Flaw Free or Mishap Free Operations?

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.

Published by Capt. Paul Miller

Aviation safety expert with 43 years in the sky

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