AOCOPM 2024 Midyear Educational Conference-346719

Video Transcription

Video Summary

Colonel Ribeiro, an aerospace medicine specialist and command surgeon at the U.S. Army Combat Readiness Center, discusses his work in mishap investigation, aiming to prevent future incidents by focusing on human factors analysis. A striking 85% of Army fatalities are due to human error. Ribeiro introduces the Human Factors Analysis and Classification System (HFACS), which is used to identify failures at different levels, ranging from individual errors to organizational deficiencies. This method emphasizes the Swiss cheese model, where multiple failures align to result in a mishap. Through a detailed case study of a training mishap involving a negligent discharge of a weapon, Ribeiro illustrates how contributory factors included individual complacency, untreated psychiatric disorders, and leadership failures. This particular mishap, he explains, demonstrates how systemic failures in training and leadership can lead to tragic outcomes, underscoring the importance of addressing both active and latent failures. Ribeiro also highlights how these investigations' findings are used not just to assign blame but to improve safety policies, training, and risk management practices to prevent future incidents.

Keywords

aerospace medicine

mishap investigation

human factors analysis

Army fatalities

HFACS

Swiss cheese model

training mishap

systemic failures

safety policies