Aviation accident statistics
Research and explain some of the categorical issues to be aware of in analyzing and comparing commercial aviation accident statistics.
Commercial Aviation Safety (6th edition) by Stephen K. Cusick, Antonio I. Cortez, Clarence C. Rodrigues
Chapter 2, Why Do Accidents Happen?
Chapter 11, Safety Data
Chapter 12, Managing Safety
https://www.ntsb.gov/safety/data/Pages/AviationDat…
Common Accident Models SFTY 409 Module 3 ▪ ▪ ▪ ▪ ▪ ▪ ▪ Domino Theory Human Factors Model Accident/Incident Theory Systems Theory Behavioral Safety Theory Managing Organizational Risk Combination Theory Overview Accident Causation Theories… A model will help you organize all the data you are finding. A model will help you find “all” the casual factors and maybe the “true” root cause. Models Accidents are always complex interactions of many factors, some are just more complex. Developed by Herbert Heinrich (Travelers Insurance Co) in 1920 ▪ 88% Caused by Unsafe Acts ▪ 10% Caused by Unsafe Conditions ▪ 2% are Unavoidable Domino Theory Permission to use image- OSHA ▪ Fault of person ▪ Unsafe act, mechanical, or physical hazard ▪ The accident itself ▪ Injury Domino Theory 2 ▪ Ancestry and social environment Social Environment & Ancestry Carelessness: Fault of the Person Unsafe Act or Condition Accident “Industrial Accident Prevention” Injury Domino Theory 3 People Dominos: ▪ Inherited ▪ Acquired ▪ Direct Cause of Accident ▪ Remove the central factor (Act/Condition) prevents accidents and injuries. ▪ Corrective Action Sequence ▪ Engineering ▪ Education ▪ Enforcement Domino Theory 4 ▪ Injuries are caused by action of preceding factors. SERIOUS 1920 Study 1 Recent Study 29 MINOR 59 300 CLOSE CALLS 600 Domino Theory 5 1 ▪ Overload (imbalance in a persons capacity) ▪ Inappropriate Response: How a person responds to a situation. ▪ Inappropriate Activity: Human error in judgment, action, direction, etc. Human Factors Three broad factors (Stressors) lead to human error: ▪ Environmental factors ▪ Internal factors ▪ Situational factors (level of risk, unclear instructions) ▪ Inappropriate Response Examples: ▪ Removal of safety provisions ▪ Disregard for instructions Human Factors 2 Overload: Affected by: ▪ A person undertaking a task he or she doesn’t know how to do. ▪ Misjudging the degree of risk involved in an activity. ▪ Not identifying to others, that additional training is required to safely perform a task. Human Factors 3 Inappropriate Activities: Accident Zone Stress Level Time Human Factors Stress Ability to Handle Stress Period of Vulnerability Multiple Accident Zones Stress Level Time Human Factors Stress 2 Affects of alcohol, fatigue, illness, etc. Reduced Ability to Handle Stress Starts with Human Factors (overload, response, actions) incorporates “ergonomic” traps ▪ Incompatible Workstations ▪ Incompatible Expectations ▪ Work rate ▪ Production levels Accident/Incident Theory Permission to use image- OSHA ▪ Deadlines ▪ Budget ▪ Schedule ▪ Peer pressure Includes systems failures, such as, poor policy or incomplete training. Proposes a causal relationship exists between management climate and focus, and accident causation. Liveware CPU Issues “Environmental Factors” influence individuals making bad decisions. Overload Inappropriate Response Human Error Accident Injury/Damage Inappropriate Activity Human Factors Theory Accident/Incident Overload ▪ ▪ ▪ ▪ ▪ ▪ Pressure Fatigue Motivation Drugs Alcohol Worry Ergonomic Traps ▪ Incompatible Workstations, i.e., size force, reach, etc. ▪ Incompatible expectations Human Error Decision to Err ▪ Misjudgment of the risk ▪ Unconscious desire to err ▪ Logical decision based on situation Accident Theory 2 Accident/Incident ▪ ▪ ▪ ▪ ▪ ▪ Overload Ergonomic Traps Decision to Err Pressure Fatigue Motivation Drugs Alcohol Worry ▪ Incompatible Workstations, i.e., size force, reach, etc. ▪ Incompatible expectations ▪ Misjudgment of the risk ▪ Unconscious desire to err ▪ Logical decision based on situation System Failure ▪ ▪ ▪ ▪ ▪ ▪ Policy Responsibility Training Inspection Correction Standards Human Error Accident Injury/Damage Accident Theory 3 Accident/Incident Environment Input PROCESS Feedback Output Systems Theory SYSTEM: A group of regularly interacting and interrelated components that form a unified whole. ▪ Workers ▪ Machinery ▪ Workplace “environment” Systems Theory 2 Proposes a linkage in the workplace “system.” Changes in patterns of system interaction can increase or decrease the probability of an accident occurring. Decision-Making The likelihood of an accident occurring is determined how the workplace “system” works together. ▪ Identify external factors ▪ Direct towards positive behavior ▪ Focus on positive consequences ▪ Application of scientific methods to improve attempts at positive behavior. ▪ Integrate information ▪ Planned intervention Behavioral Safety ▪ Intervention on employee behavior Fatality Reactive Safety 30 Lost Workday Cases 300 Recordable Injuries 3000 Near Misses (est.) 30000 At-Risk Behaviors (est.) Proactive Safety Behavioral Safety 2 1 B: Behavior C: Consequences (short-term effects) O: Outcome (long-term effects) Can be used for individuals or corporations. Behavioral Safety 3 A: Activators/Antecedent ▪ A person, place, thing, or event that happens before a behavior takes place that encourages you to perform that behavior. ▪ Activators only set the stage for behavior or performance – they don’t control it. Unsafe Behavior ▪ “A” – ANTECEDENT – Event that triggers a behavior. ▪ Any directly measurable thing that a person does, including speaking, acting, and performing physical functions. ▪ “C” – CONSEQUENCE – Outcome or result of behavior. ▪ Consequences increase or decrease the probability that the behaviors will occur again in the future. Unsafe Behavior 2 ▪ “B” – BEHAVIOR – Observable action (measurable). Three Keys The three keys to using “Consequences” to change an unsafe behavior: ▪ Timing ▪ A consequence must occur soon after a behavior to be most effective. ▪ Consistency ▪ A consequence that is certain to follow a behavior is seen as a strong deterrent to unwanted behavior. ▪ Significance ▪ The significance of a positive response has been shown to be more powerful in changing behavior than a negative exchange. ▪ Soon — The consequence occurs immediately after your behavior. ▪ Certain — There’s a high probability you’ll receive the consequence. ▪ Positive — The consequence has significant or meaningful positive benefit to you. Consequences ▪ The MOST effective consequences are: Is a behavior that is going to happen (a lot). Is going to be tough to extinguish. “ABC”s of Behavior A behavior that has a consequence that is SOON, CERTAIN, & POSITIVE. ▪ Hard defenses: physical barriers, interlocks, alarms, etc. ▪ Soft defenses: surveillance, licensing, training, etc. ▪ Layers of defense ▪ Each with its own built-in weaknesses. Organizational Risk ▪ Considers the multiple defenses to prevent accidents ▪ An awareness of local hazards. ▪ Clear guidance on safe operations. ▪ Alarms/warnings of danger. ▪ Return system to a safe state. ▪ Safety barriers between the hazards and potential losses. ▪ Contain and eliminate hazards. Organizational Risk 2 All defenses must have some of the following: ▪ Slips, lapses, fumbles, mistakes, and procedural violations. ▪ Direct; usually short-lived impact. Note: You may want to refer back to the Human Factor Review and Error Detection Models Presentation for Reason’s Swiss Cheese Model. Organizational Risk 3 Active failures — unsafe acts committed by people. ▪ Decisions made by designers, builders, procedure writers, and top level management ▪ Potential for error. Organizational Risk 4 Latent conditions — inevitable “resident pathogens” within the system. Latent conditions ▪ May lie dormant in the system for years. ▪ Often hard to foresee, identify, or remedy. Organizational Risk 5 Latent conditions — Two adverse effects ▪ Can translate into error provoking conditions (e.g., time pressure, understaffing, inadequate equipment, fatigue, inexperience, etc.). ▪ Can create long-lasting weaknesses (e.g., untrustworthy alarms, unworkable procedures, design and construction deficiencies, etc.). make errors. ▪ The key to accident reduction is to identify and repair the individual “holes” before the chain of events is complete. Organizational Risk 6 ▪ There will always be “holes” in defenses and humans will always causation factors. ▪ Use of one theory over another merely becomes an academic exercise that rarely applies to real life situations. Combination Theory ▪ Components of all accident theories have value in evaluating Aids in establishing error chains. ▪ Data can be assessed and organized for clarity. ▪ Complex interactions can be distilled into factors. ▪ Active and latent errors better visualized. ▪ Cause and effect events can be traced. ▪ Assists in categorizing specific error types. ▪ Can provides a pictorial of event sequences. ▪ Helps in developing proactive safety systems. Wrap-Up ▪ Closing All rights are reserved. The material contained herein is the copyright property of Embry-Riddle Aeronautical University, Daytona Beach, Florida, 32114. No part of this material may be reproduced, stored in a retrieval system or transmitted in any form, electronic, mechanical, photocopying, recording or otherwise without the prior written consent of the University.
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