War on Error
Lostdog65 said:
Rez...no offense...but Tony Kern's name leaves a bad taste is some people's mouth's. His book is good. But he tends to think that aviation accidents can be brought down to 0 per 1000 hrs of flight time.
The only way to do that is to stop flying.
Hey Eric,
I've read all four of Tony's book's and seen him speak three times, and I don't seem to recall him ever saying anything like that.
If you read his books carefully, what he did say is that a traditional safety or CRM program will never fix the problem of human error, that we ourselves need to untangle personal error by fighting a private battle against it. Tony and several 50-pound brain folks are currently developing and advocating a new vision of human error, with a 50-70% reduction in the frequency of errors. In other words, we need to move beyond sixth generation CRM in a fundamental shift where instead of
trapping errors, we quit
making most of them. A fair amount of training and personal hard work is needed to make this happen. Dr. Kern suggests:
- People take intentional and preemptive actions to attack personal error precursors
- People understand why they make errors-and how to prevent them.
- People realize the limits of the "system" and rely on themselves and peers to prevent errors
- Safety and training are fine tuned to build on new depth of knowledge-individual expertise on error becomes a force multiplier.
In LOSA data culled from three major airlines, procedural non-compliance resulted in over 50% of the flight crew errors made. Although CRM has taken a bite out of the total number of accidents, what it hasn't done is bring down the 80/20% ratio. (80% percent of all accidints being caused by error) CRM isn't broken, but we need to adjust it's focus towards ourselves and personal discipline. Non of us are in danger of crashing because of some bullheaded ex-WWII fighter pilot taking stupid chances with our airliner. Yet generation 6 CRM still focuses on rehashing UAL at Troutdale. When are we going to start taking flight discipline seriously and demanding accountability for our action? Wasn't it Cicero who said
"To err is human, but to persevere in error is only the act of a fool." ?
If you get the chance to take a look at what Dr. Kern is up to these days, I would highly recommend it. Within the next ten years, you're going to start hearing about in in the industry.
"All the greatest battles are waged within."
Ill get off my soapbox now, gotta spread the gospel.
Take Care,
LJDRVR