It has been said, "You seem to be convinced that a flawed world can be actually made flawless."

My response is this. Human error is part of our nature. However we can make our own flight operations mishap free by remembering Miller's Rule for Safety Management: ALL SAFETY IS LOCAL.

Any one safety manager cannot make a "flawed world ..... flawless." He or she can only affect the operation over which they have control.

I can personally recommend steps to each LOCAL Flight Operations Safety Manager that have worked extremely well to achieve mishap free flight operations.

One person commented, "In a process oriented investigation "human error" cannot be the ultimate root cause. You need to ask yourself, "Why did the humans make the errors?"

My response to this is, "True, but you also need to go further and ask what procedures can be put into the SOP and become part of the training program that will help flight crew members overcome their human errors.

For example, lets say that a very important system characteristic is buried on page 49 of a chapter in the Aircraft Operating Manual. Well, maybe if it is considered to be so important, should it be bold faced, underlined and not buried on page 49? In other words, humans make errors that can easily be corrected. Safety managers need to find ways to help the flight operation correct errors as they are occurring and are reported.


Some have also said, that crew selection and training criteria are often driven by both financial and safety level aspects. FAA and other civilian authorities have criteria set at minimal requirements. But one company may decide to exceed those.
For example, one company may decide to select pilots (1) which have a Commercial Pilots License from a school with a weak syllabus and accept those after a minimal medical and psychological selection process, accepting captains with only 3,000 flight hours. Another company may have require at least a masters degree in technical sciences and demand a very strict medical and psychological selection criteria and accept captains only after 30,000 hrs. The same could and often does apply to training. One set of training requirements are used for a Government operation and another set of training criteria are used for a major airline."

But my response is this. You still have to train flight crew in the company SOP. You still have to check to the SOP and make your operation "procedure oriented" and not technique oriented. This way flight crew are performing procedures and not using their own techniques to operate.

Further, as the operation improves its control, it will develop a need to have more standardization in procedures just so that mixed crews can operate efficiently.

Should the FAA tolerate such a wide variance between airlines? It is the Topic for another day.

Forecasting involves learning from previous mishaps

We can forecast by learning from the mishaps of other organizations.

We learn by observing the mistakes that are made. That being said, I would add that we actually have a more superior ability to observe these mistakes as they are made on the line and before they contribute to a mishap.

Did you know for example that Safety Theory tells us that flight crew will make 1000 errors which could lead to 100 reportable events, which could lead to 10 incidents and which could lead to 1 major mishap.

Many people do not believe that or do not understand this very valuable nugget of safety information. This is the key to succeeding in the safety profession and I will tell you this from my own 43 years of experience. You can achieve zero mishaps, you can prevent mishaps at your airline.

Here is how to do it. You must have a reporting system that allows flight crew members to speak about and report their errors and those that they observe. Next the safety person has to investigate these errors, figure out how they impact the operation and take steps to correct the organic reason for the errors. Most often in my experience this involved some adjustment, modification or addition to SOP. But the safety person has to be well versed in flight ops and SOP so that the changes to SOP make sense.

Unfortunately all too many people believe that until an event, incident or mishap occurs, that their operation doesn't "have a problem." However the problems are there because we are human. They will always be there. The key is to incorporate the error reporting process into day to day operations, to talk about them and fix them right then and there.

Allowing human errors to "fester," to unreported and uncorrected is to set the operation up to failure. Can an operation be made error free? Of course not. But at the same time can an operation be made mishap free? Absolutely so, by finding and fixing errors as they occur.
But I believe that as humans we are constantly making errors. A good program that enables us to report and act on these errors as they first occur will enable us to always be one step ahead of the hazards and therefore operate free from mishaps.