1. Aviation Safety Lessons Useful? January 11, 2007 Federal Aviation Administration 1 High Reliability Organizations - Importance of Information - Bottom-Line Benefits Presentation to: ISM Workshop 2007 Name: Christopher A. Hart Date: November 29, 2007 Federal Aviation Administration

2. Aviation Safety Lessons Useful? January 11, 2007 Federal Aviation Administration 2 Outline - Information - Why We Need It - How To Get It - Bottom-Line Benefits* - First Level Savings - Second Level Savings * In Addition to Safety Benefits – 65% Reduction in Fatal Aviation Accident Rate in 10 years

3. ISM Workshop 2007 November 29, 2007 Federal Aviation Administration 3 Improved Safety Information Information: The Fuel

4. ISM Workshop 2007 November 29, 2007 Federal Aviation Administration 4 More System Interdependencies – Large, complex, interactive system – Tightly coupled – Hi-tech components – Continuous innovation Safety Issues More Likely to Involve Interactions Between Parts of the System The Context: Increasing Complexity FACILITIES PEOPLE MATERIALS TOOLS PROCEDURES SOFTWAREEQUIPMENT

5. ISM Workshop 2007 November 29, 2007 Federal Aviation Administration 5 Effects of Increasing 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 “By the Book” May Not Be Optimal (“workarounds”)

6. ISM Workshop 2007 November 29, 2007 Federal Aviation Administration 6 The Result: Front-Line Staff 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

7. ISM Workshop 2007 November 29, 2007 Federal Aviation Administration 7 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

8. ISM Workshop 2007 November 29, 2007 Federal Aviation Administration 8 Fix the Person or the System? Is the Person Clumsy? Or Is the Problem... The Step???

9. ISM Workshop 2007 November 29, 2007 Federal Aviation Administration 9 Enhance Understanding of Person/System Interactions By: - Collecting, - Analyzing, and - Sharing Information

10. ISM Workshop 2007 November 29, 2007 Federal Aviation Administration 10 Objectives: Make the System Less Error Prone and More Error Tolerant

11. ISM Workshop 2007 November 29, 2007 Federal Aviation Administration 11 Objective is not to DECREASE the safety accountability of the OPERATOR... “Just Culture” Or “Non-Punitive/No-Blame”? INCREASE the safety accountability of everyone who designs, builds, manages, maintains, and regulates the SYSTEM but to...

12. ISM Workshop 2007 November 29, 2007 Federal Aviation Administration 12 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

13. ISM Workshop 2007 November 29, 2007 Federal Aviation Administration 13 Who Must Be Engaged? Labor – Pilots –Mechanics – Air Traffic Controllers Airlines Manufacturers – With the Systemwide Effort – With their own End Users Air Traffic Organizations Regulators

14. ISM Workshop 2007 November 29, 2007 Federal Aviation Administration 14 Also Important: Mid-Management Middle Management “Production First” Front-Line Employees “Please the Boss First… THEN Consider Safety? ” CEO “Safety First”

15. ISM Workshop 2007 November 29, 2007 Federal Aviation Administration 15 - Demonstrate Safety Commitment... BUT Leadership Must: - Include “Us” (e.g., System) Issues, Not Just “You” (e.g., Training) Issues - Make Safety a Middle Management Metric - Engage Labor Early - Include the System -- Manufacturers, Regulator, and Others - Encourage and Facilitate Reporting - Provide Feedback - Provide Adequate Resources - Follow Through With Action - Accept That Mistakes Will Happen

16. ISM Workshop 2007 November 29, 2007 Federal Aviation Administration 16 How To USE All That Data Another Presentation:

17. ISM Workshop 2007 November 29, 2007 Federal Aviation Administration 17 Major Benefit: $ avings* - Immediate - Significant *Significantly More Than Savings From Mishaps Prevented

18. ISM Workshop 2007 November 29, 2007 Federal Aviation Administration 18 Performance and Efficiency Improvements Ancillary to Improved Safety Examples: - Flap Overspeed - “Hot” Landings First-Level Savings

19. ISM Workshop 2007 November 29, 2007 Federal Aviation Administration 19 Second-Level Savings Ye Who Can Fix Frontline Workers Information About Safety And Productivity, Efficiency, Quality, And Other Production Metrics

20. ISM Workshop 2007 November 29, 2007 Federal Aviation Administration 20 Better Labor Relations - Transforms workforce from brunt of blame when things go wrong, to valuable source of information about potential problems and how to remedy them, i.e., converts labor and management from Adversaries to Partners in Improvement Other Potential Benefits: Reduced Legal Exposure - Collecting, analyzing, and sharing will become industry standard for most, if not all, potentially hazardous endeavors; woe to those who don’t

21. ISM Workshop 2007 November 29, 2007 Federal Aviation Administration 21 Bottom-Line Benefits Can Change the Dynamic From “Another Safety Program I Can’t Afford” Result To A Profit Center

22. ISM Workshop 2007 November 29, 2007 Federal Aviation Administration 22 Thank You!!! Questions?