The Human Factor The Quality Colloquium August 19

The Human Factor The Quality Colloquium August 19, 2008 Patient Safety Lessons from Other Industries Jim Bouey Boeing Commercial Aircraft Retired

Commercial Aviation Long History of Safety Performance Improvements North American accident rate (accidents per million departures)

Primary Causes of Hull Losses 1960 s 1996 -2005 flight crew airplane weather maintenance miscellaneous airport, ATC 4. 933 Hull Loss Rate (x 10 -6 Flights) 0. 749 From Boeing Statistical Summary of Commercial Jet Airplane Accidents – Worldwide Operations

How the mind likes to work Short cuts!

Short-Cut Trap

Federal Aviation Regulations n Title 14: Aeronautics and Space PART 25—AIRWORTHINESS STANDARDS: TRANSPORT CATEGORY AIRPLANES Subpart D—Design and Construction Personnel and Cargo Accommodations § 25. 781 Cockpit control knob shape. Cockpit control knobs must conform to the general shapes (but not necessarily the exact sizes or specific proportions) in the following figure:

Commercial Aviation Overarching Safety Philosophy FAIL-SAFE Assume that no matter what you do, something or someone will fail. Now, what do you have to do to make sure that everyone stays safe?

Fail-Safe Designs

Safety Precedence in Design n n Eliminate the hazard If it cannot be eliminated, minimize it through design selection If it cannot be eliminated or minimized, control it through the use of protective safety design features or devices When neither design not safety devices can effectively eliminate, minimize or control a hazard, detect the condition and provide a warning Resolution of hazards by the above methods can be supplemented with appropriate procedures and training, but these are not to be the sole means of hazard resolution

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