Remarks Presented to
Transportation Table
Washington, D.C.
June 14, 1996
Good afternoon, everyone. It is a pleasure to be here with you today.
I am honored to have been given the opportunity to briefly share with you
some of my thoughts regarding aviation safety questions which we, as industry
professionals, need to address. Since our group today consists of representatives
of most modes of transportation which we at the NTSB are involved with,
I will try to integrate my thoughts in order to reflect my observations
that many of the aviation safety questions which we address, in some manner
must also be addressed within the other modes of transportation. Further,
I hope that my comments will lead to your questions, and your ideas, which
we can discuss within the time which has been allotted to me.
In response to the subject which I am specifically addressing, I believe
the biggest question ahead in aviation is intrinsically inter-woven into
the fabric of the other modes of transportation. That question is - how
do we, as transportation manufacturers or operators, safety oversight officials,
regulatory agencies and legislative bodies, integrate the science of human
factors into our transportation system?
All of us in aviation know the statistics: Human error of one kind of
another is responsible, in some manner, for the majority of incidents and
accidents. This is true in all modes of transportation, and, in fact, it
is true in reference to the design, manufacture, operation and maintenance
of any technologically complex system. Similarly, every human error, regardless
of its gravity, is a product of multiple causes and factors. The performance
of individuals never takes place in a vacuum, but always occurs within
an organizational and cultural context. If this is true, then there is
another big question: Why can't the process of establishing causal factors
in transportation accidents be from a view of improving the system rather
than establishing blame?
Even with this knowledge and these questions, the science of human factors
is a relatively new field of study. However, I believe that the aviation
industry, in addressing the importance of developing aviation maintenance
human factors programs within their organizations, is leading the way in
this exceptionally important area. But this area of study is in its pioneer
stage and its complexity and is sometimes frustrating to those who have
chosen to set out on this mostly untraveled road. The exploration of the
unknown has almost always yielded tremendous dividends, and I strongly
feel that the work we can do in comprehensive human factors, is the key
to combining the rapid technological advances we are achieving in transportation
equipment and system's operations into an inter-modal transportation system
which can attain a higher degree of safety than most individuals thought
possible before the human factors pioneers began their journey just a short
time ago.
In the aviation community, most industry and regulatory representatives
have signed on to the ultimate goal of "zero accidents". This
is also a worthy goal for all other modes of transportation. The
question is - will we ever achieve "zero accidents"? Realistically,
probably not. However, I can assure you this lofty goal is beyond
our reach unless we recognize and incorporate the effects of human
factors in the workplace into the safety equation. Technology will continue
to advance. Safety regulations will continue to be promulgated and integrated
into the operation of the transportation system. However, human factors
is the only area that can successfully define the relationship of men and
machines in a transportation environment. Understanding human factors is
good business, and is the key to approaching the goal of "zero accidents".
In commercial aviation, we are combing recent accidents for the probable
cause or causes of these tragedies. Rail and surface transportation came
tragically together an Fox River Grove, Illinois. High speed rail has suffered
recent deaths in New Jersey and Maryland. Derailments have occurred recently
resulting in loss of life and environmental pollution. Pipeline explosions
have taken lives and driven people from their homes. And we are all aware
of maritime accidents which have caused irreparable damage.
Of course each of these accidents will have unique factors which contributed
to its cause or causes. But I think I can state with confidence that a
better understanding of human factors would have prevented some of these
accidents.
Are there other "Big Questions"? Certainly.
How do we streamline the regulatory process to implement safety procedures
in a more timely manner? Today, in aviation, where the FAA is 'Fast-tracking"
rulemaking in the Part 135 area, the on-demand carriers feel that their
concerns are being over-ridden by the haste in which the FAA promulgated
these changes. The question then becomes, how do we balance pertinent interests
and still achieve efficient implementation of safety rules and regulations.
In rail, we are, in certain instances, handcuffed by a regulatory system
which is unnecessarily based on rigid legislative standards which have
not kept pace with modern advances in the industry. The question is, how
do we transform this inflexible system into a system which recognizes
the economic and safety needs of modern rail transportation?
Since I do not want to extend my comments into the time remaining for
our discussion period, let me just mention some additional questions which
come to my mind.
Obviously, there are many others.
While I was given the topic of aviation safety, you can see that I believe
that the challenges which lay ahead for all of us really do transcend the
boundaries of all our transportation systems. These are challenges which
we can all work together to achieve in each of our particular modes of
transportation.
Now, let's discuss your thoughts and perspectives on these subjects.
Any questions?
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