Error analysis and correction

[Martin Gregorie]

I've just found the following reference on comp.risks:

http://www.abc.net.au/rn/talks/8.30/helthrpt/stories/s1529677.htm

It looks at the possibilities of applying aviation-style accident
prevention to medicine and contains a good, thought-provoking review of
what it is that we do to promote and maintain the aviation safety culture.

--
martin@ | Martin Gregorie
gregorie. |
org | Zappa fan & glider pilot

[Andy]

Interesting read, thanks.

Andy

[[email protected]]

How many times has your instructor said "Ah, I'm glad you did that"
when you screwed up. I believe that approach to error compensation
will help keep us alive as well as welcome more people to the sport.

Matt Michael

>From the article:

"Jim Reason: Oh yes, even the best ones have bad days. It's really
quite hard to be good all the time, but yes, one of the things that
perhaps is lacking in surgical training is the mentor who hopes that
you'll make a mistake across the table, and say, 'Ah, I'm glad
you did that; now I can tell you how to fix it'. In other words, to
watch people make errors, then to teach them how to repair, to
compensate. People who will tell you the ways of error."

[309]

I would hope that during my open heart surgery, the surgeon AND his
apprentice have studied the various and typical mistakes IN ADVANCE,
since the mistake could cost a life (e.g., mine), whereas the usual
training mistake in an aircraft usually has a 500 foot margine from a
fatal accident...at least the ones where my instructor said "I'm glad
you did that..." Usually when we were 200 feet from becoming an
accident and I made a mistake, my instructor's USUAL response was "I'VE
GOT IT!!!"

Still, a good read, thanks! FWIW, Risk MANAGEMENT has been the
approach in many Flight Test Organizations (where we do stupid things
to prove the airplane will work in extremis, so the line pilot doesn't
have to). There are studies under way to also work on THREAT
Management, a slightly different flavor ("How close do I want to get to
that other glider, mountain, etc.").

-Pete

[Andy]

Yes that bit struck a chord with me. I went grey giving tail wheel
instruction (it could have been a chronological coincidence). I never
wanted to sign anyone off that did perfect landings every time. The
mark of a competent tailwheel pilot is how they handle the inevitable
botched landing.


Andy

[309]

Andy wrote:
> The mark of a competent tailwheel pilot is how they handle the inevitable
> botched landing.
> Andy

I did one of those today!!! Well, depending on how you count the
bounces, maybe it was more than one landing. C-180, springy gear...and
I didn't have a good enough body ship (booster cushion).

No damage, except to my ego perhaps. It pays to remember that
different taildraggers have different ways of biting you...

-Pete