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Why do we experience Human Error?
By: M. Dreikorn
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Only
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Now this is a big ooooops!
Pilot giving daughter flight lesson strayed into
Bush's airspace
A pilot giving his daughter a flight
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01 July 2007
AS&D
Quality, Safety and Regulatory
Newsletter
Your
source for professional connection
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The objective of this newsletter is to
provide perspective to the Aviation, Space, and Defense
(AS&D) industry on current and relevant quality,
safety, and regulatory matters in our
industry.
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Why do we
experience Human Error?
The
concept of human error has been studied throughout the
history of mankind and there are many varying theories
and opinions to why humans make mistakes. So
here's mine.
Let's
keep the focus of human error within the context of the
AS&D industry to make things a bit simpler. Within
the civil side of the AS&D industry there is an
abundance of regulation which prescribe minimum
performance standards of certificated persons and
organizations. Within the space and defense
segments of the industry, performance standards are
established through contract requirements. So,
it's safe to say that there are documented expectations
for the entire AS&D industry for performance - and
in general terms the expectations are safety and
airworthiness.
When
it comes to the certification of persons and
organizations there is always a review of
competency. Persons must complete various
examinations, including the demonstration of
capability. Organizations are subjected to audits
and continued oversight. Nevertheless, we
experience events where things go wrong. All too
frequently, human error is to blame. But
why?
To
find out, you should do just that -ask why.
And keep asking why until you get to the end of the
man-made condition. It's people who enact
processes, and organizations are a structured social
system of people. By asking why, you peel back the
layers of symptoms and get ever closer to the root of
the cause.
If diligence
prevails, you will frequently find that the human error
is based on people not doing what they should be doing
in the first place. And this includes leadership
at all levels of business and government. Systems
are designed to perform in a specific fashion and when
humans decide to do otherwise the system
fails.
So,
my opinion as it relates to human error is that it is
always a question of personal warranty. Personal
warranty is our individual commitment to doing the right
thing every time. Key to this is establishing an
environment (aka, culture) in which people are
encouraged to do the right thing. This leads us to
commitment.
Key
to creating a culture that is committed to doing the
right thing every time (e.g., quality culture) is
ensuring people are committed. This is an
important point. Compliance does not equal
commitment.
In
order to be committed to something, people must be able
to internalize the importance of an action or role -
this will lead to believing in what they are
doing. Once a person understands and believes in
something, they can become committed. Without
understanding, at best you might find temporary
compliance.
Next
time blame is given to a person, ask what went wrong and
why. Here are a few things to consider:
-
Was
the person trained on the process?
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Did
the training address the importance of a
process?
-
Does
leadership walk the talk?
-
Are
organizational procedures adequate?
-
Are
resources adequately applied?
-
...
and the list goes on.
To
solve the issues of human error we need to consider the
concept of personal warranty at all levels of the
organization. And, organizations should strive for
a committed organization, not just one that is
compliant.
Written by: M.J.
Dreikorn
The IPL Group, LLC
|
 The
following are news links relevant to quality, safety,
and regulatory matters in the AS&D industry.
These are only events which have been reported in the
past two weeks. If you would like to see something
else or more, please let us know. Remember, part
of being a professional is being relevant. It's
your responsibility to stay informed and to provide
value.
 Space
Shuttle Atlantis safely returned to Earth when it landed
at Edwards on June 22, which concluded STS-117's
assembly mission to the International Space Station.
Graying Workforce - A looming threat for US
aerospace industry (USA)
The US
aerospace industry is now encountering some serious
problems in the form of an increasingly graying
workforce.
Concern that the UK aerospace sector is
slowly bleeding skills and experience has led the UK's
Midlands Aerospace Alliance (MAA) to develop a model for
collaboration.
A work force study issued by the Metro Denver
Economic Development Corp. has found the region's pool
of technically skilled workers is shrinking at a time
when the needs of the fastest-growing companies is
increasing demand.
The October chemical fire that forced the
evacuation of thousands of residents and gutted a
hazardous waste storage plant in suburban Apex may have
been minor if unspent oxygen generators weren't
mistakenly stored there.
European officials may look to standardise
the distance between aircraft seats, or pitch, over
fears about the speed at which passengers can leave
aircraft in an emergency.
FAA
confirms third-class medicals here to stay
(USA)
The FAA confirmed this week that it is not
interested in eliminating the requirement that private
pilots must hold a third-class medical certificate.
New SAE international
aerospace document provides standard for wire harness
marking (USA)
SAE International's new aerospace standard
-- AS5649: Wire and Cable Marking Process, UV Laser --
serves as a process standard for all organizations
involved in wire harness production requiring laser wire
marking.
NTSB wants
more oversight of substance-dependent pilots
(USA)
 The FAA
needs to do more to ensure that pilots dependent on
substances such as drugs and alcohol are properly
evaluated by aviation medical examiners.
The National Transportation Safety Board
is investigating an incident in Boston that occurred on
June 20, in which an American Eagle Embraer ERJ-135
regional jet briefly touched down on the runway without
the landing gear extended before initiating a go-around
and completing a second landing
attempt.
The FAA announced Friday it has
categorized the May 26 incident in which a Republic
Airlines pilot had to take off to avoid colliding with a
SkyWest Airlines plane on the runway as a level A
incursion. On a scale of incursions from A to D, the
most serious is A.
The House Transportation and
Infrastructure Committee added language to the Federal
Aviation Administration Reauthorization Act that would
require the federal government to make so-called
inerting systems standard equipment on commercial
airlines.
Senate Transportation Committee member
Sen. Claire McCaskill (D-Miss.) still has reservations
about non-certificated foreign repair station safety and
security following a hearing last week, and is awaiting
a response from FAA to a letter she sent expressing
those concerns before drafting amendments to the FAA
reauthorization bill.
"Glass cockpit" aircraft deliver multiple
safety benefits to general aviation (GA) pilots and have
fueled industry growth, but pilot training must still
evolve to address the safety challenges posed by
Technologically Advanced Aircraft (TAA), according to a
soon-to-be-released study of accident data by the AOPA
Air Safety Foundation.
The
European Commission has received the unanimous opinion
of its Air Safety Committee on the fourth update of the
Community list of airlines banned in the European Union.
Climate change is becoming a driving force
in the long-term planning of the next generation of
commercial airliners. The issue of what should be done
about greenhouse gas emissions created by airliners has
split the aviation industry into several camps.
The safety manager of the airline at the
centre of one of Australia's worst aviation disasters
has told an inquest it was not his responsibility to
audit, test or inspect anybody.
ICAO
conducts safety Oversight State Audit of UAE
(UAE)
The International Civil Aviation Organization
(ICAO), a Montreal based autonomous arm of the United
Nations, has recently completed its Oversight State
audit of UAE, which is represented by the General
Civil Aviation Authority (GCAA), the federal aviation
regulatory body.
Exhaustion
among pilots is threatening the safety of air travel, a
BBC investigation has shown.
In a new round of safety recommendations
announced Monday, the National Transportation Safety
Board says the FAA should keep a close watch for
possible medical and criminal issues with pilots as they
undergo aeromedical evaluations.
 After a decade of neglect
following the end of the Cold War, Russian arms-makers
and Western aerospace officials told Newsmax that
Russian aerospace is on an upwards
trajectory.
The Federal
Aviation Administration (FAA) announced Guatemala's
aviation industry now complies with international safety
standards set by the International Civil Aviation
Organization (ICAO), following a reassessment of the
country's civil aviation authority on April 16,
2007.
Man
sentenced for falsifying bomb parts test
(USA)
The sales manager of a now-defunct Florida
company has been sentenced to 15 years in federal prison
for falsifying test records for metal that was to be
made into nuclear missile components.
AAR announced that for the third consecutive
year the Company was recognized bythe Federal Aviation
Administration (FAA) for excellence in training and has
received a Diamond Certificate of Excellence at each of
its 12 FAA-certified repair stations.
Aviation fastener
supply chain is tight
(USA)
Supply of aerospace fasteners already is tight
and will get tighter, forecasts analyst David Lipschitz
at Merrill Lynch in New York, citing interviews with
Alcoa management, who says sales of aerospace fasteners
could grow by as much as 30% through 2009.
 Attorneys are asking the Federal
Aviation Administration to overturn a recent decision by
the Lafayette Airport Commission to replace the
long-time Lafayette Regional Airport's fixed-based
operator.
Indian
civil aviation minister, Praful Patel and Mary Peters,
the secretary of the US Dept. of Transportation signed a
memorandum of understanding (MoU) last Friday to set up
an Aviation Cooperation Program, hereto the
ACP.
The Indonesian Department of
Transportation has issued its the results of its
scheduled re-audit of safety and air worthiness for all
commercial air operators in Indonesia, following an
initial audit in March 2007 which failed to see even a
single domestic air carrier receive a "clean pass"
Category I rating.
CAA
revokes licences from 4 Bulgarian airlines
(Bulgaria)
The Civil Aviation Administration (CAA) in
Sofia revoked the operator licences of Air Sofia, Bright
Aviation Services, Scorpion Air and Vega Airlines after
safety deficiencies were confirmed in services provided
by the four Bulgarian carriers, the Bulgarian Transport
Ministry was cited as saying by Sofia News Agency.
Africa's ability to catch up with the rest
of the world in attaining ceaseless air navigation has
been linked to the urgent need to modernise all elements
of Aeronautical Information Services in the
continent.
Namibia has been chosen as the continental
headquarters for the African Civil Aviation Authority
(AFRO-CAA), an organisation that will deal with aviation
safety matters in Africa, which is said to have one of
the unsafest skies in the world.
Prime Minister Nahas
Angula inaugurated the Africa Civil Aviation
Authority (AFRO-CAA), a continental body that will
standardize and oversee licensing, training and
inspection of the aviation sector in
Africa. |
|
This newsletter is brought to you by The IPL Group,
LLC. We hope you find the content informative and
useful. If there are other features of this
newsletter that you would like to see, let us
know. The power of our industry is not solely
driven by mechanical means, it is our intellectual base
which brings innovation and strength.
Sincerely,
Michael
Dreikorn
President The IPL
Group, LLC
| | |
Cyber Defense Systems, Inc., a
designer and developer of next generation unmanned
aerial systems (UASs), announced that the company
has received an Experimental Airworthiness Certificate
from the Federal Aviation Administration, the first for
small hand-launched UASs under 100lbs in the United
States, allowing the CyberBug™ Unmanned Aerial System to
fly in the National Airspace System.
