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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 33... ... 33 In late 2019, in the aftermath of the 737 Max 8 crashes, the Federal Aviation Administration (FAA) conducted a safety culture survey of the roughly 7,000 member staff in its Aviation Safety (AVS) Read the entire page →
From page 34... ... 34 EMERGING HAZARDS IN COMMERCIAL AVIATION -- REPORT 1 BOX 3-1 Excerpts from Shepardson (2020) , Reuters The safety culture survey, conducted in late 2019 and in focus groups in early 2020, said employees and managers reported "external pressure from industry is strong and is impacting" the safety culture. Read the entire page →
From page 35... ... SAFETY CULTURE AND ITS ASSESSMENT 35 TABLE 3-1 Traits of a Positive Safety Culture Traits Behaviors Leadership Safety Values and Actions Leaders demonstrate a commitment to safety in their decisions and behaviors. Problem Identification and Resolution Issues potentially impacting safety are promptly identified, fully evaluated, and promptly addressed and corrected commensurate with their significance. Read the entire page →
From page 36... ... 36 EMERGING HAZARDS IN COMMERCIAL AVIATION -- REPORT 1 culture report quoted extensively herein is recommended as a reference for the research that validates and elaborates on these traits (NASEM, 2016) .1 The traits listed in the table are interrelated. Read the entire page →
From page 37... ... SAFETY CULTURE AND ITS ASSESSMENT 37 that 6% of the AVS 7,000-member workforce has raised safety issues with FAA management. The committee looks forward to learning about these reports in subsequent briefings from AVS. Read the entire page →
From page 38... ... 38 EMERGING HAZARDS IN COMMERCIAL AVIATION -- REPORT 1 BOX 3-2 Five Practices for Developing "Mindfulness" 1. Preoccupation with failure. Read the entire page →
From page 39... ... SAFETY CULTURE AND ITS ASSESSMENT 39 with focus groups are appropriate beginning steps in safety culture assessment, as described in the next section. The details of the survey instrument were not established at the time of the committee's briefing (January 2022) 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.