THE HUMAN ERROR
informed our industry that, “only the Mafi a with their cement boots have a harsher discipline policy.”
JUST CULTURE Often we will hide our errors or mistakes in fear of punish- ment. Most people will report their errors if they under- stand why they made the error and they trust the system will treat them fairly if they report them. In order for this to take place, there must be a just culture. A just culture is one where any error or near miss will
not result in discipline except in cases of recklessness or sabotage. Recklessness must be defi ned as a case of an error in which the person knew there was a signifi cant chance that an error could occur and they chose to do it anyway. These reported errors can now be analyzed (through risk analysis) and corrective actions can be put in place to eliminate or lessen the chance of the error reccurring. That is what a correctly- functioning Safety Management System will do. What we are talking about is actually really quite simple. We begin to sweat the small stuff so we don’t have to sweat the big stuff . We work, breathe and sweat the small stuff and with everyone’s participation our industry and the people in it will be safer. Pope had it correct more than
300 years ago.
Gordon Dupont worked as a special programs coordinator for Transport Canada from March 1993 to August 1999. He was responsible for coordinating with the aviation industry in
the development of programs that would serve to reduce maintenance error. He assisted in the development of Human Performance in Maintenance (HPIM) Parts 1 and 2. The “Dirty Dozen” maintenance Safety posters were an outcome of HPIM Part 1.
Prior to working for Transport, Dupont worked for seven years as a technical investigator for the Canadian Aviation Safety Board (later to become the Canadian Transportation Safety Board). He saw fi rst hand the tragic results of maintenance and human error.
Dupont has held the position of principal of an aviation vocational training school as well as chief engineer for a corporate turbine aircraft. He has been an aircraft maintenance engineer and commercial pilot in Canada, the United States and Australia.
He is the past president and founding member of the Pacifi c Aircraft Maintenance Engineers
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Association. He is a founding member and a board member of the Maintenance And Ramp Safety Society (MARSS).
Dupont, who is often called “The Father of the Dirty Dozen,” has provided human factors training around the world. He retired from Transport Canada in 1999 and is now a private consultant.
Dupont has worked on and held signing authority on aircraft from the Piper Cub on fl oats through to the Boeing 74. He also owns a pile of hangar-stored parts that will one day fl y again as a Stearman (if and when he retires).
He is interested in any work that will serve to make our industry safer. Visit
www.system-safety.com for more information.
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