you‟re - pacdeff b777 all aircraft hull loss / million departures 59 61 63 65 67 69 71 73 75 77 79...
TRANSCRIPT
How long will this go for?
You‟re
probably
thinking?
Why is he here
talking to us
about this stuff?
Threat & Error Management
TRAP ERROR
MINIMISE ERROR
MITIGATE CONSEQUENCES
OF ERROR
Safety Morale Efficiency
POOR LIGHTING
POOR EQUIPMENT
INSUFFICIENT SUPERVISION
INDIVIDUAL/TEAM PERFORMANCE/ CAPABILITIES
NIGHT SHIFT DAY SHIFT NEW TEAM - HANDOVER
POOR DOCUMENTATION
TIME PRESSURE
RUSHED HANDOVER
SITUATIONAL DEMANDS
Capability and Workload (Errors/Accident Zone Model)
POOR COMMUNICATION
STRESS
INEXPERIENCE
FATIGUE EFFECTS
SAFETY MARGIN
MAXIMISE
DANGER AREA / INCIDENT ZONE
The Reason Model: Organisational Error Chain
Organisational and
System Factors
Latent Conditions
Absent or Failed
Defences
Limited window
of opportunity
ACCIDENT /
SERIOUS
INCIDENT Active
Failures
Task and Environmental
Conditions
Individual and Team Actions
Accident Rate By Aircraft Generation
0
1
2
3
4
5
6
7
8
9
10
1st generation B707 DC8
2nd generation B727 B737-100/200 B747 DC9 DC10 A300B4
3rd generation MD80 A300-600/ A310 MD11 A319/A320/A321 MD90 A330/A340 B737-300/400/500 B757/B767 B777
All aircraft
Hull loss
/ million
departures
59 61 63 65 67 69 71 73 75 77 79 81 83 85 87 89 91 93 95
Year
Diminishing Returns
• The low
hanging fruit
has largely
been picked
• Well past
80/20 point.
source: http://recipeforlowhangingfruit.com/
Empowering Human
Performance Where do we go from here?
THE BLUE THREAT Acknowledgements to Dr Tony Kern
Convergent Performance
Human error is the thief of human
happiness and the slayer of dreams,
careers, potential, and all too frequently
– life itself.
Viewing it as anything less hostile is to
willfully expose your throat to the knife.
First words of Blue Threat (Kern, 2010)
Don‟t Minimum Standards keep us safe?
12
Who Achieves The REAL
Standards?
Regulator
Organisation
Individual
Accident
Incident
Violation
Hazard
Fatality
Safety
Effectiveness
Efficiency
Precision
Perfection
“Good Enough”
The crushing grip of
mediocrity impacted by
so-called “random
human error” and
noncompliance
Performance Evolution Ladder – Copyright 1998 T. Kern
True safety, quality and
sustainability live here
Survival
Accident
Incident
Violation
Hazard
Fatality
Safety
Effectiveness
Efficiency
Precision
Survival
Perfection
“Good Enough?”
Performance Evolution Ladder – Copyright 1998 T. Kern
Accuracy without precision is
usually good enough to earn a
wage, but not always good
enough to survive
IT’S ALL ABOUT YOU!
Aircraft
Environment
Risk
Team
Self
Discipline Skill
Proficiency
Judgment
Pillars of
Knowledge
Bedrock
Principles
Cornerstone
Situational Awareness
Expertise in Airmanship
Capstone
Outcomes
Mission
Source. Redefining Airmanship, Kern. 1995.
THE PROFESSIONAL’S TEMPLE TONY KERN’S AIRMANSHIP MODEL AS INTERPRETED BY MICK ASPINALL
DISCIPLINE
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PROFICIENCY BED
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SITUATIONAL AWARENESS
BEST
DECISIONS CAP
STONE
OUTCOMES
THE PROFESSIONAL’S TEMPLE TONY KERN’S AIRMANSHIP MODEL AS INTERPRETED BY MICK ASPINALL
DISCIPLINE
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CAP
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BEST
DECISIONS
THE PROFESSIONAL’S TEMPLE TONY KERN’S AIRMANSHIP MODEL AS INTERPRETED BY MICK ASPINALL
DISCIPLINE
SKILL
PROFICIENCY BED
ROCKS SITUATIONAL AWARENESS
CAP
STONE
OUTCOMES
BEST
DECISIONS
THE PROFESSIONAL’S TEMPLE TONY KERN’S AIRMANSHIP MODEL AS INTERPRETED BY MICK ASPINALL
DISCIPLINE
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STONE
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BEST
DECISIONS
THE PROFESSIONAL’S TEMPLE TONY KERN’S AIRMANSHIP MODEL AS INTERPRETED BY MICK ASPINALL
DISCIPLINE
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BEST
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THE PROFESSIONAL’S TEMPLE TONY KERN’S AIRMANSHIP MODEL AS INTERPRETED BY MICK ASPINALL
DISCIPLINE
SKILL
PROFICIENCY BED
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THE PROFESSIONAL’S TEMPLE TONY KERN’S AIRMANSHIP MODEL AS INTERPRETED BY MICK ASPINALL
DISCIPLINE
SKILL
PROFICIENCY BED
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THE PROFESSIONAL’S TEMPLE TONY KERN’S AIRMANSHIP MODEL AS INTERPRETED BY MICK ASPINALL
DISCIPLINE
SKILL
PROFICIENCY BED
ROCKS
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THE PROFESSIONAL’S TEMPLE TONY KERN’S AIRMANSHIP MODEL AS INTERPRETED BY MICK ASPINALL
DISCIPLINE
SKILL
PROFICIENCY BED
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THE PROFESSIONAL’S TEMPLE TONY KERN’S AIRMANSHIP MODEL AS INTERPRETED BY MICK ASPINALL
DISCIPLINE
SKILL
PROFICIENCY BED
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THE PROFESSIONAL’S TEMPLE TONY KERN’S AIRMANSHIP MODEL AS INTERPRETED BY MICK ASPINALL
DISCIPLINE
SKILL
PROFICIENCY BED
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SITUATIONAL AWARENESS
CAP
STONE
OUTCOMES
BEST
DECISIONS
Normalisation of Excellence
“I really had this obsession to keep getting better. I got hooked on the improvement, and the gains that can be made, and the satisfaction that comes from it.”
Danica Patrick, on how she became a world class Indy car racer by age 23
Individual improvement trumps organisational fixes!
Procedures
Planning, Checklists, etc.
“Key knowledge is in the work”
Person
Self Awareness, Situation
Awareness, Judgement
“Key knowledge is in the person”
Completely
Routine Totally
Unexpected
Attention
Distraction
Information Overload
Apathy
Complacency
Boredom
Span of Control
Stress Induced Error
Noncompliance
Pacing
Panic
Mastery Across Every Level of Challenge
Adapted from Jensen, Csikszentmihali, Reason and Kern
Expert’s
Curse
Procedures
Planning, Checklists, etc.
“Key Knowledge is in the Work”
Person
Self Awareness, Situation
Awareness, Judgment “Key Knowledge is in the Person”
Completely
Routine Totally
Unexpected
Attention
Distraction
Information Overload
Apathy
Complacency
Boredom
Span of Control
Stress Induced Error
Noncompliance Pacing
Panic
Where is the real risk?
Adapted from Jensen, Csikszentmihali, Reason and Kern
Risk = severity X exposure
It‟s the routine things that are likely
to cause us the most trouble………
A Different Perspective
Fighting fit:
Bright spots & fighter pilots
• Trust / Teamwork / Discipline
• Discipline
– Routine (Mission cycle)
• Dedication / Tenacity / Perfection
– Highly Developed Foundations
• SOP‟s / Training Standards / Mental models
• Precise & highly error resistant system
WGCDR Ben Cook ADF DDAAFS, Aviation Safety Spotlight 2/11
MISSION CYCLE
Plan (Meticulous / Detail)
Brief (Thorough)
Execute
Debrief
DEBRIEFING • Focussed on
growth
• Lens of SA
• Success breeds
success
• Hooked on
improvement
• Empowerment.
Amateurs work
at getting it
right.
Professionals
work until they
can't get it
wrong.
Dr Rob Forsterlee Nov 2011
37 Squadron
• Mentoring
–Self promoting
–Self regulating
• Self Awareness
–Who you are?…SDI
• Professional Aviator
• Empower the individual.
Regulation
Government
Equipment Manual
OEMs
Standard Operating Procedures
Organisation
Department
Safety Management System
Self-Discipline
Individual
Without Personal Professional
DISCIPLINE,
Safety
Management Systems
Disintegrate from Within
Copyright Kern, Ryan and Agostino, 2005
Mature Self Assessment
Can I objectively see and accept responsibility
for my weaknesses and mistakes?
What don‟t I know that I need to?
What skills don‟t I have that I need?
How do I learn from my mistakes and make
less / „better‟ mistakes tomorrow?.
THE PROFESSIONAL’S TEMPLE TONY KERN’S AIRMANSHIP MODEL AS INTERPRETED BY MICK ASPINALL
DISCIPLINE
SKILL
PROFICIENCY BED
ROCKS
T
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SITUATIONAL AWARENESS
CAP
STONE
OUTCOMES
BEST
DECISIONS
Empowering Human
Performance It‟s time to take another look at the
individual with some new ideas.
Empower them and make the accountable!.
Acknowledgements
• Dr Tony Kern
Blue Threat 2010
• Chip & Dan Heath – Switch
„How to Change When Change is Hard‟
• WGCDR Ben Cook - ADF DDAAFS HSP
Fighting Fit - „Bright spots & fighter pilots‟
Questions / Further Discussion?
