Emerging Hazards in Commercial Aviation—Report 1: Initial Assessment of Safety Data and Analysis Processes (2022) / Chapter Skim
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Pages 18-24
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18 EMERGING HAZARDS IN COMMERCIAL AVIATION -- REPORT 1 from misunderstandings and faulty sense making2 (Weick and Sutcliffe, 2015)
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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)
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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)
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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.
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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.
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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.
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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)
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