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seeing repeated patterns of error. Eventually human factors advocates aimed their appeals at a wider audience, including the board's technical staff, members of Congress and their senior aides, senior executives in the Department of Transportation, and the White House and Cabinet.

The experience of Delta Air Lines illustrates how a major air carrier can change its culture of safety. At Delta, human factors professionals faced the challenge of incorporating human factors principles into the day-to-day operations of a carrier with some 65,000 employees, 545 airplanes, and over 2,600 daily flights—and to do so with an eye toward both economics and safety.

Some key people with the major airlines believe that if a pilot or another employee makes an error, the solution is to discipline the employee. Although this may be entirely appropriate when people deliberately violate standard procedures, most errors do not fall into that category. Most are honest human errors. Airlines cannot assume error-free human performance. Instead, they must devise procedures, training programs, system redundancies, and other engineering principles that will minimize the probability of human error and, most importantly, ensure that the errors that do occur are detected, contained, and corrected before they cause an incident or accident.

Toward this end, human factors specialists and other key people at Delta are changing the company's culture to embed considerations of human performance and risk management into every job, from ramp worker to flight attendant to mechanic. Delta's human factors group spends long hours at the maintenance hangar, for example, studying people as they change shifts or try to work as a team. The group is also studying the airline's operations control center, the ''nerve center,'' to improve decision making during major storms and other unusual situations.

Because the Delta corporate leadership is strongly committed to this new culture of safety, many of the company's human factors activities no longer have to be justified on purely economic grounds—which shows what can happen when one makes a successful case to corporate executives. Nonetheless, commitments to human factors will not be sustained for long without producing concrete results. In the past, some human factors programs in the airlines were too concerned with psychological dimensions—the "hold hands and we'll fly safe" approach. These programs fell by the wayside because they did not really change how people performed in their everyday jobs.

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