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