common sense in a world of regulations a presentation at the wamea symposium “generations”
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Common Sense in a World of Regulations A Presentation at the WAMEA Symposium “Generations” Jock McTavish - 3 Apr 2008. Common Sense. What is Common Sense? Safety – our current status. The Paradox of Near Perfection. Regulations – examples of Common Sense. - PowerPoint PPT PresentationTRANSCRIPT
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Common Sense in a World of Regulations
A Presentation at the WAMEA Symposium
“Generations”
Jock McTavish - 3 Apr 2008
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Common Sense
1. What is Common Sense?2. Safety – our current status.3. The Paradox of Near Perfection.4. Regulations – examples of Common Sense.5. The Generations – whence we’ve come.
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What is Common Sense?
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Where is Hal?(2001 Space Odyssey)
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I’m sorry Dave, I can’t let you do that.
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Common Sense
• Some think Common Sense an untrustworthy instinct.
• Some think Common Sense is sufficient for decision.
• Others grow their Common Sense by their experience and training.
• I propose Common Sense is the foundation of “Standard Practice”.
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Standard Practice
• Initial education.– Awareness of References.– Hands on exposure to industry standards.– Attitude – the culture of aviation.– No-Fault – the openness to inspection.
• Continued Training– Real Experience.– Accountability - Records and Logs.– Certification Responsibility
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Common Sense Quotes
“Common sense in an uncommon degree is what the world calls wisdom.”
…Samuel Taylor Coleridge
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Common Sense Quotes
“Common Sense is that which judges the things given to it by other senses.”
... Leonardo da Vinci
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Common Sense Quotes
“Nothing is more fairly distributed than common sense: no one thinks he needs more of it than he already has”
... Rene Descartes
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Common Sense Quotes
“Common sense is genius dressed in its working clothes.”
... Ralph Waldo Emerson
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Common Sense Quotes
“The three great essentials to achieve anything worth while are, first, hard work; second, stick-to-itiveness; third, common sense.”
... Thomas Alva Edison
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Common Sense Quotes “If you are looking for perfect safety,
you will do well to sit on a fence and watch the birds; but if you really wish to learn, you must mount a machine and become acquainted with its tricks by actual trial.”
…Wilbur Wright
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Common Sense Quotes “I learned that danger is relative, and
that inexperience can be a magnifying glass.”
… Charles A. Lindbergh
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Common Sense Quotes “Flying is inherently dangerous. We
like to gloss that over with clever rhetoric and comforting statistics, but these facts remain: gravity is constant and powerful, and speed kills. In combination, they are particularly destructive.”
… Dan Manningham, BCA Mag.
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Common Sense Quotes “Of the major incentives to improve
safety, by far the most compelling is that of economics. The moral incentive, which is most evident following an accident, is more intense but is relatively short lived.”
… Jerome Lederer
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Common Sense Quotes “There is an environment of people
unwilling to admit their mistakes and move ahead. The attitude toward rule-making has been so curtailed that common sense recommendations now take years and years.”
… James Hall, NTSB, 1996.
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Common Sense Quotes “Complacency or a false sense of
security should not be allowed to develop as a result of long periods without an accident or serious incident. An organization with a good safety record is not necessarily a safe organization.”
…ICAO
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Common Sense Quotes
“Safety at sea is the business of all hands. It is difficult to talk about safety without repeating trite phrases everyone has heard many times.”
… Merchant Seaman's Manual
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Common Sense Quotes “Learning should be fun. If you don't
have fun in aviation then you don't learn, and when learning stops, you die.”
… Pete Campbell, FAA
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Safety-
Our Current Status
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3-Country - Civil Aviation - Airline Operations
Total Accident Rates Per 100,000 Flight Hours: 2000 to 2004
0.75
0.310.41
0.260.25
0.13
0.44
0.230.26
0.52
0.32
0.00
0.250.16
0.13
0.000.100.200.300.400.500.600.700.80
2000 2001 2002 2003 2004Canada United States Mexico
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3-Country - Civil Aviation - Airline Operations
Total Fatality Rates Per 100,000 Flight Hours: 2000 to 2004
0.17
0.50
3
0
2.99
00 0 0
0 0.130 0 0.01
00.00
0.50
1.00
1.50
2.00
2.50
3.00
2000 2001 2002 2003 2004Canada United States Mexico
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3-Country - Civil Aviation - General AviationTotal Accident Rates
Per 100,000 Flight Hours: 2000 to 200414.32
6.317.70
13.77
6.295.90
12.42
6.57
5.90
13.63
6.19
4.80
10.78
5.595.70
0.00
2.00
4.00
6.00
8.00
10.00
12.00
14.00
16.00
2000 2001 2002 2003 2004
Canada United States Mexico
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3-Country - Civil Aviation - General AviationTotal Fatal Accident Rates
Per 100,000 Flight Hours: 2000 to 2004
1.51
1.17
2.00
1.52
1.181.10
1.251.32
1.10
1.61
1.281.30
0.971.09
1.80
0.000.200.400.600.801.001.201.401.601.802.00
2000 2001 2002 2003 2004
Canada United States Mexico
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Where Next?-
The Paradoxof
Near Perfection
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Where Next? The Paradoxes of Almost Totally Safe
Transportation Systems– Only one disastrous event in 1,000,000 events– Don’t need more of same, we need new ideas.– Existing systems have diminishing returns.– New complexities induce new errors.– Human Error now the principle cause of accidents.– We must better understand ourselves.– Errors are to be understood, not fought.
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Where Next? Perfect Safety is being approached
– Dangerous Activity - 1 disaster in 1000 events.• Mountain climbing
– Regulated Activity - 1 disaster in 100,000 events.• Driving, Charter Flights, Chemical Industry
– Ultra-safe Activity - 1 disaster in 1,000,000 events.• Airline, Railroad, Nuclear Industry
– Ideal Activity – 1 disaster in 10,000,000 events.• Nothing has met this yet.
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Where Next? Characteristics of Present Situation
– Management Methods are Aging.– Over-Regulated and Highly Un-adaptive.– Systems nearing end of life-cycle.– Ultra-Safe System accidents are unlike the
accidents of Safe Systems• Unpredictable• Reporting is ineffective
– Situation political not scientific.• Research on Human Factors is not being applied.• Error Control is part of human behaviour.
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Where Next? Management of Human Error.• Experience Makes the Difference• We learn from our mistakes.• Human error is not constant but dynamic.• Safety must become proactive.• Safety Management Systems are needed.• New goals, new tracking needed.
“Experience is how we avoid making mistakes. Making mistakes is how we gain experience!”
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Human Error and Experience … Duffey and Saull
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Where Next? Human Contribution to Accidents – a new view• Identify the human factors that contributed to
the error.• Determine how it made sense at the time.• Do not judge the error makers.• Understand how the error was made.
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Regulations-
Examples of Common Sense
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571.02 (1) Subject to subsection (2), a person who performs maintenance or elementary work on an aeronautical product shall use the most recent methods, techniques, practices, parts, materials, tools, equipment and test apparatuses that are
(a) specified for the aeronautical product in the most recent maintenance manual or instructions for continued airworthiness developed by the manufacturer of that aeronautical product;
(b) equivalent to those specified by the manufacturer of that aeronautical product in the most recent maintenance manual or instructions for continued airworthiness; or
(c) in accordance with recognized industry practices at the time the maintenance or elementary work is performed.
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571.10 Maintenance Release 2) Maintenance Release Record Keeping(a) A maintenance release applies only to the
particular maintenance task or tasks to which it relates. Therefore:
(i) it is acceptable to sign a maintenance release in respect of a single task or group of tasks, even if other work is outstanding on the aircraft, provided that the wording of the entry leaves no doubt as to the scope of work being certified; and
(ii) it is the responsibility of the person signing a maintenance release to ensure that the technical record is correct in respect of the status of any outstanding task.
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From “About Aviation Enforcement”
“Transport Canada’s aviation enforcement policy recognizes the fact that “voluntary compliance” with the regulations is the most progressive and effective approach to achieving aviation safety. It is assumed that most people are rational, responsible, law abiding citizens in the own right and self-interest, and share an interest and commitment to the aviation community. However, for those individuals in the aviation community who are less motivated by such factors as common sense, personal and civil responsibility, pride and professionalism, and especially safety, they will become the focus for enforcement actions.”
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COMMON SENSE
+REGULATIONS
=STANDARD PRACTICE
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The Generations-
Whence We’ve Come
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From Whence We’ve Come
• I’ve been fortunate to inherit the libraries of two men that helped make aviation what it is in Western Canada.
• Stan Green founded aviation training at SAIT, and Gerry Stauffer was one of his best students.
• Both were men of practiced common sense.• Here are some photos and some common
sense words from their collections.
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Stan Green
His 1954 replica Bleriot(that later flew the channel)
and his SAIT studentsthat built it.
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Gerry Stauffer
His “best airplane” (Navion)
and “best engine” (300 hp Lycoming)
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Old Navion Tech Log - 1
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Old Navion Tech Log - 2
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Old Navion Tech Log - 0
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Old Navion Tech Log - 0
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Austin Airways – Changing an Anson Engine on the ramp. 1950
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Austin Airways – DC3 on Baffin Island
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Austin Airways – Canso
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Austin Airways – Summer & Winter
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Austin Airways – Norseman and Bombardier at Moose Factory
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Austin Airways – Norseman water-skiing
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Austin Airways – Norseman at Sugluk
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The Aviation Pocketbook - 1917
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The Air Ministry
Handbook of Strength
Calculations
1930
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The Wright Flyer – Wing warping and steering mechanism
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The Wright Aerodynamic Research Bicycle
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The Wright Aerodynamic Research Lab
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The Wright Flyer Engine
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Calgary Airport - 1941
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A landing by Captain Fred McCall - 1919
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* Max Ward *
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* Max Ward *
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Credits 11. The Paradoxes of almost totally safe transportation systems. R
Amalberti. Safety Science. 2001.2. The Probability and Management of Human Error. RB Duffey JW
Saull. 12th ICONE. 2004.3. Reconstructing Human Contributions to Accidents. S Dekker. Safety
Research. 2002.4. Human factors analysis of Australian aviation accidents and
comparison with the United States. ATSB Transport Safety Investigation Report B2004/0321
5. CASA Safety Statistics Presentation Brisbane GA Summit. Sept 06.6. Human Error and Commercial Aviation Accidents: A Comprehensive,
Fine-Grained Analysis Using HFACS. DOT/FAA/AM-06/18 |July06
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Credits 21. Transportation Safety and Security 2002. TC. Stats Tables.2. Bureau of Transportation Statistics Activity Data for US Airlines.
1995-2000, A-Z 3. The Pace Quickens – aviation sharpens its focus on SMS. David
Olson, Wings Magazine July/August 20064. Aviation Safety: Human Factors, System Engineering, Flight
Operations ... By Hans M. Soekkha, Brill 1997 . Google Books.5. The Evolution of Policy and Regulation in the First Century of
American Aviation. El-Kasaby, O’Neil, Tarry. 2007. Ch 18 of Handbook of Transportation Policy and Administration. Google Books.
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Credits 31. Google Talk Computers and Common Sense