What are the three areas the Titanic accident can be observed from?
3 Perspectives...
-Design (built to remain afloat if as many as 4 of its compartments... [Show More] were flooded)
-Manufacturing (supposedly built to highest standards however allegations against this were made)
-Safety Equipment (not enough life boats)
Describe the risk management process in one sentence?
→ Identification of a hazard, threat or risk and determining its associated likelihood and consequences is applying risk analysis = RISK MANAGEMET
What ways could risk have been reduced in the Titanic scenario?
Ways to reduce risk in this scenario...
-reduce speed
-increase visual vigilance
-reinforce radio monitoring
-take more Southerly route
-take timely effective management decision
What does the traditional concept of safety look like?
Traditional Concept of Safety
What?, Who? And When? always determined however not necessarily Why? And How?
What are the characteristics of the safety culture?
Characteristics of Safety Culture
Informed, Wary, Just, Flexible and Learning
What did James Reason say in relation to organizational accidents?
'The incidence of organizational accidents is increasing as the world is growing and using more complex higher technology solutions.'
What is the difference between a hazard and a defense?
-A hazard is something causing unavoidable danger, peril, risk or difficulty possibly with the absence of predictability, chance or uncertainty.
- Defenses are the barriers and safeguards that separate damaging and injurious hazards from losses, which are vulnerable people or assets
What are the two conditions under which defenses can be breached?
-Active Failures. Human decisions and actions are implicated in organizational accidents where people make errors and commit
violations that are 'unsafe acts' as a result of human psychology.
-Latent Conditions. 'Latent conditions' are those where people working in complex systems make unintentional errors or violations as a result of the working environment
What is systems thinking?
-Systems thinking means understanding how individual elements within a system influence one another as a whole:
→ Establishes the root causes of any problem, accident or incident
- Analysis using this method must establish all known causal relationships between the root cause(s) and the defined problem, accident or incident
How many steps does root cause analysis have?
7
What is the definition of safety outline in the Chicago Convention, Annex 19?
The state in which risks associated with aviation activities, related to, or in direct support of the operation of aircraft, are reduced and controlled to an acceptable level.
Finish this sentence;
Safety is a dynamic characteristic of the aviation system,...
...whereby safety risks must be continuously mitigated which leads to improved 'safety performance'.
What is 'Practical Drift' as described by Scott A. Snook?
'In most activities including aviation, the baseline performance of any system drifts away from its original design when the organization's processes and procedures cannot anticipate all situations that may arise in daily operations'
Essentially, the difference between baseline performance and actual operational performance → Can be forseeable
List some possible reasons for practical drift?
-staff self-optimising their interactions with technology;
-technology that does not always operate as predicted;
-procedures that cannot be executed as planned under certain operational conditions;
-regulations that are not applicable within certain contextual limitations;
-introduction of changes to the system, including the addition of new
components;
-the interaction with other systems
List the components of the SHELL model?
S = Software: procedures, training, support, etc.
H = Hardware: machines and equipment.
E = Environment: the working environment in which the rest of the L-H-S system must function
L = Liveware: humans in the workplace.
L = Liveware: humans in the workplace.
Define 'Error'...
and in doing so, define 'mistakes' and 'slips and lapses'?
Error - 'an action or inaction by an operational person that leads to deviations from organizational or the operational person's intentions or expectations.'
Mistake - Mistakes are failures in the plan of action.
Slips and Lapses - are failures in the execution of the intended action [Show Less]
