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Global Aviation Information Network

Document Series:
Publications
Author:
  • Christopher Hart
Subject:
Risk Reduction Program
Keywords:
C3RS
Document
closecalls_hart.pptx (454.4 KB)
Workshop: Improving Railroad Safety through Understanding Close Calls
Christopher Hart Presentation

 

 Slide 1:
Global Aviation Information Network (gainweb.org) [GAIN logo: airliner circling globe] Christopher A. Hart Federal Aviation Administration Assistant Administrator for System Safety

 

 Slide 2:
[GAIN logo] Introduction to GAIN * Goal: Develop Tools and Processes for the Aviation Community to Make Data-Driven Decisions Using Data Beyond Accidents or Incidents * Challenges and Solutions * Participants * Significant Immediate Savings * Applicable to Many Industries ?Other Transportation Modes, Health Care, National Security, Others

 

 Slide 3:
[GAIN logo] The Hands-On &##39;&##39;Front Line&##39;&##39; Folks: &##39;&##39;We All Knew About That Problem&##39;&##39;

 

 Slide 4:
[GAIN logo] Benefits of Routine FDR Use [line graph entitled:] Hull Losses as a Percent of Total Turbine Fleet Flight Data Recorder Users vs. U.S. vs. World, [graph lines illustrate] FDR Use <7Years; FDR Use 7-14 Years; FDR Use >14 Years; Worldwide; Total U.S. [percentage over] 1976-82; 1983-89; 1990-96 Sources: Total U.S. - FAA NASDAC; Other - Skandia Insurance Co. Ltd.

 

 Slide 5:
[GAIN logo] [line graph entitled:] Norwegian Rail Experience [graph lines illustrate] Total number of reported and analyzed events [number unspecified]; Number of reported and analyzed near-misses [number unspecified]; Lost Time: 37% reduction; Accidents:40% reduction [annually over] 1995, 1996, 1997, and 1998 [notation:] Synergi implemented [1996] Source: Pride AS

 

 Slide 6:
[GAIN logo] Current System Data Flow Almost all Data is Lost Forever Currently Only a Minute Portion of Data is Collected and Analyzed [illustration of Sherlock Holmes figure studying small leak in flowing pipeline]

 

 Slide 7:
[GAIN logo] Heinrich Pyramid [pyramid graph of] ACCIDENTS [small tip of pyramid]; INCIDENTS [larger area near top of pyramid]; UNREPORTED OCCURRENCES [most of pyramid extending up from base to approximately 2/3 of total height]

 

 Slide 8:
[GAIN logo] National Civil Aviation Review Commission:* &##39;&##39;The aviation community must look deeper than accidents and incidents to identify latent and emerging problems and fix them before a mishap occurs.&##39;&##39; Avoiding Aviation Gridlock & Reducing the Accident Rate, Dec. 1997, p. III-20 * Chair: Hon. Norman Y. Mineta, now Secretary, U.S. Department of Transportation

 

 Slide 9:
[GAIN logo] Common Characteristics * Inadvertent * Could Be A Link In An Accident Chain * Happens Repeatedly

 

 Slide 10:
[GAIN logo] So Should We... * Regulate More? * Punish More? * Increase Training? OR... Share Information to Fix the System?

 

 Slide 11:
[GAIN logo] Fix the Person or the System? Is the Person Clumsy? Or Is the Problem . . . The Step??? [illustration of a figure running up steps]

 

 Slide 12:
[GAIN logo] GAIN is: * A network ?NOT A BIG CENTRAL DATABASE * Privately owned and operated * An international cooperative effort * Voluntary [illustration entitled] GAIN: The Coordinator [of multi-nodal network connecting] Systems A, B, C, D, E, F

 

 Slide 13:
[GAIN logo] Former FAA Administrator Jane Garvey: &##39;&##39;GAIN is one of our best hopes for enhancing aviation safety in the next century.&##39;&##39; GAIN III World Conference November 1998

 

 Slide 14:
[GAIN logo] Information: The Fuel for Our Engine [illustration of a car with a fuel tank full of] Information [moving the car toward] Improved Safety

 

 Slide 15:
[GAIN logo] Concerns That Discourage Collection and Analysis * Public Disclosure * Job Sanctions and/or Enforcement * Criminal Sanctions * Civil Litigation

 

 Slide 16:
[GAIN logo] Shifting the Paradigm How It Is Now . . . You are highly trained and If you did as trained, you would not make mistakes so You weren’t careful enough so You should be PUNISHED! How It Should Be . . . You are human and Humans make mistakes so Let’s also explore why the system allowed, or failed to accommodate, your mistake and Let’s IMPROVE THE SYSTEM!

 

 Slide 17:
[GAIN logo] Challenges [illustration of a runner leaping over hurdles entitled] Legal Issues [and] Improved Analytical Tools As we begin to get over the first hurdle, we must start working on the second.

 

 Slide 18:
[GAIN logo] Is This Light Random? [illustration of beam of light emitted from a hole at the end of a long box]

 

 Slide 19:
[GAIN logo] Accidents Result From a Combination of Events [illustration of cutaway view of a long box showing openings in wheels unaligned, blocking beam of light] [illustration of cutaway view of a long box showing shining beam of light passing through openings in aligned wheels]

 

 Slide 20:
[GAIN logo] Information Overload [illustration of a large wave about to engulf a figure on the beach, who sees the wave and says:] &##39;&##39;Eureka, more information!&##39;&##39; ?1996 Ted Goff

 

 Slide 21:
[GAIN logo] All Accidents Involve Human Factors * Pilots * Air Traffic Controllers * Mechanics * Cabin Crew * Dispatchers * Ramp Personnel * Airport Operators * Manufacturers * Designers * Management: Agency/Corporate [added together equals] 100%

 

 Slide 22:

 

 Slide 23:

 

 Slide 24:
[GAIN logo] Steering Committee Airlines jetBlue (Chair) Alaska Airlines American Airlines Middle East Airlines Japan Airlines Air Transport Association Int’l Air Transport Association Regional Airline Association Manufacturers Airbus Boeing Labor Air Line Pilots Association Int’l Association of Machinists & Aerospace Workers National Air Traffic Controllers Association General Aviation National Business Aviation Association Helicopter Association Int’l U.S. Military Flight Safety Foundation

 

 Slide 25:
[GAIN logo] Working Groups Working Group A Aviation Operator Safety Practices Working Group B Analytical Methods and Tools Working Group C Global Information Sharing Prototypes Government Support Team (GST) Several Countries, JAA, European Commission, ICAO Working Group E Flight Ops/ATC Ops Safety Information Sharing

 

 Slide 26:
[GAIN logo] Moral: Joint Effort Required All Segments of the Industry Must Work Together * Management * Labor * Manufacturers * Governments

 

 Slide 27:
[GAIN logo] Industry Taking Charge First Two GAIN Conferences: * Sponsored by FAA, UK CAA, Royal Aeronautical Society (UK) Industry Has Taken the Lead: * Conference Hosts ?Alitalia, Airbus Industrie (twice), Delta Airlines, Air France, United Airlines * GAIN Steering Committee ?Led by Industry * Working Groups ?Mostly Industry

 

 Slide 28:
[GAIN logo] Many Have Already Begun The Process [illustration of foundation] Foundation: Collecting and Analyzing [and wall] Sharing * Airlines * Manufacturers * Unions * Government

 

 Slide 29:

 

 

 

 

 

Slide 30:

 [GAIN logo] Others Who Are Interested Transportation Department * Coast Guard, MARAD (IMISS) * Highway Administration * Railroad Administration * Pipeline Safety

 Slide 31:
[GAIN logo] Others (con’t) * Critical Infrastructure Assurance Office (CIAO) * Nuclear Power * Chemical Manufacturing * Public Utilities * Firefighters * Health Care Industry
  Slide 32:
[GAIN logo] The Health Care Industry To Err Is Human: Building a Better Health Care System &##39;&##39;The focus must shift from blaming individuals for past errors to a focus on preventing future errors by designing safety into the system.&##39;&##39; Institute of Medicine, Committee on Quality of Health Care in America, 1999

 

  Slide 33:
[GAIN logo] The Future: Role of GAIN In Security???

 

  Slide 34:
[GAIN logo] Want To Get Involved? Next GAIN World Conference: Rome, June 18-19, 2003 Sponsored by Alitalia [logo] www.gainweb.org

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Last updated: Wednesday, April 23, 2003