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Best Training PracticesUsing the “Dirty Dozenu”rcesLack ofoCommunicationComplacencyLack of KnowledgeDistractionworkmaeTfL ack ouegitaFPresented forWorld Aviation Training ConferenceOrlando, FloridaApril 29, 2009R esfokL acPressureLack of AssertivenessStressLack of Aw arenessN o rmsPresented byRenée Dupont
First a Few Givens Over 80% of aviation accidents are due to HumanError Humans do not make these errors on purpose Training the person on how to avoid the error theydon’t intend to make will lower the number of errors The “Dirty Dozen” are the contributing factors orpreconditions to that Human ErrorTrain the person to recognize and understand the“Dirty Dozen” and there will be less errorsWB 2
The Dirty Dozen1. Lack of Communication 7. Lack of ResourcesLetslook at the contributing8. Pressure factors2.Complacency9. LackAssertiveness3. Lackof Knowledgethatcancause any oneof ofusto makeStress to make4. theDistractionerror we don’t 10.intend5. Lack of Teamwork11. Lack of Awareness6. Fatigue12. NormsG. Dupont1993WB 2
Safety Nets A Safety Net is a Regulation, Policy, Practice orProcedure which, if in place might break a linkor prevent a link in the chain of events The regulatory body controls the regulations The company controls the policies The individual controls the practice orproceduresWB 2
1The Dirty DozenLack ofCommunication The failure to exchangeinformation Seek first to understand,then be understood(Learn to listen) The “Mental Pictures”must matchWB 3
Thefailure to communicatecorrectlycan have serious, painfulconsequencesNot in WB
Ouch!!!What we had there wasaFailure To CommunicateFor Communication To OccurThe Mental Pictures MUST MatchNot in WB
The Dirty Dozen2Complacency Self satisfaction resulting ina loss of awareness of thedangers The greater the competencyof the person, the morecommon this contributingfactor is The person will begin to seeand hear what he/she expectsto see and hearWB 3
3The Dirty DozenLack of Knowledge A lack of understanding orexperience for the task athand Can occur at any stage of awork career with constantchanges Training is always a Safetynet and a good investmentWB 4
Lack of KnowledgeDon’t let this be YOUNot in WB
The Dirty Dozen4Distraction Anything that takes yourmind off the job at hand Responsible for 15% ofall human error Number one cause offorgetting Our mind can workfaster than our handsWB 4
5The Dirty DozenLack ofTeamwork A failure to seek andconsider the input of others Becomes more common asa company grows Calls for trust, a commongoal and communication Is a must for any SMS tosucceedWB 5
6FatigueThe Dirty Dozen A loss of alertness and afeeling of tiredness thateventually ends in sleep The #1 contributor toerror We (the industry) tend tounderestimate the problem We (the individual) tend tooverestimate our ability todeal with itWB 6
Fatigue?Not in WB
Fatigue?Not in WB
7The Dirty DozenLack ofResources A lack of material orsupport to Safely carry outthe task at hand It is not uncommon, whentimes get tough for persons tobe expected to do more withless One has to learn when tosay NO if it affects SafetyWB 6
The Dirty Dozen8Pressure The urgency of mattersrequiring immediate attention Most pressure is selfpressure but the person failsto realize it Training must provide amodel to help them recognizethe true source of pressureWB 6
NowTHISis what realPressurelooks likeNot in WB
The Dirty Dozen9Lack ofAssertiveness Failing to act in a bold andconfident manner on Safetyconcerns Has caused many accidentswhere one person hadknowledge but failed to share it Can be difficult to achieve insome culturesWB 7
10StressThe Dirty Dozen The subconscious responseto the demands placed on aperson The person often bringsthe stressor to work withthem Their mind is never fullyon the jobWB 7
11The Dirty DozenLack ofAwareness A lack of alertness andvigilance in observing Usually occurs to the veryexperienced Believe they are doing theright thing but have notthought it through Needs to ask more “Whatifs”WB 8
This is NOT Lack of AwarenessNot in WB
Lack of Awareness ?Whatever made you think your catwould enjoy taking a shower with you?”Not in WB
12NormsThe Dirty Dozen Unwritten rules dictatedand followed by the majorityof the group Peer pressure and the desireto “fit in” are majorinfluencers Not all norms are negativeWB 8
This is an example oftaking advantage of aNormNot in WB
r cesuosf ReokcLaLack ofCommunicationComplacencyPressureLack of KnowledgeLack of AssertivenessDistractionStressLack of Aw arenessN o rmsworkmaeTfL ack oueFatigThe Dirty Dozen are simple and easy to understandThe Dirty Dozen are practicalThe Dirty Dozen can apply to any occupation or even ourdaily livesThe Dirty Dozen, if trained correctly, will reduce humanerrorWB 9
Thank you for the opportunityto speak to you todayIf we can be of further assistance to youContact us atSystem Safety ServicesEmail: dupontr@system-safety.comWebsite: www.system-safety.com
First Fatal Airplane CrashSeptember 17, 1908Lt. Thomas Selfridge killed1st Fatality in Almost 5 Years
The Dirty DozenThe Dirty Dozen WB 3 Self satisfaction resulting in a loss of awareness of the dangers The greater the competency of the person, the more common this contributing factor is The person will begin to see and hear what he/she expects to see and hear
