The Human Factor: A Different Approach to Accidents
There has been considerable consternation in the aviation media recently about the lack of progress in improving the general aviation accident rate. National Transportation Safety Board Chairman Deborah Hersman recently expressed her frustration that the general aviation accident rate in the United States has essentially plateaued at around 1,500 accidents every year, emphasizing that the board sees the same types of accidents over and over again and that many of the accidents are “entirely preventable.”
Hersman proposed three steps to reduce the GA accident rate:
1. Understand what is causing the accidents.
2. Identify preventive
3. Get the word out to the GA community.
While I have always admired Hersman’s insight into accidents, especially her emphasis on fatigue as a factor that is often ignored or understated, I don’t have much hope for any amazing new insights into what is causing GA accidents. As Hersman herself said, we are seeing the same kinds of accidents year after year, so the likelihood of coming up with any startling new information at this point is very small. In fact, my November 1999 article titled “Is General Aviation Safe?” stated that “many professionals involved in aviation training are very frustrated by our lack of success in making a dramatic impact on the accident and fatality rates,” so we haven’t made much progress over the past 14 years.
On the other hand, it may be possible to come up with some new preventive strategies for specific weaknesses in the system. For example, the focus on runway incursions has resulted in hardware fixes, such as the flashing yellow lights across the entrance to the active runway at major airports; procedural fixes, such as a change in how clearances are issued; and a major education program about the importance of avoiding incursions. Most of the successful fixes have been focused on this type of clearly defined problem that lends itself to hardware, procedural and educational improvements. There is, however, no silver bullet — that one significant change that will result in major improvements across the GA community.
Robert Goyer said in his December 2012 Going Direct column that many accidents in GA are the result of the vagaries of human nature, suggesting that it was time to try a different approach. It just so happens that I have been trying a different approach for the last 23 years. Shortly before I started writing for Flying in September 1992, I founded the Error Prevention Institute and began teaching our Preventing Human Error seminar. It is based on the very simple premise that nobody wants to make a mistake, but there are traps of human nature that lead to human factor mistakes, incidents and accidents. We call them traps because we typically are not aware of them when they are working. If we were, we wouldn’t do the stupid things we seem to do all too often.
While we will never be able to avoid all errors, I have found it is possible to teach people about these traps and to set warning alarms in their heads to go off whenever one or more of the traps are working. I also provide practical tools people can use to successfully avoid or deal with these traps. Because they are a function of human nature, these traps and tools are the same for everyone. Other than incorporating client-specific examples and case studies, I presented the same four-hour seminar to more than 100 organizations, including flight departments, fire and police departments, major aerospace corporations, hospitals, military units and even a large metropolitan parks and recreation department.
Of course the most important question is: Does it work? The answer has been overwhelmingly positive. In one typical case, a major aerospace corporation with 15,000 employees across the country experienced an 80-percent decrease in significant incidents and accidents during the first two years after they started requiring their employees to take error-prevention training. Fifteen years later, error prevention continues to be a foundation of their corporate culture. The statistical results are backed up by exciting stories of specific situations in which error prevention was credited with avoiding a serious incident or accident, as well as helping to achieve the best possible results. Employees tell us that the error-prevention training has also helped them to avoid mistakes and to be more effective in their personal lives.