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The Quality Colloquium August 19, 2008

The Human Factor. The Quality Colloquium August 19, 2008. Patient Safety Lessons from Other Industries. Jim Bouey Boeing Commercial Aircraft Retired. Commercial Aviation Long History of Safety Performance Improvements. North American accident rate (accidents per million departures).

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The Quality Colloquium August 19, 2008

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  1. The Human Factor The Quality Colloquium August 19, 2008 Patient Safety Lessons from Other Industries Jim Bouey Boeing Commercial Aircraft Retired

  2. Commercial Aviation Long History of Safety Performance Improvements North American accident rate (accidents per million departures)

  3. flight crew airplane weather maintenance miscellaneous airport, ATC Primary Causes of Hull Losses 1960s 1996-2005 4.933 Hull Loss Rate (x10-6 Flights) 0.749 From Boeing Statistical Summary of Commercial Jet Airplane Accidents – Worldwide Operations

  4. How the mind likes to work Short cuts!

  5. Short-Cut Trap

  6. Federal Aviation Regulations • Title 14: Aeronautics and SpacePART 25—AIRWORTHINESS STANDARDS: TRANSPORT CATEGORY AIRPLANESSubpart D—Design and ConstructionPersonnel and Cargo Accommodations § 25.781   Cockpit control knob shape. Cockpit control knobs must conform to the general shapes (but not necessarily the exact sizes or specific proportions) in the following figure:

  7. Commercial AviationOverarching Safety Philosophy FAIL-SAFE Assume that no matter what you do, something or someone will fail. Now, what do you have to do to make sure that everyone stays safe?

  8. Fail-Safe Designs

  9. Safety Precedence in Design • Eliminate the hazard • If it cannot be eliminated, minimize it through design selection • If it cannot be eliminated or minimized, control it through the use of protective safety design features or devices • When neither design not safety devices can effectively eliminate, minimize or control a hazard, detect the condition and provide a warning • Resolution of hazards by the above methods can be supplemented with appropriate procedures and training, but these are not to be the sole means of hazard resolution

  10. In commercial aviation, everyone involved believes that safety is their job #1 and improvements have come about because everyone knows that the pilot is the last person you want to depend on for a safe flight.

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