AVSAFETY Flashcards
(30 cards)
5 basic characteristics that are universally associated with effective safety reporting systems
information, accountability, willingness, learning, flexibility
people are knowledgeable about the human, technical and organizational factors that determine the safety of the system as a whole
information
people are willing to report their errors and experiences
willingness
people are encouraged (and rewarded) for providing essential safety related information. however, there is a clean line that differentiates between acceptable and unacceptable behaviour.
accountability
people can adapt reporting when facing unusual circumstances, shifting from the established mode to a direct mode thus allowing information to quickly reach the appropriate decision-making level
flexibility
people have th competence to draw conclusions from safety information systems and the will to implement major reforms
learning
hide the information
pathological
restrain the information
bureaucratic
value the information
generative
when an accident or serious incident occurs, what is set in motion
accident investigation process
what is accident investigation process for
to find out any possible failure within the aviation system and the reasons thereof; and to generate the necessary countermeasures to prevent recurrence.
distinct role of accident investigation process
being an essential process which deploys when safety defenses, barriers, checks, and counterbalances in the system have failed.
Being an important reactive component of the elements contained in what frameworks
Safety Management System and State Safety Progrom
accident
investigations contribute to what
continuous improvement of the aviation system by providing the root causes of accidents/incidents and lessons learned from analysis of events
what provides for the investigation of lower-consequence events
mature safety management environment
investigation exercises
establishing findings and the root causes of accidents/incidents and uncover hazards/threats
An effective and comprehensive investigation process includes
the identification of and discrimination between an ultimate consequence, an unsafe event and hazards/threats that contribute to the accident/incident. This may include any systemic, latent or organizational factors within the entire
aviation system framework.
what has shown that accidents are often preceded by safety-related incidents and deficiencies thereby
revealing the existence of safety hazards
experience
obvious and fortunately rare in the industry but near misses as well as minor incidents are very common.
accidents
The reporting of
incidents enables the industry to
learn from them, and make the system as a whole safer
The chain of events
that lead to a near miss are the same chain of events that led up to what?
accident
important resource for the detection of potential safety hazards
safety data
Everyone from front-line staff, line managers to senior management need to understand their
“just culture” and internal reporting processes.
Organizations should have
clear reporting processes, organization-wide communication and provide all staff with effective training.
