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IT WAS PILOT ERRORIT WAS PILOT ERROR
OKOK
NOW WHAT?NOW WHAT?
Paul McCarthyPaul McCarthy
IFALPA Rep. to ICAOIFALPA Rep. to ICAO
ERRORERROR
• 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
OBJECTIVEOBJECTIVE
• Constantly adjust the system
• Error proof all aspects of the operation
• Account for humans acting as humans
• Fault tolerant system
PRECURSORSPRECURSORS
• Not all errors become accidents
• A series of events which are traced to a particular error become precursors of an accident
A PROBLEMA 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?
POINTPOINT
• What is an error?
• “An act, assertion, or belief that UNINTENTIONALLY deviates from what is correct, right or true”
American Heritage Dictionary
POINTPOINT
• An Intentional [bad] act is NOT an error
• It is an intentional act
POINTPOINT
• Punishment can deter an Intentional act.
• The actor must consider the consequences of the action to be taken
POINTPOINT
• Punishment cannot deter an unintentional deviation (an error)
• The actor believes the action is correct and so without adverse consequences
BAD ACTS
• ICAO has defined acts for which discipline or punishment is appropriate
• Annex 13, Attachment E:
INTENTIONAL ACTSINTENTIONAL ACTS
• The International pilot community DEMANDS that intentional bad acts related to aviation be punished with zero tolerance
POINTPOINT
• 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
HUMAN NATUREHUMAN 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
HUMAN NATUREHUMAN NATURE
• BUT …. • (here it comes)
• The threat of prosecution dramatically impedes the acquisition of data on causal factors leading to an error
HUMAN NATUREHUMAN 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
ERROR CATEGORIZATIONERROR 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
ERROR CATEGORIZATIONERROR CATEGORIZATION
• Categorization involves determining why an individual acted in a particular way
• Categorization cannot be performed in a vacuum
ERROR CATEGORIZATIONERROR 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
HOW DO WE DO THIS?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
HOW DO WE DO THIS?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
MOTIVATIONMOTIVATION
• Threat of punishment?
• Exposure to peer censure?
• Intense interrogation?
• OF COURSE NOT!
MOTIVATIONMOTIVATION
• The best motivation seems to be establishing a system based on mutual trust and professionalism.
• Make the individuals WANT to improve the system
MOTIVATIONMOTIVATION
• We are all proud to be known as aviation professionals
• Professionals constantly seek self improvement
• Trade on that characteristic
PUNISHMENTPUNISHMENT
• Punishment of error is simply inconsistent with proven techniques of accident prevention
• This creates a dilemma for States
PUNISHMENTPUNISHMENT• Public sentiment will continue
to demand punishment.
• States cannot allow this sentiment to override the fundamental principle that punishment does not improve safety.
ATTACHMENT EATTACHMENT 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.
ATTACHMENT EATTACHMENT E
• Experience with:
• accident investigation • mandatory reporting schemes • voluntary reporting schemes • flight recorder analysis programs
• indicate that these principles work.
ATTACHMENT EATTACHMENT E
• Intended as a template• Amend Laws• Amend Regulations• Amend Personnel Policies• Must do for• Just Culture
CONCLUSIONCONCLUSION
• Improvement in air safety requires error elimination
• Error elimination must be data driven
• Data acquisition is impeded by punishment
CONCLUSIONCONCLUSION
• Punishment in error cases is contrary to air safety principles
• Use Annex 13, Attachment E
• Questions?
• Thank You for your attention