The Human Factor: A Different Approach to Accidents

Why smart pilots do dumb things.

Human Factor Different Approach
Human Factor Different ApproachFlying

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

strategies.

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.

So while the aviation industry and the NTSB should continue looking for systemic weaknesses that can be strengthened through technological or procedural improvements, I agree with Robert that it is time we take a different approach to the human factor accidents that result from poor judgment and decision making. The simple fact is that the same traps of human nature can lead to:

• A pilot flying low over a friend’s house.

• The captain of a large ship passing close to an island at high speed.

• The engineer of a train going twice the allowed speed.

• Two teenagers racing each other down a city street.

The people involved in these acts did not need training on the dangers of flying low, of passing close to an island, of going too fast or of racing on city streets. All of these people were well aware that they were taking risks and breaking the rules. What they needed was an understanding of the traps of human nature that can lead us to break the rules and take unnecessary risks that can result in devastating consequences, along with simple, practical tools they could have used to avoid or deal with those traps.

The challenge is how to provide this training to general aviation pilots. The material in our Preventing Human Error seminar was inspired by the cockpit resource management training I was involved with in the 1980s. When I first contacted Mac McClellan 21 years ago, I was hoping to write one article about applying CRM principles to general aviation. Instead, he surprised me by asking if I would like to write a monthly article. Over the past 21 years, I have covered many of the traps and tools of error prevention in my articles in Flying. However, this is not an efficient way to provide this information, as probably very few pilots have carefully studied and learned each trap and tool and many recently licensed pilots were not even born when I started writing these Human Factor articles. (Yes — that does make me feel old!)

There is now another approach to providing error-prevention training to the GA community that should be much more effective. At the request of one of our corporate clients, I developed a three-hour e-learning error-prevention course titled "Why Smart People Do Dumb Things and How to Avoid the Same Mistakes." This course presents the traps and tools of error prevention in six 30-minute modules that can be completed at the convenience of the person taking the course. I have also developed a new website to make the e-learning error-prevention course available to the general public. The website provides a searchable library of error-prevention articles related to many different fields, including all the articles I have written for Flying. It is my hope that this website will develop into a community of concerned individuals and organizations who will share stories about their own successes and mistakes, allowing everyone to learn from each other and encourage each other in our efforts to reduce errors and operate more effectively in everything we do.

In order to focus my full attention on reducing mistakes, incidents and accidents through the website and the e-learning error prevention course, this will be my last article in Flying. When I contacted Mac about writing an article for Flying, I never imagined I would write 254 of them over the next 21 years. Writing for Flying has been an amazing experience. I especially appreciate the positive feedback I have received from many readers and have enjoyed getting to know some of you through correspondence and occasionally in person. I hope to continue that relationship through the website and e-learning course and plan to work with aviation organizations to make this training available to as wide a population as possible in the hope that it can contribute to a significant decrease in aviation accidents.

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