Past the Edge of Chaos What we can learn from Helios 522 about how we learn about aviation safety

Abstract. The August 2005 Helios 522 accident may end up demonstrating that the reductionist model we apply to understanding safety and risk in aviation (taking systems apart and checking whether individual components meet prespecified criteria) no longer works well. Through a concurrence of functions and events, of which a language barrier was a product as well as constitutive, Helios 522 may have been pushed past the edge of chaos, that area in non-linear dynamics where new system behaviors emerge that cannot be anticipated using reductive logic. Complexity theory, in contrast, encourages us to fix on higher-order system properties if we want to gain confidence about the resilience of a system, i.e. its ability to recognize, adapt to, and absorb a disruption that falls outside the disturbances the system was designed to handle

Human-Centered Technologies and Procedures for Future Air Traffic Management

The use of various methodologies to predict the impact of future Air Traffic Management (ATM) concepts and technologies is explored. The emphasis has been on the importance of modeling coordination and cooperation among multiple agents within this system, and on understanding how the interactions among these agents will be influenced as new roles, responsibilities, procedures and technologies are introduced. To accomplish this, we have been collecting data on performance under the current air traffic management system, identifying critical problem areas and looking for examples suggestive of general approaches for solving such problems. Using the results of these field studies, we have developed a set of concrete scenarios centered around future designs, and have studied performance in these scenarios with a set of 40 controllers, dispatchers, pilots and traffic managers

Human-Centered Technologies and Procedures for Future Air Traffic Management: A Preliminary Overview of 1996 Studies and Results

In this project, we have been exploring the use of a general methodology to predict the impact of future Air Traffic Management (ATM) concepts and technologies. In applying this methodology, our emphasis has been on the importance of modeling coordination and cooperation among the multiple agents within this system, and on understanding how the interactions among these agents will be influenced as new roles, responsibilities, procedures and technologies are introduced. To accomplish this, we have been collecting data on performance under the current air traffic management system, trying to identify critical problem areas and looking for exemplars suggestive of general approaches for solving such problems. Based on the results of these field studies, we have developed a set of scenarios centered around potential future system designs, and have conducted studies using these scenarios involving a total 40 controllers, dispatchers, pilots and traffic managers. The purpose of this report is to provide NASA with an early summary of the major recommendations that have resulted from our research under the AATT Program thus far. Recommendations 1-3 deal with general approaches that our findings suggest should be incorporated in future AATT Program activities, while Recommendations 4-11 identify some specific topics and technologies that merit research and development activities. Detailed technical reports containing supporting data, as well as the results of our still ongoing analyses, will be provided at a later date. The remainder of this report is organized as follows. Section 1 briefly describes the general design philosophy supported by our empirical studies. Section 2 presents the research methods we have used for identifying requirements for future system designs and for evaluating alternative design solutions. Section 3 discusses preliminary results from an initial set of investigations that we have conducted using these research methods. Section 4 then provides an overall summary. An outline of the rest of this preliminary project summary is provided on the following page

Restorative Just Culture: a Study of the Practical and Economic Effects of Implementing Restorative Justice in an NHS Trust

Restorative justice is an approach that aims to replace hurt by healing in the understanding that the perpetrators of pain are also victims of the incident themselves. In 2016, Mersey Care, an NHS community and mental health trust in the Liverpool region, implemented restorative justice (or what it termed a 'Just and Learning Culture') to fundamentally change its responses to incidents, patient harm, and complaints against staff. Although qualitative benefits from this implementation seemed obvious, it was also thought relevant to identify the economic effects of restorative justice. Through interviews with Mersey Care staff and collecting data pertaining to costs, suspensions, and absenteeism, an economic model of restorative justice was created. We found that the introduction of restorative justice has coincided with many qualitative improvements for staff, such as a reduction in suspensions and dismissals, increase in the reporting of adverse events, increase in the number of staff that feel encouraged to seek support and a slowing down of the upward trend in absence due to illness. It also improved staff retention. The economic benefits of restorative justice appear significant. After corrections for inflation, acquisitions and anomalies, we found that the salary costs averaged over two fiscal years were reduced by £ 4 million per year, coinciding with the introduction of a just and learning culture in 2016. In addition, Mersey Care reaped around £ 1 million in saved legal and termination expenses. We conservatively attribute half of these savings to the introduction of a just and learning culture itself, and the other half to non-related factors. Using this assumption, we estimate the total economic benefit of restorative justice in the case of Mersey Care NHS Foundation Trust to be about £ 2.5 million or approximately 1% of the total costs and 2% of the labour costs

Ergonomics and sustainability: Towards and embrace of complexity and emergence

Technology offers a promising route to a sustainable future, and ergonomics can serve a vital role. The argument of this article is that the lasting success of sustainability initiatives in ergonomics hinges on an examination of ergonomics' own epistemology and ethics. The epistemology of ergonomics is fundamentally empiricist and positivist. This places practical constraints on its ability to address important issues such as sustainability, emergence and complexity. The implicit ethical position of ergonomics is one of neutrality, and its positivist epistemology generally puts value-laden questions outside the parameters of what it sees as scientific practice. We argue, by contrast, that a discipline that deals with both technology and human beings cannot avoid engaging with questions of complexity and emergence and seeking innovative ways of addressing these issues.No Full Tex

Consensus guidelines for the diagnosis and management of pyridoxine-dependent epilepsy due to alpha-aminoadipic semialdehyde dehydrogenase deficiency

Pyridoxine-dependent epilepsy (PDE-ALDH7A1) is an autosomal recessive condition due to a deficiency of α-aminoadipic semialdehyde dehydrogenase, which is a key enzyme in lysine oxidation. PDE-ALDH7A1 is a developmental and epileptic encephalopathy that was historically and empirically treated with pharmacologic doses of pyridoxine. Despite adequate seizure control, most patients with PDE-ALDH7A1 were reported to have developmental delay and intellectual disability. To improve outcome, a lysine-restricted diet and competitive inhibition of lysine transport through the use of pharmacologic doses of arginine have been recommended as an adjunct therapy. These lysine-reduction therapies have resulted in improved biochemical parameters and cognitive development in many but not all patients. The goal of these consensus guidelines is to re-evaluate and update the two previously published recommendations for diagnosis, treatment, and follow-up of patients with PDE-ALDH7A1. Members of the International PDE Consortium initiated evidence and consensus-based process to review previous recommendations, new research findings, and relevant clinical aspects of PDE-ALDH7A1. The guideline development group included pediatric neurologists, biochemical geneticists, clinical geneticists, laboratory scientists, and metabolic dieticians representing 29 institutions from 16 countries. Consensus guidelines for the diagnosis and management of patients with PDE-ALDH7A1 are provided. This article is protected by copyright. All rights reserved

An efficient strategy for evaluating new non-invasive screening tests for colorectal cancer: the guiding principles

Objective: New screening tests for colorectal cancer (CRC) are rapidly emerging. Conducting trials with mortality reduction as the end point supporting their adoption is challenging. We re-examined the principles underlying evaluation of new non-invasive tests in view of technological developments and identification of new biomarkers. Design: A formal consensus approach involving a multidisciplinary expert panel revised eight previously established principles. Results: Twelve newly stated principles emerged. Effectiveness of a new test can be evaluated by comparison with a proven comparator non-invasive test. The faecal immunochemical test is now considered the appropriate comparator, while colonoscopy remains the diagnostic standard. For a new test to be able to meet differing screening goals and regulatory requirements, flexibility to adjust its positivity threshold is desirable. A rigorous and efficient four-phased approach is proposed, commencing with small studies assessing the test’s ability to discriminate between CRC and non-cancer states (phase I), followed by prospective estimation of accuracy across the continuum of neoplastic lesions in neoplasia-enriched populations (phase II). If these show promise, a provisional test positivity threshold is set before evaluation in typical screening populations. Phase III prospective studies determine single round intention-to-screen programme outcomes and confirm the test positivity threshold. Phase IV studies involve evaluation over repeated screening rounds with monitoring for missed lesions. Phases III and IV findings will provide the real-world data required to model test impact on CRC mortality and incidence. Conclusion: New non-invasive tests can be efficiently evaluated by a rigorous phased comparative approach, generating data from unbiased populations that inform predictions of their health impact