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June 2007
content
􀀴 Concept of safety
􀀴 The evolution of safety thinking
􀀴 A concept of accident causation – Reason model
􀀴 The organizational accident
􀀴 People, context and safety – SHEL(L) model
􀀴 Errors and violations
􀀴 Organizational culture
􀀴 Safety investigation
􀀴 Questions and answers
􀀴 Points to remember
A project supported by AIRBUS and the CAAC
A project supported by AIRBUS and the CAAC
June 2007
Concept of safety
􀀴 What is safety?
􀂃 Zero accidents or serious incidents (a view widely
held by the travelling public).
􀂃 Freedom from hazards (i.e. those factors which
cause or are likely to cause harm).
􀂃 Attitudes towards unsafe acts and conditions by
employees of aviation organizations.
􀂃 Error avoidance.
􀂃 Regulatory compliance.
􀂃 … ?
A project supported by AIRBUS and the CAAC
June 2007
Concept of safety
􀀴 Consider (the weaknesses in the notion of perfection)
􀂃 The elimination of accidents (and serious incidents)
is unachievable.
􀂃 Failures will occur, in spite of the most accomplished
prevention efforts.
􀂃 No human activity or human-made system can be
guaranteed to be absolutely free from hazard and
operational errors.
􀂃 Controlled risk and controlled error are acceptable
in an inherently safe system.
A project supported by AIRBUS and the CAAC
A project supported by AIRBUS and the CAAC
June 2007
Concept of safety (Doc 9859)
􀀴 Safety is the state in which the risk of harm to
persons or property damage is reduced to, and
maintained at or below, an acceptable level through a
continuing process of hazard identification and risk
management.
A project supported by AIRBUS and the CAAC
June 2007
Safety
􀂙 Traditional approach – Preventing accidents
􀂾 Focus on outcomes (causes)
􀂾 Unsafe acts by operational personnel
􀂾 Attach blame/punish for failures to “perform safely”
􀂾 Address identified safety concern exclusively
􀂙 Identifies:
WHAT? WHO? WHEN?
WHY? HOW?
􀂙But not always discloses:
A project supported by AIRBUS and the CAAC
A project supported by AIRBUS and the CAAC
June 2007
The evolution of safety thinking
TODAY
1950s 1970s 1990s 2000s
HUMAN FACTORS(INDIVIDAL )
Fuente: James Reason
A project supported by AIRBUS and the CAAC
June 2007
A concept of accident causation
Latent conditions trajectory
Technology
Training
Regulations
Defences
Errors
and
violations
People Accident
Working
conditions
Organization Workplace
Management
decisions and
organizational
processes
Source: James Reason
A project supported by AIRBUS and the CAAC
A project supported by AIRBUS and the CAAC
June 2007
The organizational accident
Organizational processes
Activities over which any organization has a reasonabledegree
of direct control
􀂾Policy-making
􀂾Planning
􀂾Communication
􀂾Allocation of resources
􀂾Supervision
􀂾 ...
A project supported by AIRBUS and the CAAC
June 2007
The organizational accident
Conditions present in the system before the accident, made evident
by triggering factors.
􀂾 Inadequate hazard
identification and
risk management
􀂾 Normalization of
deviance
A project supported by AIRBUS and the CAAC
A project supported by AIRBUS and the CAAC
June 2007
The organizational accident
Resources to protect against the risks that organizations involved
in production activities generate and must control.
􀂾Technology
􀂾Training
􀂾Regulations Defences
Organizational processes
Latent
conditions
A project supported by AIRBUS and the CAAC
June 2007
The organizational accident
Factors that directly influence the efficiency of people in
aviation workplaces.
􀂾 Workforce stability
􀂾 Qualifications and
experience
􀂾 Morale
􀂾 Credibility
􀂾 Ergonomics
􀂾 ...
A project supported by AIRBUS and the CAAC
A project supported by AIRBUS and the CAAC
June 2007
The organizational accident
　
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