The Quality Colloquium August 19, 2008

Patient Safety Lessons from Other Industries

Jim BoueyBoeing Commercial AircraftRetired

The Human Factor

Commercial AviationCommercial Aviation Long History of Safety Performance Long History of Safety Performance

ImprovementsImprovements

North American

accident rate(accidents per million departures)

0

10

20

30

40

50

5960 62 64 66 68 70 72 74 76 78 80 82 84 86 88 90 92 94 96 98 00 02 0405

Year

Primary Causes of Hull Losses

From Boeing Statistical Summary of Commercial Jet Airplane Accidents – Worldwide Operations

1960s

flight crewairplaneweathermaintenancemiscellaneousairport, ATC

1996-2005

4.933 0.749Hull Loss Rate (x10-6 Flights)

How the mind likes to workHow the mind likes to work

Short cuts!

Short-Cut TrapShort-Cut Trap

Federal Aviation RegulationsFederal Aviation Regulations Title 14: Aeronautics and SpaceTitle 14: Aeronautics and Space

PART 25—AIRWORTHINESS STANDARDS: TRANSPORT CATEGORY AIRPLANEPART 25—AIRWORTHINESS STANDARDS: TRANSPORT CATEGORY AIRPLANESS Subpart D—Design and ConstructionSubpart D—Design and Construction Personnel and Cargo AccommodationsPersonnel and Cargo Accommodations

§ 25.781   Cockpit control knob shape.§ 25.781   Cockpit control knob shape. Cockpit control knobs must conform to the general shapes (but Cockpit control knobs must conform to the general shapes (but not necessarily the exact sizes or specific proportions) in the not necessarily the exact sizes or specific proportions) in the following figure:following figure:

Commercial AviationCommercial AviationOverarching Safety PhilosophyOverarching Safety Philosophy

FAIL-SAFEFAIL-SAFE

Assume that no matter what you do, Assume that no matter what you do, something or someone will fail.something or someone will fail.

Now, what do you have to do to make Now, what do you have to do to make sure that everyone stays safe?sure that everyone stays safe?

Fail-Safe DesignsFail-Safe Designs

Safety Precedence in DesignSafety Precedence in Design Eliminate the hazardEliminate the hazard If it cannot be eliminated, minimize it If it cannot be eliminated, minimize it

through design selectionthrough design selection If it cannot be eliminated or minimized, If it cannot be eliminated or minimized,

control it through the use of protective control it through the use of protective safety design features or devicessafety design features or devices

When neither design not safety devices When neither design not safety devices can effectively eliminate, minimize or can effectively eliminate, minimize or control a hazard, detect the condition and control a hazard, detect the condition and provide a warningprovide a warning

Resolution of hazards by the above methods can Resolution of hazards by the above methods can be supplemented with appropriate procedures be supplemented with appropriate procedures and training, but these are and training, but these are notnot to be the sole to be the sole means of hazard resolutionmeans of hazard resolution

In commercial aviation, everyone In commercial aviation, everyone involved believes that safety is their involved believes that safety is their job #1 and improvements have come job #1 and improvements have come about because everyone knows that about because everyone knows that the pilot is the last person you want the pilot is the last person you want to depend on for a safe flight.to depend on for a safe flight.