The Self-Designing High- Reliability Organization

Recent studies of large, formal organizations that perform complex, inherently hazardous, and highly technical task under conditions of tight coupling and severe time pressure have generally concluded that most will fail spectaculatory at some point, with attendant human and social const of great severity. The notion that accidents in these systems are normal, that is, to be expected given the coditions and risks of operations and risk of operation, appears to be as well grounded in experience as in theory

The Self-Designing High-Reliability Organization: Aircraft Carrier Flight Operations at Sea

Of all activities studied by our research group, flight operations at sea is the closest to the edge of the envelope -operating under the most extreme conditions in the least stable environment, and with the greatest tension between preserving safety and reliability and attaining maximum operational efficiency

The blameworthiness of health and safety rule violations

Man-made disasters usually lead to the tightening of safety regulations, because rule breaking is seen as a major cause of them. This reaction is based on the presumptions that the safety rules are good and that the rule-breakers are wrong. The reasons the personnel of a coke factory gave for breaking rules raise doubt about the tenability of these presumptions. It is unlikely that this result would have been achieved on the basis of a disaster evaluation or High-Reliability Theory. In both approaches, knowledge of the consequences of human conduct hinders an unprejudiced judgement about the blameworthiness of rule breaking

Development Of The Flight Crew Human Factors Integration Tool

In May 1996, the FAA announced a new and innovative approach to reach a goal of "zero accidents," known as the Global Analysis and Information Network (GAIN). This would be a privately owned and operated international information infrastructure for the collection, analysis, and dissemination of aviation safety information. It would involve the use of a broad variety of worldwide aviation data sources, coupled with comprehensive analytical techniques, to facilitate the identification of existing and emerging aviation safety problems. A major component of the GAIN approach is the application of innovative analysis capabilities to identify the types of human error that contribute to aviation accidents and incidents in order to develop prevention strategies. As part of its Flight Crew Accident and Incident Human Factors Project initiated in 1993, the FAA Office of System Safety has developed a new process that uses a prototype website-based Integration Tool (IT) to access, integrate, and analyze flight crew human factors data relevant to safety. In September 1996, the FAA Office of System Safety funded the National Center of Excellence for Aviation Operations Research to initiate a program of research to provide human factors support for the GAIN concept. The first phase of this research performed a technical review of the results achieved to date by the flight crew human factors project and developed a strategic plan to lay the foundations for a sound scientific approach to the analysis of human factors issues within the framework of the GAIN concept. This report documents follow-on research activities directed at continued development of the Integration Tool and developing better ways to identify error reduction strategies

Improving The Representation Of Human Error In The Use Of The Flight Crew Human Factors Integration Tool

In May 1996, the FAA announced a new and innovative approach to reach a goal of "zero accidents," known as the Global Analysis and Information Network (GAIN). This would be a privately owned and operated international information infrastructure for the collection, analysis, and dissemination of aviation safety information, that would involve the use of a broad variety of worldwide aviation data sources, coupled with comprehensive analytical techniques, to facilitate the identification of existing and emerging aviation safety problems. A major component of the GAIN approach is the application of innovative analysis capabilities to identify the types of human error that contribute to aviation accidents and incidents in order to develop prevention strategies. As part of its Flight Crew Accident and Incident Human Factors Project, the FAA Office of System Safety has developed a new process that uses a prototype website-based Integration Tool (IT) to access, integrate, and analyze flight crew human factors data relevant to safety. In September 1996, the FAA Office of System Safety funded the National Center of Excellence for Aviation Operations Research to initiate a program of research to provide human factors support for the GAIN concept. The first phase of this research performed a technical review of the results achieved to date by the flight crew human factors project and developed a strategic plan to lay the foundations for a sound scientific approach to the analysis of human factors issues within the framework of the GAIN concept. This report documents follow-on research activities directed at improving the representation of human error within the Integration Tool and developing better ways to identify error reduction strategies. While the current version of the IT performs a useful function by identifying specific records in a large database that meet certain criteria, and then allowing the user to display the contents of the database records for further review, its usefulness in analyzing the underlying causes of flight crew error and hence identifying strategies to reduce the frequency of occurrence of those errors is presently limited by several constraints

Development Of The Flight Crew Human Factors Integration Tool

In May 1996, the FAA announced a new and innovative approach to reach a goal of "zero accidents," known as the Global Analysis and Information Network (GAIN). This would be a privately owned and operated international information infrastructure for the collection, analysis, and dissemination of aviation safety information. It would involve the use of a broad variety of worldwide aviation data sources, coupled with comprehensive analytical techniques, to facilitate the identification of existing and emerging aviation safety problems. A major component of the GAIN approach is the application of innovative analysis capabilities to identify the types of human error that contribute to aviation accidents and incidents in order to develop prevention strategies. As part of its Flight Crew Accident and Incident Human Factors Project initiated in 1993, the FAA Office of System Safety has developed a new process that uses a prototype website-based Integration Tool (IT) to access, integrate, and analyze flight crew human factors data relevant to safety. In September 1996, the FAA Office of System Safety funded the National Center of Excellence for Aviation Operations Research to initiate a program of research to provide human factors support for the GAIN concept. The first phase of this research performed a technical review of the results achieved to date by the flight crew human factors project and developed a strategic plan to lay the foundations for a sound scientific approach to the analysis of human factors issues within the framework of the GAIN concept. This report documents follow-on research activities directed at continued development of the Integration Tool and developing better ways to identify error reduction strategies.Aircraft accidents--Human factors--Mathematical models, Aircraft accidents--Human factors--Data processing, Flight crews, Aeronautics--Human factors

Improving The Representation Of Human Error In The Use Of The Flight Crew Human Factors Integration Tool

In May 1996, the FAA announced a new and innovative approach to reach a goal of "zero accidents," known as the Global Analysis and Information Network (GAIN). This would be a privately owned and operated international information infrastructure for the collection, analysis, and dissemination of aviation safety information, that would involve the use of a broad variety of worldwide aviation data sources, coupled with comprehensive analytical techniques, to facilitate the identification of existing and emerging aviation safety problems. A major component of the GAIN approach is the application of innovative analysis capabilities to identify the types of human error that contribute to aviation accidents and incidents in order to develop prevention strategies. As part of its Flight Crew Accident and Incident Human Factors Project, the FAA Office of System Safety has developed a new process that uses a prototype website-based Integration Tool (IT) to access, integrate, and analyze flight crew human factors data relevant to safety. In September 1996, the FAA Office of System Safety funded the National Center of Excellence for Aviation Operations Research to initiate a program of research to provide human factors support for the GAIN concept. The first phase of this research performed a technical review of the results achieved to date by the flight crew human factors project and developed a strategic plan to lay the foundations for a sound scientific approach to the analysis of human factors issues within the framework of the GAIN concept. This report documents follow-on research activities directed at improving the representation of human error within the Integration Tool and developing better ways to identify error reduction strategies. While the current version of the IT performs a useful function by identifying specific records in a large database that meet certain criteria, and then allowing the user to display the contents of the database records for further review, its usefulness in analyzing the underlying causes of flight crew error and hence identifying strategies to reduce the frequency of occurrence of those errors is presently limited by several constraints.Aircraft accidents--Human factors--Data processing, Aircraft accidents--Human factors--Mathematical models, Flight crews, Aeronautics--Human factors