A publication of the National Air Traffic Controllers Association
Issue link: http://natca.uberflip.com/i/802044
W E D N E S D AY, M A R C H 2 2 , 2 0 1 7 N AT C A D A I LY D I S PAT C H 9 sorts of consequences." "Things don't go right, people die. Things don't go right, people get hurt. Things don't go right, there's organizational, personal, professional embarrassment. Things don't go right, there's internal investigation. Things don't go right, there are criminal filings against our own personnel. Things don't go right, we get sued." "How dare we take a high risk job like air traffic control operations and not be talking about this stuff (risk management) all the time?" "All it takes is all of the holes in the Swiss cheese to line up and something bad can happen." On lawyers: "Day school people know theory. Night school people win cases." "Two ways we get in trouble: Somebody did something bad on purpose, or somebody made a mistake." "Stay away from beer, the volume's too great. Stay away from wine, the volume's too great. The answer is vodka." "In a free society, if somebody wants to behave badly today, they can pull it off with great ease. How do we stop this stuff from happening? We can thwart it with two concepts. Concept number 1: Vigilance…Bring back the vigilance. We've got to bring back the vigilance…Concept number 2: Random irregularity. We've got to build in some random irregularity." "It's very difficult to stop intentional bad behaviors." "The question you should be asking yourself is what control measures do we have in place to address those issues." "People who lie on their applications will lie whenever it's convenient for them." "Scares the crap out of me. They're (General Aviation pilots) not bad people, but they make mistakes. You don't have to be a bad or evil person to cause a tragedy on the runway." "Internal error: where our own people do stupid things that cause us grief. They make mistakes." "The question you need to ask in any operation, in any job description, in any profession is where is error most likely to occur?" "Rarely do we make mistakes on high frequency events unless we allow one of these five to happen: complacency, fatigue, hubris, distractions, and risk homeostasis." "Where I worry for everybody is in this top left box. When good people get involved in high risk / low frequency events, bad things are much more likely to happen." "Study your past tragedies. The errors you're going to make can be predicted form the errors already made." "Every day, we've got to train." Gordon Graham, continued from page 1