The development and deployment of a maintenance operations safety survey

Objective: Based on the line operations safety audit (LOSA), two studies were conducted to develop and deploy an equivalent tool for aircraft maintenance: the maintenance operations safety survey (MOSS). Background: Safety in aircraft maintenance is currently measured reactively, based on the number of audit findings, reportable events, incidents, or accidents. Proactive safety tools designed for monitoring routine operations, such as flight data monitoring and LOSA, have been developed predominantly for flight operations. Method: In Study 1, development of MOSS, 12 test peer-to-peer observations were collected to investigate the practicalities of this approach. In Study 2, deployment of MOSS, seven expert observers collected 56 peer-to-peer observations of line maintenance checks at four stations. Narrative data were coded and analyzed according to the threat and error management (TEM) framework. Results: In Study 1, a line check was identified as a suitable unit of observation. Communication and third-party data management were the key factors in gaining maintainer trust. Study 2 identified that on average, maintainers experienced 7.8 threats (operational complexities) and committed 2.5 errors per observation. The majority of threats and errors were inconsequential. Links between specific threats and errors leading to 36 undesired states were established. Conclusion: This research demonstrates that observations of routine maintenance operations are feasible. TEM-based results highlight successful management strategies that maintainers employ on a day-to-day basis. Application: MOSS is a novel approach for safety data collection and analysis. It helps practitioners understand the nature of maintenance errors, promote an informed culture, and support safety management systems in the maintenance domain

Project pathogens: The anatomy of omission errors in construction and resource engineering project

Construction and engineering projects are typically complex in nature and are prone to cost and schedule overruns. A significant factor that often contributes to these overruns is rework. Omissions errors, in particular, have been found to account for as much as 38% of the total rework costs experienced. To date, there has been limited research that has sought to determine the underlying factors that contribute to omission errors in construction and engineering projects. Using data derived from59 in-depth interviews undertaken with various project participants, a generic systemic causal model of the key factors that contributed to omission errors is presented. The developed causal model can improve understanding of the archetypal nature and underlying dynamics of omission errors. Error management strategies that can be considered for implementation in projects are also discussed

Managing the Change of Cultural Resistance

The review of numerous Australian and International Transport and Health Safety cases has highlighted the detrimental effect of cultural resistance when engineers and regulators seek to improve transport safety. This paper will define culture and cultural resistance. It will review a number of cases and provide an overview of the effect of cultural resistance, demonstrating some common characteristics of these cases. A limited number of risk management disciplines will be reviewed as they apply to the problem, and demonstrate how expertise in these fields can be advantageous to the engineer and regulator. The paper will provide the reader with a number of resolution strategies to manage cultural change by reducing resistance using practical methods. This paper has specific relevance to transport safety initiatives in Australia. This paper is an extract of a full research paper "Making the Kingfisher Archipelago a Safer Place", Smith, D.B., 2005, available from the author upon request

Committed to Safety: Ten Case Studies on Reducing Harm to Patients

Presents case studies of healthcare organizations, clinical teams, and learning collaborations to illustrate successful innovations for improving patient safety nationwide. Includes actions taken, results achieved, lessons learned, and recommendations

Clinical quality improvement and medicine

Medical practice is facing many pressures, all requiring ever-higher standards and better 'quality' in the provision of clinical care. Medicine is not alone in facing such forces, and it may be appropriate to apply the methodology used in other disciplines to address this issue; common problems are generally amenable to common solutions. The 'quality' approach was initially applied to health care in the USA, presumably because of the accent on market forces and the relationship with market share. In recent years, other health care systems have invested in this approach, applying lessons learned from management disciplines and the aviation industly. The Institute of Medicine's report on health care quality noted that 'every system is perfectly designed to obtain the results it gets' fll The European Union has thus far not included quality as a formal item on its agenda; however, with increasing mobility of patients and health professionals, there is pressure for legislative action addressing risk management and quality improvement. The development of a European approach to ensure the highest quality standards, free movement in the European Union, as well as the medical devices industry, are all areas that are raising interest. Overall, it behooves the individual clinician to be aware of developments in the area.peer-reviewe

Open Educational Content for Digital Public Libraries

If the production of digital content for teaching -- particularly free content -- is to expand substantially, there must be mechanisms to establish a link to fame and fortune that was not perceived in a pre-digital world. How that might be done is the central question this report addresses, in the context of examining the movement for open educational content. Understanding that movement requires delving into the history of what may seem, on first pass, a totally unrelated field of endeavor. The reader's patience is requested....

Risk analysis: comparative study of various techniques

Researchers in the safety field are facing more challenges everyday with the expanding modern socio-technical systems. Safety analysis such as hazard analysis, accident causation analysis, and risk assessment are being revisited to overcome the shortcoming of the conventional safety analysis. With increasingly complex human system interaction in today\u27s modern systems, new safety challenges are being faced that needed to be assessed and addressed. Managers and engineers face the challenge to choose from the vast amount of techniques available and utilize the correct one. Indeed, new or improved risk assessment tools that can address these complexities are needed. One of the most important steps in assessing risk is first to categorize it. There are risks associated with product component failure, human error, operational failure, environmental disasters, etc. So far, however, there has been little discussion about how do managers choose between the available risk assessments tools, which this considered the first step in risk analysis. In this research, risk assessment tools have been investigated, analyzed, categorized, and then applied to case studies in different industries. A pathway for researchers has been paved to overcome the difficulties in choosing risk assessment tools --Abstract, page iv

Software reliability and dependability: a roadmap

Shifting the focus from software reliability to user-centred measures of dependability in complete software-based systems. Influencing design practice to facilitate dependability assessment. Propagating awareness of dependability issues and the use of existing, useful methods. Injecting some rigour in the use of process-related evidence for dependability assessment. Better understanding issues of diversity and variation as drivers of dependability. Bev Littlewood is founder-Director of the Centre for Software Reliability, and Professor of Software Engineering at City University, London. Prof Littlewood has worked for many years on problems associated with the modelling and evaluation of the dependability of software-based systems; he has published many papers in international journals and conference proceedings and has edited several books. Much of this work has been carried out in collaborative projects, including the successful EC-funded projects SHIP, PDCS, PDCS2, DeVa. He has been employed as a consultant t

INTEGRATED RISK ASSESSMENT IN RAMP HANDLING OPERATIONS: RISK MAPPING FOR TURKISH AIRPORTS

Ramp handling acts a vital role in sustainable airport operations. The ramp related services provided to aircraft and their passengers at the airports are related to the landing, take-off, unloading and loading of the aircraft. Human resource is a key component in ramp handling operation and errors by employees cause significant accidents or incidents. The main purpose of the current study is to prioritize critical risk factors in ramp handling operations by using an integrated risk management approach and optimizing human performance while minimizing both failures and errors by employees. In this study, an integrated qualitative and quantitative risk assessment method is carried out by considering the factors that affect the possibility of ramp handling personnel errors. Initially, 113 risk factors are identified by using the academic literature, documents prepared by international organizations, and then by consulting expert opinions. Subsequently, a prioritization by professionals working on the ramp handling operations, based on the principles of the Analytic Hierarchy Process (AHP) method resulted in the final selection of the 41 most important risks. Then, a risk assessment approach is applied by designing a matrix, based on three dimensions; probability, severity (impact) and relation ratio which ultimately resulted in risk index generation and a risk map model is developed. Finally eleven (11) risk factors are identified as they have higher probabilities to occur and possible higher negative consequences. Thanks to the integrated risk assessment applied in this study, it is aimed to ensure that all systems of the organization operate in a safe way and that an efficient safety culture is formed. Allocating a single resource to many risks, instead of facing the risks of the ramp personnel one by one, leads to more efficient use of resources and higher performance of ground handling companies