welcome report tomorrow 32 years ago my
brother died in a car crash it was his
fault his mistake he did not have his
system which protected him seven years
later I was in bed at home with my
girlfriend Stella she’s now my wife and
the mother of our beloved children Maria
in power on a Sunday evening the
telephone rings while we were in bed and
I said no I don’t pick it up I don’t
want to we did not have cell phones at
that day the telephone rang a second
time and I said it’s my day off
I don’t pick it up after the fifth time
the telephone rang I decided I have to
pick it up something must have happened
seven years after we lost my brother my
sister’s on the phone she’s crying she’s
laughing at the same time after having
tried five times to get me on the phone
and I said Monica what happened what’s
the matter with you she said you cannot
possibly imagine how happy I am to hear
your voice right now and I said but why
and she said an airplane has crashed a
couple of hours ago and I said Monica
I’m 23 years old I’m flying a Boeing 767
as a co-pilot for Lauda here and not
every airplane which comes down is an
airline is an airplane of laudare we
only have two 767 and she said switch on
the TV look at it and then I said where
should it have happened and she said in
Bangkok and then it was very silent on
the phone because I recalled that I was
on the phone with her a couple of days
ago and I said bye-bye Monica I’m flying
to Bangkok on Thursday and I will be
back on Sunday Sunday night it was the
Sunday but I was not on board I did not
get the flight I didn’t carry the sign
somebody else did and at that day safety
became paramount
because I knew I lost friends in the
airline in a car in an airplane crash I
lost a brother in a car crash
what’s the reason why things go wrong on
that airplane
the pilots didn’t do anything wrong the
engineers did and engineers are humans
and he did not know how an airplane
behaves that altitude when a thrust
reverser just suddenly extends and makes
the airplane unflyable what we learned
in the last 25 years is that engineering
is based on human experience human
knowledge flying airplanes is based on
human knowledge human intelligence but
we also realized that we make mistakes
everybody of us every day and would like
to ask you who during the last day has
made a mistake an error raise your hands
quiet everybody thank you quite
everybody makes a mistake
and it is the responsibility of safe
systems of safe organizations to make
this human imperfection not having a
consequence all modern cars have impact
protection have airbags have a system
where the truck will not kill the truck
driver with the next years that’s a law
the accident my brother had will not
happen so the question is what can we do
what can you do for yourself first of
all we have aviation as a system and
aviation itself that’s my office it’s
worth about a hundred million US dollars
I get it in the morning and I say Huntz
make yourself a nice day and bring it
back safely and I say I will and my
system knows I’m now working for
Austrian Airlines I’m kept on the a320
my system knows that everybody makes
mistakes the best pilot the best doctor
the best engineer but it’s our common
task to make sure that the mistake of
one single person does not have a
consequence which is doing harm and
which is ruining lives an error for you
might be painful it might ruin your
career
it might do harm so it’s very wise to
check what system has
evolved the best way to guarantee safety
and as I might say it’s aviation
actually as one of the systems who are
really doing a good job this is our
statistic at the moment and I want to
show you this point this point 2015
those are various safety levels various
safety levels in international aviation
we are talking about jet aircraft in
commercial operation in 2015 was the
first year we achieved zero casualties
zero accidents in international airline
operations with the exception of two
crashes which were security and a
sabotage problem but talking safety we
achieved this and how and there are two
interesting components the first
component is we have to escape
complexity when you think about your
personal life how many emails do you get
per day how many Calendar duties do you
have per day how many things do you have
to remember per day what knowledge have
you had to administer per day everything
is getting more complex rapidly when we
go to a company or to a hospital we ask
one very mean question when we’re there
and when we see how complicated things
are managed we ask why are you doing it
that way
and they say we don’t know we always did
it this way because when somebody wants
to solve a problem he very often adds
one process step it’s reserved for the
other one what we actually do is we
multiply process steps and every step
you introduce to protect another step is
one more chance of failure we introduce
checklists in hospitals and we think
people use checklists people don’t use
checklists regularly checklists are not
cool checklists if you don’t train them
and not an instrument of a professional
checklist is something sometimes
regarded as being hey I don’t need it I
know what I’m doing
not everybody remembers everything what
is important all the time and the other
thing is since the first of October 2010
sixteen since one month European
Aviation Regulations send out a
regulation which is compulsory if a
flight crew on a simulator or on a Czech
flight is not behaving as we expect them
to behave international norms of non
technical skills of very well team
behavior of structured decision-making
of good leadership if they do not behave
that way they might fail the Czech
flight whereas they provided excellent
technical skills so what we do is we
know humans are the subject that needs
to be trained that needs to be
fascinated for tools who guarantees
safety in their own interest in their
own responsibility for our system for
our organization and for yourself
and if you think as I might see you’re
not very convinced that you make
mistakes all the time I can prove it
I want you to use the tools and to think
about aviation as a system has developed
a set of tools it’s free to use you just
need to take it and ask what they are
doing when you look at this picture and
you have a glance across it it’s that
picture appearing as if it’s moving or
is it standing still you can take a
choice if it is moving it’s the one
thing then you see it as you should see
it but it’s wrong because the picture is
not moving if you don’t see it moving
you’re perfectly correct but you might
have a medical problem you can take a
choice now but the point in this picture
is it’s a very simple demonstration of
human factors we are not constructed for
what we are actually doing this picture
is evolving in your brain with the
information your eyes present and if
you’re not aware that your brain is
cheating on you if it gets
trap then you won’t succeed bear that in
mind for our safety when you fly with us
when you go to a hospital we have a lot
to achieve and we have to escape this
bloody complexity which is making
everything much more difficult than it
could be thank you
[Applause] [Music]
brother died in a car crash it was his
fault his mistake he did not have his
system which protected him seven years
later I was in bed at home with my
girlfriend Stella she’s now my wife and
the mother of our beloved children Maria
in power on a Sunday evening the
telephone rings while we were in bed and
I said no I don’t pick it up I don’t
want to we did not have cell phones at
that day the telephone rang a second
time and I said it’s my day off
I don’t pick it up after the fifth time
the telephone rang I decided I have to
pick it up something must have happened
seven years after we lost my brother my
sister’s on the phone she’s crying she’s
laughing at the same time after having
tried five times to get me on the phone
and I said Monica what happened what’s
the matter with you she said you cannot
possibly imagine how happy I am to hear
your voice right now and I said but why
and she said an airplane has crashed a
couple of hours ago and I said Monica
I’m 23 years old I’m flying a Boeing 767
as a co-pilot for Lauda here and not
every airplane which comes down is an
airline is an airplane of laudare we
only have two 767 and she said switch on
the TV look at it and then I said where
should it have happened and she said in
Bangkok and then it was very silent on
the phone because I recalled that I was
on the phone with her a couple of days
ago and I said bye-bye Monica I’m flying
to Bangkok on Thursday and I will be
back on Sunday Sunday night it was the
Sunday but I was not on board I did not
get the flight I didn’t carry the sign
somebody else did and at that day safety
became paramount
because I knew I lost friends in the
airline in a car in an airplane crash I
lost a brother in a car crash
what’s the reason why things go wrong on
that airplane
the pilots didn’t do anything wrong the
engineers did and engineers are humans
and he did not know how an airplane
behaves that altitude when a thrust
reverser just suddenly extends and makes
the airplane unflyable what we learned
in the last 25 years is that engineering
is based on human experience human
knowledge flying airplanes is based on
human knowledge human intelligence but
we also realized that we make mistakes
everybody of us every day and would like
to ask you who during the last day has
made a mistake an error raise your hands
quiet everybody thank you quite
everybody makes a mistake
and it is the responsibility of safe
systems of safe organizations to make
this human imperfection not having a
consequence all modern cars have impact
protection have airbags have a system
where the truck will not kill the truck
driver with the next years that’s a law
the accident my brother had will not
happen so the question is what can we do
what can you do for yourself first of
all we have aviation as a system and
aviation itself that’s my office it’s
worth about a hundred million US dollars
I get it in the morning and I say Huntz
make yourself a nice day and bring it
back safely and I say I will and my
system knows I’m now working for
Austrian Airlines I’m kept on the a320
my system knows that everybody makes
mistakes the best pilot the best doctor
the best engineer but it’s our common
task to make sure that the mistake of
one single person does not have a
consequence which is doing harm and
which is ruining lives an error for you
might be painful it might ruin your
career
it might do harm so it’s very wise to
check what system has
evolved the best way to guarantee safety
and as I might say it’s aviation
actually as one of the systems who are
really doing a good job this is our
statistic at the moment and I want to
show you this point this point 2015
those are various safety levels various
safety levels in international aviation
we are talking about jet aircraft in
commercial operation in 2015 was the
first year we achieved zero casualties
zero accidents in international airline
operations with the exception of two
crashes which were security and a
sabotage problem but talking safety we
achieved this and how and there are two
interesting components the first
component is we have to escape
complexity when you think about your
personal life how many emails do you get
per day how many Calendar duties do you
have per day how many things do you have
to remember per day what knowledge have
you had to administer per day everything
is getting more complex rapidly when we
go to a company or to a hospital we ask
one very mean question when we’re there
and when we see how complicated things
are managed we ask why are you doing it
that way
and they say we don’t know we always did
it this way because when somebody wants
to solve a problem he very often adds
one process step it’s reserved for the
other one what we actually do is we
multiply process steps and every step
you introduce to protect another step is
one more chance of failure we introduce
checklists in hospitals and we think
people use checklists people don’t use
checklists regularly checklists are not
cool checklists if you don’t train them
and not an instrument of a professional
checklist is something sometimes
regarded as being hey I don’t need it I
know what I’m doing
not everybody remembers everything what
is important all the time and the other
thing is since the first of October 2010
sixteen since one month European
Aviation Regulations send out a
regulation which is compulsory if a
flight crew on a simulator or on a Czech
flight is not behaving as we expect them
to behave international norms of non
technical skills of very well team
behavior of structured decision-making
of good leadership if they do not behave
that way they might fail the Czech
flight whereas they provided excellent
technical skills so what we do is we
know humans are the subject that needs
to be trained that needs to be
fascinated for tools who guarantees
safety in their own interest in their
own responsibility for our system for
our organization and for yourself
and if you think as I might see you’re
not very convinced that you make
mistakes all the time I can prove it
I want you to use the tools and to think
about aviation as a system has developed
a set of tools it’s free to use you just
need to take it and ask what they are
doing when you look at this picture and
you have a glance across it it’s that
picture appearing as if it’s moving or
is it standing still you can take a
choice if it is moving it’s the one
thing then you see it as you should see
it but it’s wrong because the picture is
not moving if you don’t see it moving
you’re perfectly correct but you might
have a medical problem you can take a
choice now but the point in this picture
is it’s a very simple demonstration of
human factors we are not constructed for
what we are actually doing this picture
is evolving in your brain with the
information your eyes present and if
you’re not aware that your brain is
cheating on you if it gets
trap then you won’t succeed bear that in
mind for our safety when you fly with us
when you go to a hospital we have a lot
to achieve and we have to escape this
bloody complexity which is making
everything much more difficult than it
could be thank you
[Applause] [Music]
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