The authors believe that a systematic organizational approach to aviation safety must replace the piecemeal approaches largely favoured in the past, but this change needs to be preceded by information to explain why a new approach is necessary. Accident records show a flattening of the safety curve since the early Seventies: instead of new kinds of accident, similar safety deficiencies have become recurrent features in accident reports. This suggests the need to review traditional accident prevention strategies, focused almost exclusively on the action or inaction’s of front-line operational personnel. The organizational model proposed by the authors is one alternative means to pursue safety and prevention strategies in contemporary aviation; it is also applicable to other production systems. The model argues for a broadened approach, which considers the influence of all organizations (the blunt end) involved in aviation operations, in addition to individual human performance (the sharp end). If the concepts of systems safety and organizational accidents are to be advanced, aviation management at all levels must be aware of them. This book is intended to provide a bridge from the academic knowledge gained from research, to the needs of practitioners in aviation. It comprises six chapters: the fundamentals, background and justification for an organizational accident causation model to the flight deck, maintenance and air traffic control environments. The last chapter suggest different ways to apply the model as a prevention tool which furthermore enhances organizational effectiveness. The value of the organizational framework pioneered by Professor Reason in analyzing safety in high-technology production systems is felt by his co-authors to have an enduring role to play, both now and in coming decades. Applied now in this book, it has been adopted by ICAO, IFATCA, IMO, the US National Transportation Safety Board, the Transportation Safety B
Table of Contents
Contents: Foreword by the Honorable Mr. Justice Virgil P. Moshansky; Widening the search for accident causes: a theoretical framework; Erebus and beyond; Pathogens in the snow: the crash of flight 1363; The BAC 1-11 windscreen accident; The Australian airmiss study; Remedial implications: some practical applications of theory; Index.
Captain Daniel E. Maurino is the Coordinator of the Flight Safety and Human Factors Study Programme, International Civil Aviation Organization (ICAO). Professor James Reason is Professor of Psychology at the University of Manchester, England. He is the author of Human Error. Captain A. Neil Johnston is an Airbus 330 Captain with Aer Lingus. He is Associate Editor of The International Journal of Aviation Psychology and co-editor of Aviation Psychology in Practice. Dr Rob Lee is the Director of the Australian Bureau of Air Safety Investigation (BASI). He was formerly with the Royal Australian Air Force.
’This is serious and good stuff and should be compulsory reading for every accident investigator and for safety officers of any technology-based organization.’ Aerospace ’This important volume will be of relevance to all operational aviation management, technical and non-technical personnel in aviation, other transportation and high technology production industries.’ Occupational Safety and Health ’...provides a clear insight into the sequence of circumstances that can occur and cause an accident to happen. In this the book is enlightening and more than a little worrying.’ Ergonomics Abstracts ’...makes fascinating reading from the first page to the last...Highly recommended!’ The Controller ’...very valuable because it described an alternative methodology for investigating accidents and provided sufficient information to allow the reader to think about strategy for considering the role of latent organizational failures.’ Aviation, Space and Environmental Medicine