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Why do good people like You

Why do good people like You. Johnny Rush Northwest Aviation Training. (Or I ). Make errors?. Our Belief. Learning is finding out what you already know. Doing is demonstrating that you know it.

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Why do good people like You

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  1. Why do good people like You Johnny Rush Northwest Aviation Training (Or I ) Make errors?

  2. Our Belief Learningis finding out what you already know. Doingis demonstrating that you know it. Teaching is reminding others that they know it just as well as you. We are all learners, doers and teachers. Richard Bach

  3. The older I get, the more I realize that there are an ever increasing number of things that I know nothing about Gordon Dupont System Safety Services

  4. Our objective • To introduce you to why we make errors and • To provide you some insights into how you can avoid making an error you never intended to make.

  5. When you work • You carefully think out all the angles. • You've done it a thousand times. • It comes naturally to you. • You know what you're doing, its what you've been trained to do your whole life. • Nothing could possibly go wrong, right ?

  6. Think Again And Again

  7. What is Human Error? • Human Error is: “When the outcome of something we did or didn’t do, is not what we expected.” Gordon Dupont

  8. errors The causes are to be found in whatever it was that interfered with the workers performance at a critical moment are not the cause of accidents. the outcome of which is a human error Jerome Lederer Flight Safety Foundation

  9. A Very Little History “Human”Causes “Machine” Causes

  10. Careless Stupid Dumb And a little bit Lazy

  11. If not “Careless, Stupid, Dumb and Lazy!!!” Than WHY?

  12. #1 Contributing Factor “It will never happen to me” Y E T But it can! ou’re ligible oo

  13. It can and does Wright Flyer Sept. 17, 1908 1 Fatality

  14. Concorde Air France July 25, 2000 113 Fatalities

  15. Why? 113 Fatalities

  16. Why? 113 Fatalities

  17. Maintenance may have played a role

  18. January 31, 2000 Alaska Airlines MD80 88 Fatalities ?

  19. Sept. 3, 1998 Swissair MD11 ? 229 Fatalities

  20. May 11, 1996 ValuJet DC9 110 Fatalities

  21. July 11, 1991 Nationair DC8 261 Fatalities

  22. Aloha Airlines B737 April 28,1988 1 Fatality

  23. But It’s Just Common Sense “Yea… I found it helps to let the air out of it first”

  24. What about Common Sense? • Common sense is the collective wisdom of a group which results in an understanding or point of view shared by the majority of the group. • It is often made up of unwritten rules followed, often without question, by the majority of the group. • What we come to think is the right way to do things Gordon Dupont

  25. Common Sensehas nothing to do with Human Factorsandis not that common

  26. What are Human Factors? Don’t panic… These are for the neighbour’s daughter Factors, circumstances, situations that influence or cause us humans to do the things we do. Gordon Dupont

  27. Why do we need Human Factors Training? “They”don’t want it” “We” can’t afford it” AND

  28. Here’s Why • Human Failure is responsible for at least 80% of aviation’s accidents • 99.99+% of these failures are not intentional • Most persons who cause an error have no idea why they made the error • Lack of Knowledgeof what causes a person to make an error is one of the major contributing factors to the error. • Human Factors training gives him that Knowledge.

  29. The Dirty Dozen 1 3 Lack of Communication Lack of Knowledge 4 2 Complacency Distraction

  30. The Dirty Dozen(continued) 7 5 Lack of Teamwork Lack of Resources 6 8 Fatigue Pressure

  31. The Dirty Dozen (continued) 9 11 Lack of Assertiveness Lack of Awareness 10 Stress

  32. Lack of Awareness? “Whatever made you think your cat would enjoy taking a shower with you?”

  33. The Dirty Dozen (continued) 9 11 Lack of Assertiveness Lack of Awareness 10 12 Stress Norms

  34. Safety Nets • A Safety Net is a Regulation, Policy, Practice or Procedure which, if in place might break a link or prevent a link in the chain of events • The regulatory body controls the regulations • The company controls the policies • The individual controls the practice or procedures.

  35. We must learn to put “Safety Nets” in place Because: “It can happen to us” And; When we make an error Sometimes, Someone else pays the price

  36. The story of a “someone else”

  37. Accident Diagram X X X

  38. But its only a small clamp

  39. A very small clamp

  40. With Disastrous Consequences

  41. Lets Recap • It’ll never happen to us until it does • It’s not just Common Sense • We lack the knowledge of why we make errors • If we are to reduce errors we must train people on how to avoid them

  42. Thank You Have a safe and rewarding career Johnny Rush

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