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IT WAS PILOT ERROR

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

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IT WAS PILOT ERROR

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  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 Publicdemands 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

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