Most Airplane Crashes Caused by Human Error
Experts who study airplane accidents say the mistakes that lead to crashes are the same kinds of mistakes people make all the time, akin to locking keys in the car or forgetting an item on a shopping list.
“In an airplane, it gets you in trouble,” says Scott Shappell, a professor at Clemson University who studies human error in aviation accidents.
Scholars say as many as 80% of airplane accidents are caused by what aviation experts call human factors, which will probably be deemed one of the leading causes of the August crash of Comair Flight 5191. The plane crashed after trying to take off from the wrong runway at Blue Grass Airport in Lexington, KY, killing more than 40 people.
The study of human factors in aviation examines how a cockpit is run and how mechanical repairs are made. Specialists in the area work for the Federal Aviation Administration, the National Transportation Safety Board and as consultants to airplane manufacturers.
They develop techniques and procedures to catch mistakes before they cause problems. Several such mistakes were factors in the Comair crash.
On the morning of the crash, the pilots initially boarded the wrong plane, putting them behind schedule. After they boarded the correct plane, the one air traffic controller on duty cleared the flight onto runway 22 and then turned his back to catch up on paperwork. According to FAA policy, two controllers should have been on duty.
The plane’s captain, who died in the accident, taxied the plane into position, but instead of turning onto runway 22, which is used by commercial flights, the plane turned onto runway 26, which was unlit and is meant for smaller planes.
The approach to runway 22 had been changed by recent construction, which was not reflected in the chart of the airport given to the pilots.
To figure out what went wrong, human factors investigators will want to know what the pilots were talking about in the cockpit, Shappell says. They will also look at when the pilots went to bed, how they slept, what they ate and drank, if they were having difficulties at home, and issues such as Comair’s bankruptcy proceedings and staff morale.
After the pilots chose the wrong runway, another factor that could have come into play is confirmation bias—the tendency to ignore evidence that proves a decision wrong.
“Once you make a decision, you seek out those things that confirm your original decision and ignore everything else,” Shappell says.
Shalala to Speak at World Conference
Former U.S. Secretary of Health and Human Services (HHS) Donna Shalala will be a keynote speaker at ASQ’s 2007 World Conference on Quality and Improvement, April 30-May 2, in Orlando, FL.
Shalala will deliver the keynote address Wednesday, May 2. She plans to speak on leadership in quality and also will present the 2007 International Team Excellence Awards. Currently the president of the University of Miami, Shalala served at HHS secretary for eight years under Bill Clinton.
Author, speaker and columnist Jim Carroll has also agreed to speak at the World Conference. Carroll’s keynote address, Tuesday, May 1, will focus on how organizations can understand and cope with trends in a changing world.
ASQ is pursuing other keynote speakers for the remaining days of the conference. For updates, go to http://wcqi.asq.org.
New Standard Covers Audit, Certification Bodies
ISO/IEC 17021:2006, Conformity Assessment—Requirements for Bodies Providing Audit and Certification of Management Systems, places competence and impartiality requirements on organizations that offer audit and certification to standards such as ISO 9001 and ISO 14001.
The standard also covers activities related to new standards for food safety (ISO 22000), information security (ISO/IEC 27001) and supply chain security (ISO/PAS 28000), as well as others that might be developed.
ISO/PAS 28000, a publicly available specification for security management systems for supply chains, was just published by the International Organization for Standardization (ISO). It includes an option for independent auditing, allowing customs agencies to check and verify completed work rather than be directly involved in assessments.
Other standards news includes:
- ANSI and the National Institute of Standards and Technology have launched a standards portal, www.standardsportal.org, to facilitate trade between the United States and China. The portal contains educational materials in Mandarin and English, a database of 1,000 standards from each country and access to nearly 300,000 other standards and guidelines.
- ANSI and the Internet Security Alliance have developed a resource package to help business leaders manage information security. The resources include INCITS/ISO/IEC 17799:2005, the code of practice for information security management developed internationally and adopted as an American national standard, and Contracting for Information Security in Commercial Transactions: An Introductory Guide. The package can be purchased at www.isaalliance.org or www.webstore.ansi.org.
ASQ representatives attended meetings at the National Assn. of Manufac-turers and its Manufacturing Institute in Washington, DC, in mid-September.
The institute has called on ASQ to rapidly develop and deploy a series of manufacturing process and skill certifications based on the ASQ quality body of knowledge. The ASQ certification board and office of the president members are expected to quickly consider the opportunity.
In meetings with U.S. Senate staff, ASQ representatives were asked to have society members promote the National Competitive Investment Act, a bill designed to spur investment in mathematics, science, technology and engineering education programs, and establish a presidential council on innovation and competitiveness.
Other meetings with Senate and House of Representatives staff were related to lifting the category cap that is now part of the Malcolm Baldrige National Quality Award legislation. Current law sets a limit of three yearly recipients in each award category—manufacturing, service, small business, education and healthcare.
ASQ MEMBER NEWSLETTER GETS NEW LOOK, NAME ASQ’s e-newsletter, previously called ASQwire, has been redesigned and renamed ASQ Weekly. The changes to the newsletter, which has about 40,000 subscribers, are in response to a reader survey conducted in July. To subscribe to ASQ Weekly, go to www.asq.org/keepintouch.html.
BIOMEDICAL DISCUSSION GROUP TO MEET The ASQ Northern California Biomedical Discussion Group will hold the final session in its 2006 process series on Dec. 26 in Palo Alto, CA. The event will recap the year of process engineering for the biomedical industry. For more information, go to www.asq.org/biomed/project/ncdg_event.html or e-mail Brian McCollum at firstname.lastname@example.org.
STANDARDS COMMITTEES NEED VOLUNTEERS ASQ’s standards committees, which help negotiate and write international and national standards such as ISO 9001 and ISO 14001, are looking for volunteers. Involvement in a standards committee connects you and your organization to industry experts, gives you a preview of standards before they are published and directly involves you in standards development. For more information, contact the ASQ standards team at 800-248-1946 x7474 or email@example.com.
DIVISION VOLUNTEERS NEEDED The Electronics and Communications Division (ECD) needs volunteers for committee chair and officer positions, as regional counselors and speakers, and for a position as moderator of ECD’s discussion groups. For more information or to volunteer, e-mail the ECD chair, David G. Fernald Jr., at firstname.lastname@example.org.
Institute of Medicine Report Slams FDA
The U.S. drug safety system is feeble in its drug approval efforts and suffers from “organizational and cultural problems,” an independent federal report claims.
The Institute of Medicine (IOM) report echos the harshest critics of the Food and Drug Administration’s (FDA) drug safety regime. The conclusions find “a lack of clear regulatory authority, chronic underfunding, organizational problems and scarcity of postapproval data about drugs’ risks” in the FDA safety regulation.
The IOM report recommends a number of remedies, which range from direct FDA changes to Congressional intervention for funding and legal changes.
Although it is unclear how many of the recommendations will be implemented, the report’s findings will add to pressure on the pharmaceuticals industry. Additional attention to drug risks after approval could affect sales, and drug makers have pushed resources to speed approval of new drugs.
The FDA commissioned the IOM report after drug maker Merck suddenly withdrew Vioxx from the market two years ago. A company study found Vioxx increased the risk of heart attack and stroke.
The IOM report cites “problems within the FDA that hinder its post-approval drug safety activities.” It recommends making the drug safety office equivalent in stature to the office of new drugs.
Other recommendations include: giving the FDA more enforcement power, including fines and injunctions, on drug makers; more money and fewer restrictions on how to spend it; the establishment of an FDA unit to gather and analyze safety and benefit data on drugs; and formal review of a drug’s risks and benefits every five years.
It also calls for drug labels to clearly denote a product as a new drug for two years and a ban on advertising new products in that period.
The report broadly echoes legislation already proposed seeking to restructure the FDA and to require public disclosure of drug trial data. Charles Grassley, Republican senator from Iowa and bill sponsor, has consistently called FDA’s drug safety system “too cozy” with drug makers.
For more information and to purchase a copy of the report, go to www.iom.edu/cms/3793/26341/37329.aspx.
Members, Staff Working to Improve Education, Training
ASQ has launched an initiative to improve its education and training program, aiming to provide members with products from their sections, divisions and ASQ headquarters that more closely aligns with their needs.
It is part of ASQ’s Summit Outcome Activity Response (SOAR) initiative, an organizationwide program responding to needs identified at last year’s member leader summit.
More than 60 ASQ members and staff have been working for the past several months on the education and training project. Three subteams are working on separate goals: establishing a sustainable method for capturing the voice of the customer, improving the overall education and training management structure, and converting course materials into smaller segments of information called modules.
Susan Westergard, ASQ’s manager of education development and promotion, says members should begin to see benefits immediately but expects the initiative to take “many months, even years, to fully deploy.”
See December’s “Keeping Current“ for more information on the SOAR initiative.
A QUESTIONNAIRE ABOUT HOW PROCESS IMPROVEMENT concepts such as lean and Six Sigma should be applied to government services is available online at www.rh.edu/~maleyeff/IBM/Survey.htm (case sensitive). The questionnaire is part of study being conducted by John Maleyeff, a professor at the Hartford, CT, campus of Rensselaer Polytechnic Institute. The three-page Word document takes about 10-15 minutes to complete, according to Maleyeff.
THE AMERICAN SOCIETY OF SAFETY ENGINEERS (ASSE) has kicked off its annual kids’ Safety-on-the-Job poster contest, which runs through Feb. 14. ASSE members’ children, grandchildren, nieces and nephews, aged 5 to 14, can participate. The contest is divided into five age categories, and the winning poster in each category will be featured on the 2007 North American Occupational Safety and Health Week poster. Winners also will receive a $1,000 savings bond. For more information, go to www.asse.org/naosh or e-mail email@example.com.
JOINT COMMISSION INTERNATIONAL (JCI) has launched a Middle East office in Dubai, United Arab Emirates. JCI says the new office will enable it to better support its Middle East clients and improve coordination of JCI quality and patient safety initiatives with other international agencies. JCI has ongoing projects in more than 80 countries and provides services to more than 33 healthcare organizations in the Middle East. It is an affiliate of the Joint Commission on Accreditation of Healthcare Organizations. For more information, go to www.jointcommissioninternational.com.
THE HOSPITAL QUALITY ALLIANCE says its Hospital Compare website, www.hospitalcompare.hhs.gov, now has quality information on about 4,000 hospitals, which voluntarily submit data to share with the public. As of Sept. 30, 74% of all reporting hospitals provided information on all 18 measures related to three common medical conditions: heart attack, heart failure and pneumonia. That’s an in-crease from 23% of hospitals that were reporting on all measures when Hospital Compare was launched in April.
THE INSTITUTE FOR HEALTHCARE IMPROVEMENT (IHI) has announced the plenary speakers for its National Forum on Quality Improvement in Healthcare, Dec.12-13. They are Donald M. Berwick, president and CEO of IHI; Rosabeth Moss Kanter, professor at Harvard Business School; David Whyte, writer and speaker; and Lawrence L. Weed, president and founder of PKC Corp. For more information, go to www.ihi.org.
THE NATIONAL EDUCATION ASSN. is urging more teacher education programs at colleges and universities to participate in existing professional accreditation programs. The call is in response to a report by the Education Schools Project that says teacher education programs are not sufficiently rigorous, not systematically tied to outcomes, and not governed by uniform and meaningful state standards. The report also calls for a new system of professional accreditation to ensure quality and accountability. The report is available at www.edschools.org/reports.htm.
THE AMERICAN ASSN. FOR LABORATORY ACCREDITATION (A2LA) has completed the Asia Pacific Laboratory Accreditation Cooperation (APLAC) peer re-evaluation process and added inspection body accreditation to its scope of recognition. Previously A2LA accredited testing and calibration laboratories had been recognized by APLAC.
THE INSTITUTE FOR SUPPLY MANAGEMENT (ISM) has awarded grants of $12,000 to two doctoral candidates who are conducting research in supply management or related fields. Recipients are James W. Hamister of the State University of New York, Buffalo, and Heng Xu of Massachusetts Institute of Technology. ISM also has recommended $5,000 senior fellowships be awarded to support researchers A. Michael Knemeyer of Ohio State University and Jayanth Jayaram of the University of South Carolina.
THE AUTOMOTIVE INDUSTRY ACTION GROUP has upgraded its supply chain training and process offerings to its member companies in China. The upgrades include courses, technical documents and publications, events and workshops. For more information, go to www.aiag.org.
BRAZIL, RUSSIA, INDIA AND CHINA are projected to account for a significant portion of automotive assembly growth during the next four years, according to PricewaterhouseCoopers’ “Global Automotive Financial Review.” The four nations will account for more than 40% of global light vehicle assembly increases and 52% of capacity expansion. The complete report can be found at www.pwc.com/extweb/ ncpressrelease.nsf/docid/cf6d44ad1a35ab99852571f400559150.
THE SUPPLY-CHAIN COUNCIL is seeking submissions for its 2007 awards for excellence in supply chain operations and management. The submissions are due Dec. 15 and the winners will be invited to present their projects during the Supply-Chain World North American Conference March 19-21 in Philadelphia. For additional information, go to www.supply-chain.org.
The FACE of Quality
Name: Edrin Rouse.
Residence: Greensboro, NC.
Education: Master’s degree in industrial technology (quality systems) from Eastern Michigan University in Ypsilanti. Currently working on a doctorate of business ad-ministration in management of engineering and technology from North-central University, an on-line institute.
First job in quality: Quality assurance supervisor at Philip Morris.
Current job: Senior vice president, quality and productivity Black Belt. Uses Six Sigma and other quality principles to increase customer satisfaction, revenue and productivity.
ASQ activities: Senior member, certified quality manager and engineer.
Other activities: GE Capital certified Six Sigma Black Belt, past examiner for the North Carolina Performance Excellence Process, adjunct instructor at California National University.
Recent honor: Recipient of ASQ’s 2006 Richard A. Freund International Scholarship. The $5,000 scholarship, named after a past ASQ president, supports a quality professional’s study.
Personal: Married, two children.
Favorite ways to relax: Listening to jazz, watching action packed movies.
Quality quote: As quality professionals, we are commissioned to support our organizations as they improve business performance. This should always be the aim. We should not engage in wasteful activities not aligned with the major imperatives of our organizations. In fact, we should be at the forefront of all planning processes, using the appropriate business and quality tools to set the appropriate course of action with our business partners. If we are confident and diligent in our approach to achieve this vision, as Thoreau said, “We [our organizations] will meet with success unexpected in common hours.”
Too Many Hospital Quality Programs?
The large number of hospital quality reporting programs and the lack of coordination among them means hospitals are scrambling to fulfill the many various requirements, according to a study by the Center for Studying Health System Change.
The study, based on site visits to hospitals in 12 nationally representative markets, found all the hospitals participated in at least one quality reporting program, with some hospitals using as many as seven. Overall, there were 38 unique reporting programs that had at least one hospital in the study as a member.
The programs varied not only in clinical focus and reporting requirements but also in sponsorship, incentives, mandatory vs. voluntary nature, inclusion of outcome measures, and provision of concrete quality improvement support.
According to the study, hospitals have devoted additional resources and staff to quality measurement and improvement, but inadequate IT systems have made the reporting a burden to staff.
Given that there is, as of yet, little evidence hospital reporting programs actually improve the quality of care, the difficulty of fulfilling the complicated requirements might not be worth it, according to Hoangmai H. Pham, a senior researcher at the center and the study’s lead author.
To reduce the burden on hospitals, the researchers recommend increased coordination between programs and standardized technical reporting formats.
For an abstract of the study, go to www.hschange.com/CONTENT/871 (case sensitive).