IT WAS PILOT ERROR

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 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

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