ASAP: A Checklist For Success Michael Whitehouse FlyteDATA

p/training_material/media/ _A SAP_Training_Student_Guide_for_Mod ule_A.pdf p/reports_presentations/media/Best_ Practices_for_ERCs.pdf

1. Philosophical Challenges 2. Organization/Process 3. Nuts and Bolts (data)

Philosophical Challenges: EXECUTIVE BUY-IN

Philosophical Challenges: TRUST Build it. Protect it. Deserve it.

Philosophical Challenges: COURAGE

Organization/Process:CONSISTENCY

Organization/Process: PLAN for SMS

Nuts and Bolts: DATA SHARING

Nuts and Bolts: HAVE The RIGHT TOOLS

Relational Aggregate Data Analysis

What Is It? A tool to identify binary causal chains for any event type in order to pinpoint specific cause and effect problems and facilitate risk mitigation. A B C D The undesirable state

How Does It Work? An analyst orders the elements of an event type, i.e. the threats and errors, in relational order. An analyst orders the elements of an event type, i.e. the threats and errors, in relational order. Each pairing in the causal chain is counted. Each pairing in the causal chain is counted. The causal chains of significant frequency are identified for risk mitigation. The causal chains of significant frequency are identified for risk mitigation. Break the Chain: Prevent the Occurrence

But Why? Why do this?

Binary Causal Chains 4Aircraft system malfunction / failureOther maintenance documentation error/complication 3Aircraft system malfunction / failure Reviewing, recording or departing with wrong logbook or information 1Aircraft system malfunction / failureDistraction/Task Interruption/Mechanical 1Aircraft system malfunction / failureReturn to field/Air return 1Aircraft system malfunction / failure (multiple)Task saturation 1Attention to/Distraction from flight duties Reviewing, recording or departing with wrong logbook or information 1Channeled AttentionMemory lapse 1Channeled Attention Reviewing, recording or departing with wrong logbook or information Proprietary information. Not to be reproduced or disseminated. 49 U.S.C

Causal Chains Visualized Departed with Open/Incorrect Logbook Item Reviewing, recording or departing with wrong logbook Operational Time Pressure Crew scheduling event, late arriving crew or aircraft Memory lapse Job task analysis less than adequate Aircraft system malfunction, failure Other Maintenance documentation Task saturation Other Mtc documentation error/complication Proprietary information. Not to be reproduced or disseminated. 49 U.S.C

By the Numbers The were 147 causal chains identified. The were 147 causal chains identified. The most frequent causal chains (three or more occurrences) made up 58 percent of the linkages. The most frequent causal chains (three or more occurrences) made up 58 percent of the linkages. The top four causal chains led to 42 percent of the occurrences. The top four causal chains led to 42 percent of the occurrences. Key Point: Target elimination of the top four binary chains, and you reduce occurrences by 42%! Proprietary information. Not to be reproduced or disseminated. 49 U.S.C