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in Aviation
Jim Reason
University of Manchester
Two kinds of accidents
Individual Organizational
accidents accidents
Frequent Rare
Limited consequences Widespread consequences
Few or no defences Many defences
Limited causes Multiple causes
Slips, trips and lapses Product of new technology
Short ‘history’ Long ‘history’
Two ways of looking at
accidents
• The person approach: Focuses on the errors
and violations of individuals. Remedial
efforts directed at people at the ‘sharp end’.
• The system approach: Traces the causal
factors back into the system as a whole.
Remedial efforts directed at situations and
organisations.
The person approach
Defences
Losses
Hazards
‘Hard’ defences
‘Soft’ defences
The Swiss cheese model of
accident causation
Some holes due
to active failures Hazards
Losses
Hazards
Latent Causes
condition Unsafe acts Investigation
pathways
Organisational factors
Types of unsafe act
• Errors
– Slips, lapses and fumbles
– Mistakes
• Rule-based mistakes
• Knowledge-based mistakes
• Violations
– Routine violations
– Violations for kicks
– Situational violations
Two influential accidents
• Mount Erebus, 1979: one accident, two
inquiries:
– Chippindale Report (‘pilot error’)
– Mahon Report (‘orchestrated litany of lies’)
• Dryden, 1989: Moshansky Report, an
indictment of the entire Canadian air
transport system.
Three aviation applications
of the ‘Swiss cheese’ model
• Bureau of Air Safety Investigation (BASI),
Canberra.
• International Civil Aviation Organization
(ICAO): Amendment to Annex 13, the
guide to accident investigators.
• As applied by an airline to a recent air
accident in North America.
BASI
• 1n the early 1990s, BASI resolved to apply the
model to all accident investigations.
• In June 1993, a small commuter aircraft crashed at
Young, NSW. All died.
• The BASI report focused on the deficiencies of the
regulator, the Oz CAA.
• Following a similar accident in 1994, the Oz CAA
was disbanded. Replaced by CASA.
ICAO Accident Investigation
Divisional Meeting (2/92)
Traditionally, investigations have been limited to
the persons directly involved. Current accident
prevention views supported the notion that additional
preventive measures could be derived from
investigations if management policies and
organisational factors were also investigated.
(excerpt from minutes)
Inadequate monitoring
Too low by Captain (SOPs)?
Sufficient?
Delayed go-around order
Implications of event tree - 1
• Two main clusters of contributing factors:
– those relating to the aircraft
– those relating to handling and flight operations
• Two main pathways for back-tracking:
– to the manufacturer (not our immediate
concern)
– to flight operations and the system as a whole
(the priority pathway)
Implications of event tree - 2
• The Harrytown accident involved the
combination of several contributing factors
that were very hard to anticipate.
• The local circumstances were such that it
took very little in the way of less-than-
adequate pilot performance to push the
system over the edge.
• This was an ‘organizational accident’.
Pruned event tree
ORGANIZATIONAL ISSUES
Prone to inducing
TRAINING
‘ground shyness’
Aircraft
factors +
Nose-up response
TRAINING
to power increase
Stall protection
system
Airmanship
Training, checking,
SOPs
Hiring, placement, contracts,
exposure to safe culture
Key issues for review
• Operating procedures
• Training
• Checking
• Hiring and placement of pilots
• Assimilation of new hires into
airline culture
Comments on the culture