIS? Post accident/serious incident Conduct the technical investigation without imbedded judicial (police) involvement Comply with ICAO Annex 13, 5.12 and Att. E on protection of information

20. HOW DO WE DO THIS? Other incident or event When an individual identifies a error in operation, the individual must be motivated to report and submit to investigation

21. MOTIVATION Threat of punishment? Exposure to peer censure? Intense interrogation? OF COURSE NOT!

22. MOTIVATION The best motivation seems to be establishing a system based on mutual trust and professionalism. Make the individuals WANT to improve the system

23. MOTIVATION We are all proud to be known as aviation professionals Professionals constantly seek self improvement Trade on that characteristic

24. PUNISHMENT Punishment of error is simply inconsistent with proven techniques of accident prevention This creates a dilemma for States

25. PUNISHMENT Public sentiment will continue to demand punishment. States cannot allow this sentiment to override the fundamental principle that punishment does not improve safety.

26. ATTACHMENT E ICAO worked very hard to set out general principles to facilitate the acquisition of safety related data from operational personnel in Attachment E to Annex 13.

27. ATTACHMENT E Experience with: accident investigation mandatory reporting schemes voluntary reporting schemes flight recorder analysis programs indicate that these principles work.

28. ATTACHMENT E Intended as a template Amend Laws Amend Regulations Amend Personnel Policies Must do for Just Culture

29. CONCLUSION Improvement in air safety requires error elimination Error elimination must be data driven Data acquisition is impeded by punishment

30. CONCLUSION Punishment in error cases is contrary to air safety principles Use Annex 13, Attachment E Questions? Thank You for your attention