1. International Helicopter Safety Symposium 2005 September 28, 2005 Federal Aviation Administration 0 0 Using Information Proactively to Address Human Performance Issues Presentation to: International Helicopter Safety Symposium 2005 Name: Christopher A. Hart Date: September 28, 2005 Federal Aviation Administration

2. International Helicopter Safety Symposium 2005 September 28, 2005 Federal Aviation Administration 1 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 SOFTWAREEQUIPMENT

3. International Helicopter Safety Symposium 2005 September 28, 2005 Federal Aviation Administration 2 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

4. International Helicopter Safety Symposium 2005 September 28, 2005 Federal Aviation Administration 3 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

5. International Helicopter Safety Symposium 2005 September 28, 2005 Federal Aviation Administration 4 When Things Go Wrong... How It Is Now...How It Should Be... You are humanYou are highly trained and 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

6. International Helicopter Safety Symposium 2005 September 28, 2005 Federal Aviation Administration 5 Fix the Person or the System? Is the Person Clumsy? Or Is the Problem... The Step???

7. International Helicopter Safety Symposium 2005 September 28, 2005 Federal Aviation Administration 6 Enhance Understanding of Person/System Interactions By: - Collecting, - Analyzing, and - Sharing Information

8. International Helicopter Safety Symposium 2005 September 28, 2005 Federal Aviation Administration 7 Objectives: Make the System (a) Less Error Prone and (b) More Error Tolerant

9. International Helicopter Safety Symposium 2005 September 28, 2005 Federal Aviation Administration 8 INCIDENTS ACCIDENTS UNREPORTED OCCURRENCES Heinrich Pyramid (NEAR MISSES) Mandatory Reporting Voluntary Reporting

10. International Helicopter Safety Symposium 2005 September 28, 2005 Federal Aviation Administration 9 Benefits of Routine FDR Use Worldwide FDR Use <7Years Total U.S. FDR Use 7-14 Years FDR Use >14 Years Sources: Total U.S. - FAA NASDAC Other - Skandia Insurance Co. Ltd.

11. International Helicopter Safety Symposium 2005 September 28, 2005 Federal Aviation Administration 10 “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

12. International Helicopter Safety Symposium 2005 September 28, 2005 Federal Aviation Administration 11 Legal Concerns That Discourage Voluntary Collection, Analysis, and Sharing Public Disclosure Job Sanctions and/or Enforcement Criminal Sanctions Civil Litigation

13. International Helicopter Safety Symposium 2005 September 28, 2005 Federal Aviation Administration 12 Typical Cultural Barrier Middle Management “Production First” Front-Line Employees “Please the Boss First… THEN Consider Safety? ” CEO “Safety First”

14. International Helicopter Safety Symposium 2005 September 28, 2005 Federal Aviation Administration 13 Next Steps Legal/Cultural Issues Improved Analytical Tools As we begin to get over the first hurdle, we must start working on the second...

15. International Helicopter Safety Symposium 2005 September 28, 2005 Federal Aviation Administration 14 Information Overload

16. International Helicopter Safety Symposium 2005 September 28, 2005 Federal Aviation Administration 15 Immediate Benefit: $ avings

17. International Helicopter Safety Symposium 2005 September 28, 2005 Federal Aviation Administration 16 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:

18. International Helicopter Safety Symposium 2005 September 28, 2005 Federal Aviation Administration 17 Other Transportation Modes Nuclear Power Chemical Manufacturing Public Utilities Firefighters Health Care Industry Others Who Are Interested

19. International Helicopter Safety Symposium 2005 September 28, 2005 Federal Aviation Administration 18 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

20. International Helicopter Safety Symposium 2005 September 28, 2005 Federal Aviation Administration 19 Thank You!!! Questions?