Federal Aviation
Administration
Aviation Safety
Information
Processes:
Useful in Health
Care?
Presentation to: Pillsbury Winthrop
Shaw Pittman Health TechNet
Name: Christopher A. Hart
Date: October 17, 2008
Aviation Safety Information Processes Useful?
October 17, 2008
Federal Aviation
Administration
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Using Information
Proactively in Health Care?
• Can Aviation Help Health Care Use
Information Proactively to Reduce
Mishaps?
• The Context
• Challenges and Solutions
• Similarities and Differences
• Aviation Successes and Failures
• Improving Safety and Productivity, Too
• The Role of Leadership
Aviation Safety Information Processes Useful?
October 17, 2008
Federal Aviation
Administration
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The Context: Increasing Complexity
• More System
Interdependencies
– Large, complex,
interactive system
– Often tightly coupled
– Hi-tech components
– Continuous innovation
– Ongoing evolution
• Safety Issues More
Likely to Involve
Interactions Between
Parts of the System
Aviation Safety Information Processes Useful?
October 17, 2008
PEOPLE
MATERIALS
PROCEDURES
The System
SOFTWARE
TOOLS
EQUIPMENT
FACILITIES
Federal Aviation
Administration
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Effects of Increasing Complexity:
Human Error More Likely Because
• System More Likely to be Error Prone
• Operators More Likely to Encounter
Unanticipated Situations
• Operators More Likely to Encounter
Situations in Which “By the Book”
May Not Be Optimal (“workarounds”)
Aviation Safety Information Processes Useful?
October 17, 2008
Federal Aviation
Administration
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The Result:
Front-Line Staff Who Are
- Highly Trained
- Competent
- Experienced,
-Trying to Do the Right Thing, and
- Proud of Doing It Well
. . . Yet They Still Commit
Inadvertent
Human Errors
Aviation Safety Information Processes Useful?
October 17, 2008
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Administration
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When Things Go Wrong
How It Is Now . . .
How It Should Be . . .
You are highly trained
You are human
and
and
If you did as trained, you
would not make mistakes
Humans make mistakes
so
You weren’t careful
enough
so
You should be PUNISHED!
Aviation Safety Information Processes Useful?
October 17, 2008
so
Let’s also explore why the
system allowed, or failed to
accommodate, your mistake
and
Let’s IMPROVE THE SYSTEM!
Federal Aviation
Administration
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Fix the Person or the System?
Is the Person
Clumsy?
Or Is the
Problem . . .
The
Step???
Aviation Safety Information Processes Useful?
October 17, 2008
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Administration
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Enhance Understanding of
Person/System Interactions By:
- Collecting,
- Analyzing, and
- Sharing
Information
Aviation Safety Information Processes Useful?
October 17, 2008
Federal Aviation
Administration
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Major Source of Information:
Hands-On “Front-Line” Employees
“We Knew About
That Problem”
(and we also knew
it might hurt someone)
Aviation Safety Information Processes Useful?
October 17, 2008
Federal Aviation
Administration
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Objectives:
Make the System
(a) Less
Error Prone
and
(b) More
Error Tolerant
Aviation Safety Information Processes Useful?
October 17, 2008
Federal Aviation
Administration
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The Health Care Industry
To Err Is Human:
Building a Safer Health System
“The focus must shift from
blaming individuals for past
errors to a focus on preventing
future errors by designing safety
into the system.”
Institute of Medicine, Committee on Quality
of Health Care in America, 1999
Aviation Safety Information Processes Useful?
October 17, 2008
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Administration
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Health Care and Aviation Working
Together: A Significant Win-Win
• Similarities:
– Stigma Associated With Errors
– Many Interacting Components Working
Together
– Continuous Innovation, Rapid Introduction of
Complex New Technologies
– Usually Several Links in Mishap Chains
– Typical Response to Errors is Punishment
– Safety vs. Production and/or Throughput
– Litigation Potential
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Federal Aviation
Administration
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Win-Win (con’t)
• Differences – Aviation Has:
– Inherent Reporting Incentive (e.g., Pilots)
– Less Operational Variability; Thus, Activities
Generally More Prescriptive, Less Judgmental
– Less of a “Craftsman’s Guild” Environment
– Smaller, More Homogeneous “Teams”
– Workforce Consisting Mostly of Employees
– More Media, Political Attention – Public Fear of
Flying, Thus
 More robust data collection infrastructure
 Reporting, tracking, and trending of near misses
– Non-Adversarial Mishap Investigation (NTSB)
– Federal vs. State Law
Aviation Safety Information Processes Useful?
October 17, 2008
Federal Aviation
Administration
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Current System Data Flow
Most Data
Lost Forever
Currently Only a Minute
Portion of Data is
Collected and Analyzed
Aviation Safety Information Processes Useful?
October 17, 2008
Federal Aviation
Administration
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Heinrich Pyramid
ACCIDENTS
Mandatory
Reporting
INCIDENTS
Voluntary
Reporting
(NEAR MISSES)
UNREPORTED
OCCURRENCES
Aviation Safety Information Processes Useful?
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Federal Aviation
Administration
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Legal Concerns That Discourage
Voluntary Collection, Analysis, and Sharing
• Public Disclosure
• Job Sanctions
and/or Enforcement
• Criminal Sanctions
• Civil Litigation
Aviation Safety Information Processes Useful?
October 17, 2008
Federal Aviation
Administration
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Typical Cultural Barrier
Middle
Management
CEO
Front-Line
Employees
“Safety First”
“Production First”
“Please the Boss First…
THEN Consider Safety?”
Aviation Safety Information Processes Useful?
October 17, 2008
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Administration
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Next Challenge
Improved Analytical Tools
Legal/Cultural Issues
As we get over the first hurdle, we
must start working on the second . . .
Aviation Safety Information Processes Useful?
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Administration
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Information Overload
Aviation Safety Information Processes Useful?
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Administration
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From Data to Information
Tools and processes to convert
large quantities of data into useful information
Smart Decisions
Data Sources
Info from
front
line
staff
and
other
sources
• Identify
issues
USEFUL
DATA
• Prioritize
• Develop
INFORMATION solutions
• Evaluate
interventions
Analysts
Tools
Aviation Safety Information Processes Useful?
October 17, 2008
Processes
Federal Aviation
Administration
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Analytical Challenges
Analytical Tools Must Support Development
of -• Interventions that address SYSTEM
issues, not just OPERATOR issues, and
• System interventions that
– Are SYSTEM-WIDE in scope, and
– Focus more extensively on HUMAN
FACTORS
Aviation Safety Information Processes Useful?
October 17, 2008
Federal Aviation
Administration
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Aviation Success Story
65% Decrease in Commercial Aviation
Fatal Accident Rate Since 1997
largely because of
Proactive
Safety Information Programs
plus
System Think
P.S. Aviation was already considered VERY SAFE in 1997!!
Aviation Safety Information Processes Useful?
October 17, 2008
Federal Aviation
Administration
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Aviation “System Think” Success
Engage All Participants In The Process of
Identifying Problems and Developing Remedies
• Airlines
• Manufacturers
– With the systemwide effort
– With their own end users
• Air Traffic Organizations
• Labor
– Pilots
– Mechanics
– Air traffic controllers
• Regulator(s)
Aviation Safety Information Processes Useful?
October 17, 2008
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Administration
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Manufacturer “System Think” Success
Aircraft Manufacturers are Increasingly
Seeking Input, Throughout the Design
Process, From
(User Friendly)
- Pilots
- Mechanics
(Maintenance Friendly)
- Air Traffic Services
Aviation Safety Information Processes Useful?
October 17, 2008
(System Friendly)
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Administration
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Failure:
Inadequate “System Think”
• 1995 – Cali, Colombia
• Risk Factors
–
–
–
–
Night, Mountainous Terrain
Airport in Valley
No Ground Radar
Airborne Terrain Alerting
Limited to “Look-Down”
– Last Minute Change in Approach
 More rapid descent (throttles idle, spoilers deployed)
 Hurried reprogramming
• Navigation Radio Ambiguity
• Spoilers Do Not Retract With Power
Aviation Safety Information Processes Useful?
October 17, 2008
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Administration
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Recommended Remedies Include:
• Operational
– Extra Vigilance re Last Minute Changes in an Approach!!!
• Aircraft/Avionics
–
–
–
–
Enhanced Ground Proximity Warning System
Spoilers That Retract With Maximum Power
Require Confirmation of Non-Obvious Changes
Unused or Passed Waypoints Remain In View
• Infrastructure
– Three-Letter Navigational Radio Identifiers
– Ground-Based Radar
– Improved Reporting of, and Acting Upon, Safety Issues
Note: All but one of these eight remedies address system issues
Aviation Safety Information Processes Useful?
October 17, 2008
Federal Aviation
Administration
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Icing on the Cake:
$avings*
- ImmediateMore
*Significantly
Than
Savings From
- Significant
Mishaps Prevented
Aviation Safety Information Processes Useful?
October 17, 2008
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Administration
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Two Levels of Savings
• First level (immediate) savings
– Bottom-line benefits ancillary to safety improvements
• Second level (potentially much larger) savings
– Information pipeline contains more than safety
Staff AND
OTHER Sources
Information about Safety,
Efficiency, Reliability,
and Other Productivity Metrics
Aviation Safety Information Processes Useful?
October 17, 2008
Ye
Who
Can
Fix
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Administration
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Other Potential Benefits:
• Better Labor Relations
- Transforms workforce from brunt of blame
when things go wrong, to valuable source
of information about potential problems
and how to remedy them, i.e., converts
labor and management from Adversaries to
Partners in Improvement
• Reduced Legal Exposure
- Collecting, analyzing, and sharing will
become industry standard for most, if not
all, potentially hazardous endeavors; woe to
those who don’t
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Administration
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The Role of Leadership
- Demonstrate Safety Commitment . . .
But Acknowledge That Mistakes Will Happen
- Include “Us” (e.g., System) Issues,
Not Just “You” (e.g., Training) Issues
- Make Safety a Middle Management Metric
- Engage Labor Early
- Include the System -Manufacturers, Operators, Regulator(s), and Others
- Encourage and Facilitate Reporting
- Provide Feedback
- Provide Adequate Resources
- Follow Through With Action
Aviation Safety Information Processes Useful?
October 17, 2008
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Administration
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Thank You!!!
Questions?
Aviation Safety Information Processes Useful?
October 17, 2008
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Administration
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