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