Using Information Proactively to Address Human Performance Issues

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

The Context: More Complexity • 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 PEOPLE MATERIALS PROCEDURES SOFTWARE EQUIPMENT TOOLS FACILITIES

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

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

When Things Go Wrong . . . How It Is Now . . . How It Should Be . . . You are highly trained You are human and and Humans make mistakes If you did as trained, you would not make mistakes so so Let’s also explore why the system allowed, or failed to accommodate, your mistake You weren’t careful enough so and You should be PUNISHED! Let’s IMPROVE THE SYSTEM!

Fix the Person or the System? Is the Person Clumsy? Or Is the Problem . . . The Step???

Enhance Understanding of Person/System Interactions By: • - Collecting, • - Analyzing, and • - Sharing Information

Objectives: Make the System (a) Less Error Prone and (b) More Error Tolerant

Mandatory Reporting Voluntary Reporting (NEAR MISSES) Heinrich Pyramid ACCIDENTS INCIDENTS UNREPORTED OCCURRENCES

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.

Other Major Source of Information: Hands-On “Front-Line” Employees “We All Knew About That Problem” (and we knew it might hurt someone sooner or later)

Legal Concerns That Discourage Voluntary Collection, Analysis, and Sharing • Public Disclosure • Job Sanctions and/or Enforcement • Criminal Sanctions • Civil Litigation

Middle Management CEO Front-Line Employees “Safety First” “Production First” “Please the Boss First… Typical Cultural Barrier THENConsider Safety?”

Next Steps Improved Analytical Tools Legal/Cultural Issues As we begin to get over the first hurdle, we must start working on the second . . .

Information Overload

Immediate Benefit: $avings

Other Potential Benefits: • More Robust Communications Process -- • Helps Labor and Management Become Partners Improving Safety, Rather Than Adversaries, and • Can Also Improve: • Productivity, • Quality, • Reliability, and • Efficiency

Others Who Are Interested • Other Transportation Modes • Nuclear Power • Chemical Manufacturing • Public Utilities • Firefighters • Health Care Industry

The Health Care Industry 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

Thank You!!! Questions?

Using Information Proactively to Address Human Performance Issues