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From page 13... ... 13 Commercial aviation, and other safety-critical activities that society depends on, recognize that hazards1 can never be fully eliminated, particularly those that come from outside the system (e.g., weather's impact on aviation operations) Read the entire page →
From page 14... ... 14 EMERGING HAZARDS IN COMMERCIAL AVIATION -- REPORT 1 in which the "front-line" personnel operate with its corresponding supports for, or stressors on, their performance. Thus, these accidents are sometimes termed "organizational accidents," reflecting the many contributors to them, and the many facets of processes required throughout all aspects of the organization to protect against them (Reason, 1997) Read the entire page →
From page 15... ... MANAGING SAFETY IN COMPLEX SYSTEMS 15 are processes to identify and characterize all the hazards that could lead to catastrophes to inform safety management. Industries that produce explosive or otherwise hazardous products typically use the term "barrier" to control hazards because their primary intent is to contain hazardous materials from release into the workspace and broader environment. Read the entire page →
From page 16... ... 16 EMERGING HAZARDS IN COMMERCIAL AVIATION -- REPORT 1 also cover principles for the design and test of safety-critical hardware and software. The standards are developed based on in-depth assessment of hazards and build mitigations into the design. Read the entire page →
From page 17... ... MANAGING SAFETY IN COMPLEX SYSTEMS 17 of causality including complex interactions among system components and even circular causality, which forms the basis for system dynamics (Sterman, 2000) Read the entire page →
From page 18... ... 18 EMERGING HAZARDS IN COMMERCIAL AVIATION -- REPORT 1 from misunderstandings and faulty sense making2 (Weick and Sutcliffe, 2015) Read the entire page →
From page 19... ... MANAGING SAFETY IN COMPLEX SYSTEMS 19 and testing to ensure the procedure is accurate and appropriate to the task at hand (Ockerman and Pritchett, 2000) Read the entire page →
From page 20... ... 20 EMERGING HAZARDS IN COMMERCIAL AVIATION -- REPORT 1 system within modern autoflight serves to protect against low speed and stall. However, several accident reports revealed that when the auto flight system is commanded in an unanticipated manner, or used in unusual flight operations, or a vital sensor fails, these systems can instead create unexpected behaviors or fail to act as expected, contributing to accidents, particularly when personnel are trained to depend on them.7 In 2015, FAA required Part 121 air carriers to implement safety management systems (SMSs) Read the entire page →
From page 21... ... MANAGING SAFETY IN COMPLEX SYSTEMS 21 Importantly for this report, an effective SMS will ensure that an organization will generate and analyze indicator and precursor measures that managers can apply to a continuous safety improvement process. This information can be generated from all facets of safety-critical organization operations, including flight, communications, and maintenance. Read the entire page →
From page 22... ... 22 EMERGING HAZARDS IN COMMERCIAL AVIATION -- REPORT 1 Accidents typically involve more than a single contributing cause. Trends in any of these measures, however, could be worrisome and highlight where deeper analysis of the system of controls and shifts in safety management may be needed. Read the entire page →
From page 23... ... MANAGING SAFETY IN COMPLEX SYSTEMS 23 this time dimension would also differ. For future and intermediate emerging hazards for which no measures are available, one might rely on simulations or workshops to elicit judgments from subject-matter experts representing a range of perspectives. Read the entire page →
From page 24... ... 24 EMERGING HAZARDS IN COMMERCIAL AVIATION -- REPORT 1 FIGURE 2-2 Control in a socio-technical system. SOURCE: Based on Figure 4, the STAMP model, in Leveson (2004) Read the entire page →
From page 25... ... MANAGING SAFETY IN COMPLEX SYSTEMS 25 (Identifying emerging hazards from issues such as a new generation of vertical take-off and landing air taxis and UASs, as described in Chapter 5, would require different approaches at the design and certification levels.) As depicted in Table 2-1, the organizational level can be thought of as having three elements: the operational front line or "sharp end" of the organization; management; and culture. Read the entire page →
From page 26... ... 26 EMERGING HAZARDS IN COMMERCIAL AVIATION -- REPORT 1 TABLE 2-1 Illustrative Generic Accident Precursor Measures Control Layers Function Socio-Technical System Individual Organizations Example Interactions Among Organizations Providing Sources of Precursor MeasuresFront Line Management Safety Culture Flight Operations Adverse events, alarms, flight deviations, runway incursions, etc. Line audits Voluntary and mandatory reports Research indicating inadequate humansystems design in displays and automation Software issues Rigor of hazard ID and risk assessment Procedure/control lapses Voluntary and mandatory reports SMS outputs (selfaudit reports and timeliness of CAPs) Read the entire page →
From page 27... ... MANAGING SAFETY IN COMPLEX SYSTEMS 27 TABLE 2-1 Illustrative Generic Accident Precursor Measures Control Layers Function Socio-Technical System Individual Organizations Example Interactions Among Organizations Providing Sources of Precursor MeasuresFront Line Management Safety Culture Flight Operations Adverse events, alarms, flight deviations, runway incursions, etc. Line audits Voluntary and mandatory reports Research indicating inadequate humansystems design in displays and automation Software issues Rigor of hazard ID and risk assessment Procedure/control lapses Voluntary and mandatory reports SMS outputs (selfaudit reports and timeliness of CAPs) Read the entire page →
From page 28... ... 28 EMERGING HAZARDS IN COMMERCIAL AVIATION -- REPORT 1 methods of abnormalities and potential hazards beyond those that measure exceedances. The above examples come from operational experience, but precursors can also be generated from research and experimentation. Read the entire page →
From page 29... ... MANAGING SAFETY IN COMPLEX SYSTEMS 29 operational errors, failures in carrying out procedures and policies, failures in compliance, weak monitoring and control practices, increasing weakening and misalignment of organizational culture (differences in espoused and actual behavior) , managerial defensiveness and simplified views, decreases in audits, decreases in training, increases in regulatory complaints, missed audits, missed deadlines, and increased staff turnover (Roux-Dufort, 2007; Williams et al., 2017) Read the entire page →
From page 30... ... 30 EMERGING HAZARDS IN COMMERCIAL AVIATION -- REPORT 1 socio-technical system. Therefore, it is desirable to have precursor measures available for monitoring whether troublesome trends are becoming apparent in any area of the system. Read the entire page →
From page 31... ... MANAGING SAFETY IN COMPLEX SYSTEMS 31 first designed and implemented. Reason describes this tendency as "trading off added protection for improved production" (Reason, 1997, p. Read the entire page →
From page 32... ... 32 EMERGING HAZARDS IN COMMERCIAL AVIATION -- REPORT 1 Reason, J Read the entire page →

From page 13...

... 13 Commercial aviation, and other safety-critical activities that society depends on, recognize that hazards1 can never be fully eliminated, particularly those that come from outside the system (e.g., weather's impact on aviation operations)