Letter to the Editor: The New Yorker
The growing interest in National Transportation Safety Board-style sentinel event reviews in high-consequence industries such as healthcare and law enforcement is based, in large part, on the perceived success of the US commercial aviation industry (see Douglas Starr’s “A New Way to Reform the Judicial System,” published in The New Yorker online on March 31, 2015). However, the key to aviation’s success came not from investigating past accidents, but in a more scientific approach to prevention through predictive
Between 1995 and 2005, the US airline industry achieved a 78% reduction in the fatal accident rate, sustained through present day. During this period, while the Safety Board’s investigative approach remained essentially unchanged from its inception in 1959, the airlines, their unions, and the Federal Aviation Administration transformed the industry through partnership programs that collected, analyzed, and managed risk before accidents occurred. Notably, two predictive programs are seen as cornerstones of this success: one examining the statistical digital data of routine operations (Flight Operations Quality Assurance, or FOQA), and the other a voluntary human factors-based reporting program offering preventative action in lieu of legal enforcement (Aviation Safety Action Programs, or ASAPs).
The outcomes we produce in daily life, as well as in high-consequence industries, are probabilistic. The latest science offers systematic methods of prediction, including socio-technical probabilistic risk modeling and intervention, which are proving successful in high-consequence industries across the globe. Investigating yesterday’s plane or train crash, patient death, or fatal citizen arrest is far less likely to prevent the next adverse event than the collaborative approach to identifying and managing risk in a proactive fashion.
Captain K. Scott Griffith, American Airlines Chief Safety Officer (retired)
Chief Charles “Chuck” Gruber, President of the International Association of Chiefs of Police (retired)
Fiona Lawton, Safety Programs & Promotions Manager at Airservices Australia
Chief Paul LeSage, Assistant Fire Chief and Flight Paramedic, Portland, Oregon (retired)
John Overton, MD, Medical Officer of the National Transportation Safety Board (retired)
Captain James T. Schultz, Associate Administrator for Safety, Federal Railroad Administration (retired)
April 5, 2015