How to Learn from Errors: Lessons from Aviation Industry

• Focused efforts in 1960’s/1970’s to reduce accidents/fatalities
  
• Key aspects of safety program
  
  • Mandatory reporting, public investigation of all accidents (with potential sanctions)
    
  • Voluntary, confidential reporting of near-misses (which are often richer learning opportunities than accidents themselves!)
    
  • Emphasis on simulation exercises, including simulations involving entire team (Crew Resource Management), to practice responses to rapidly changing, unstable flight conditions – error recognition and recovery