Accident Precursor Analysis and Management Reducing Technological Risk Through Diligence (2004) / Chapter Skim
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Section III Risk Assessment4 Understanding Accident Precursors
Section III Risk Assessment4 Understanding Accident Precursors
Pages 61-78
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Section m Risk Assessment
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The types of accidents or adverse events vary among industries, from airplane crashes in the aviation industry to lethal emissions in the chemical indush y to patient injuries and deaths in the health care industry. These harmful events differ in their probability of occurrence; in the distribution of their negative consequences among employees, clients, and the public; in the complexity and interdependence embedded in their technologies; and in the regulatory context in which they operate (Petrow, 1984)
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, such as in the Patient Safety Reporting System. SEEKING ACCIDENT PRECURSORS AMONG NEAR ACCIDENTS Accidents md adverse events provide critical sources of information about accident precursors.
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First, the Aviation Safety Reporting System (ASRS) is described to illustrate some common processes involved in detecting md identifying accident precursors md to provide a common frame of reference.
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Individuals working in airlines, aim, arts, and air traffic control facilities are encouraged to file reports. Although pilots submit most of the repo Is, ASRS encourages reporting by air traffic controllers and other groups to the aviation community.
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Third, pilots receive limited immunity from administrative action by the FAA if they have filed m ASRS report regarding a possible infraction. The FAA may still take action agamst the pilot, but the simctions will not include certificate suspension, thus allowmg the pilot to contmue flying Finally, ASRS uses deidentffication of both mdividuals and airlmes to ensure that reports are not used as a basis for regulatory enforcement, disciplinary action, or litigation.
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ASRS safety analysts identify accident precursors by exa dining critical incidents in detail and by noticing patterns in the data. After an arrcraR accident, ASRS safety analysts routinely search the database for near accidents that occu red under similar conditions.
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Disseminating information ASRS representatives regularly brief FAA policy makers and issue wammgs about hazardous situations m air traffic control facilities and airports. ASRS also publishes r.tfommation about accident precursors on the Web and m print.
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Indeed, based on ASAP reports, the arrlme has identified and used accident precursors in pilot training sessions, updated unclear and potentially confusing arrlme procedures, and clarified regulatory expectations. By comparison, ASRS aggregates data at a national level, which enables safety atlalysts to identify patterns m rare events that, ff repo ted only to m airlme, might be classified as isolated events.
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In addition, the Institute of Nuclear Power Operations HIPPO) encourages, but does not require, plant managers to report such events to a closed information dissemination system operated by INPO, Health Care Health care organizations, including blood banks, hospitals, and pharmaues, have begun to pool data regarding actual and potential adverse events.
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By Using a broad, general defmition of safety-related events, ASRS cm capture data on events that may lead to the identification of previously unknown accident precursors. By contrast, the FAA-operated computerized surveillance system used m air traffic control centers applied specific, precisely measured definitions of deviations from safety standards that tended to identify well known conditions that were unlikely to yield new insights into accident precursors (Tamuz, 2001)
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Aviation Automated safety surveillance systems have been Implemented in the air transportation indust y. As early as 1986, the FAA implemented a computerized surveillance system m air traffic control centers that automatically detected when m aircraft failed to maintain its assigmed separation distance (Tamuz, 1987)
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Consider the desigm choices in the FAA Near Midair Collision Reporting System and ASRS. If a pilot reports a near miss to the FAA Near Midair Collision Reporting System m which m air traffic negularion was violated, the FAA can initiate enforcement action against the pilot based on his own report.
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Health Care Two health care reporting systems are modeled after ASRS: (1) the VHA Patient Safety Reporting System and (2)
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For example, the aviation industry has developed several methods of detecting and gathering information about potential accident precursors. In addition, they have de signed alternative models for aggregating data on different organizational levels, from the airline level to the level of air traffic control facilities to the interorganizational level encompassing everyone who uses the national airspace.
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Flight Safety Digest 17(7-9) : 1 56 Griffth, S
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78 ACCIDENT PRECURSOR AVALYSIS A VD IUA VAGEIUENT Reynard, W.D., C.E.
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