If we don't train people
on how to control their own personal error patterns...
..first of all, identify them,
and then control their own personal error patterns,
what we call error control centres of gravity,
then we are asking for something that doesn't yet exist.
We are not empowering people to be accountable,
yet we're expecting them to be accountable,
and that's where many, many of our problems begin -
when we continue to see
80% of accidents and incidents caused by human error.
So how can an organisation put in place an error management philosophy?
Well...I think the first thing we need to recognise
is that errors don't occur randomly, so...
You need to take a shared accountability
or responsibility approach,
so on the one hand, the organisation sets the tone,
so the organisation needs to have good clear procedures,
good standards, availability of proper equipment and tools,
and then encourage that open reporting of at-risk issues
or human factors issues.
But on the other hand, the individual engineer needs to ensure
that they have a disciplined approach to applying
standards and those procedures that are in place,
come to work fit for duty, engage in clear communication,
and have the courage to speak up.
When it comes to looking at why errors occur in the workplace,
we do need to take a learning approach, so...
You know, when the events or the incidents
or even the near misses occur, we need to look at them
and investigate them, and this doesn't have to be very complex,
but what we need to understand is that, you know,
you're going to see error in an incident, or even a near miss,
bit like breathing oxygen.
Therefore, we want to really ask ourselves is why did the error occur?
What were the conditions that led to that error?
And generally when we think about those conditions,
they generally have existed already for some time in the workplace.
It might be design. It might be poor training.
It might be ambiguous procedures.
So...our approach should be to fix those things primarily
to ensure that other people aren't committing the same errors.
Team training, crew resource management,
maintenance resource management, safety management systems,
these are all good things, but they occur at the organisational level,
and they occur at the team level.
And the missing piece of the puzzle is personal accountability
and people that can control the errors that they make.
You don't necessarily have to trap errors
to make a good, effective human factors program.
What if you had a lot less errors to trap?
So it's vitally important we take this opportunity
to reduce error at the source.
You know, I kind of joke that says, threat and error management programs
have three fundamental principles.
The first one is reduce avoidable errors.
The second one is trap the errors that occur
before they result in a consequence.
And the third principle is reduce the consequences
of the errors that occur.
But we don't start with number one.
It reminds me of a Steve Martin shtick I once saw where he said...
..he wrote a book called
'How to Make a Million Dollars and Not Pay Any Taxes'.
And the first page of the book said, "First, get a million dollars."
You know, when we say "Just reduce avoidable errors"
and we don't provide that opportunity
for people to know how to do that,
we are making a huge mistake.
We're making an assumption,
and we know what assumption does in aviation,
that people... that their technical training,
how to do something right is also training them how not to do it wrong.
That is a totally flawed assumption, and it's a reason...
We've buried way too many pilots as a result of thinking
that error control is something people understand intuitively.
It's not. It's a learned skill, but it is currently not a taught skill.
When we talk about error management in an organisation,
people can start to get confused or even panic.
What they don't realise is...
Aviation maintenance has been using error management for years.
Everything they do with our maintenance processes and procedures
is error management.
So when we carry out inspections, we're trying to capture error.
When we use approved procedures and data,
that lets us carry out a task with the least chance of an error,
if we follow them properly, and when we authorise people,
what we're doing is we're making sure we're fitting the person to the task.
So we've got someone, if we authorise them properly,
who's trained, competent and confident to carry that task out.
So it's nothing new.
It is really helping to define what maintenance tries to do
through all of our processes and procedures,
and by doing that, we let people really understand
why we're doing it so they can make it more effective.
And HF should help to define and...
..and train people to use error management
as effectively as possible.