Discusses the concept of intentional vs non-intentional errors

1. IT WAS PILOT ERROR
OK
NOW WHAT?

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
• Thank You for your attention