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Posted on Feb 01, 2022

1. Which area do you think safety analysts should focus on the most today: technical factors, human factors, or organizational factors? 2. How do

1. Which area do you think safety analysts should focus on the most today: technical factors, human factors, or organizational factors? 2. How do the recommendations stemming from West Caribbean Airways Flight 708 illustrate the need for root cause analyses to prevent future accidents in commercial aviation? 3. Explain the difference between active causes and root causes. 4. Explain the difference between findings, causes, and recommendations. 5. Why do we use models, such as the SHELL and 5-Factor models, to learn accident theory? 6. Do you think it is possible to develop simple solutions to complex aviation problems? 7. What are some logical fallacies that directly relate to accident theory? 8. Do all problems stem back to one or more root causes, or is it possible that some causes are simplyactive and exist without roots? 9. Explain Reason's "Swiss Cheese" model of defensive layers to include the concept of latent and active failures. 10. Develop a fictional accident that is the result of two holes in the "Swiss Cheese" model. 11. Why is "Liveware" always in the center of the SHELL model? 12. Are there any other elements that you think should be accounted for in the 5-Factor model? 13. The medium or environment includes two parts, the natural environment and the artificial environment. Compare and contrast the two parts. 14. How does the role of luck impact commercial aviation safety? How is luck featured in accident models? 15. Write a short paragraph explaining how the case study of Air France Flight 4590 exhibits the major concepts of this chapter. 16. Produce a recommendation to prevent accidents based on the Air France Flight 4590 case study, then speculate as to reasons why such a recommendation may not have been part of the accident report.

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1 I think it is human factors Human factors is the science of people at work It is primarily concerned with understanding human capabilities and then applying this knowledge to the design of equipments tools systems and processes of work 2 Recommendations stemming from Western Caribbean Airlines Flight 708 highlight the need for causal analysis as it goes deeper into the multifaceted cause of accidents And suggest preventive measures to reduce the likelihood of accidents that may have similar causes from the root cause 3 Active causes are obvious such as stalling the aircraft and root causes are hidden such as pilots not receiving high altitude stall recovery training The root cause is the trigger for the occurrence of the technical cause the active cause is the reason for the incident 4 A finding is something you have found A cause is something that brings about an effect or a result trying to find the cause of the accident A recommendation is something someone else has suggested that you do because they think its a good idea that theyve tried and it has worked for them 5 We use these models to better organize through what is a complex situation To Trace the root causes of accidents to errors that occur in the higher management levels of an organization These errors are also known as latent errors 6 No it is not possible to develop 7 Accident Fallacy Accident misconception happens once somebody applies a general rule to a case during which the rule is unsuitable Taking a life could be a crime and virtuously wrong so insect management could be a crime and virtuously wrong No one ought to ever visit war After all everybody is aware of that one mustnt kill another person Birds will fly so emus should be ready to fly too Nuts square measure tried to possess a range of nice health edges to individuals Thus it should be right to mention that everybody ought to be intake them 9 Reason developed the Swiss cheese model to illustrate how analyses of major accidents and catastrophic systems failures tend to reveal multiple smaller failures leading up to the actual hazard In the model each slice of cheese represents a safety barrier or precaution relevant to a particular hazard For example if the hazard were wrongsite surgery slices of the cheese might include conventions for identifying sidedness on radiology tests a protocol for signing the correct site when the surgeon and patient first meet and a second protocol for reviewing the medical record and checking the previously marked site in the operating room Many more layers exist The point is that no single barrier is foolproof They each have holes hence the Swiss cheese For some serious events eg operating on the wrong site or wrong person even though the holes will align infrequently even rare cases of harm errors making it through the cheese will be unacceptable While the model may convey the impression that the slices of cheese and the location of their respective holes are independent this may not be the case For instance in an emergency situation all three of the surgical identification safety checks mentioned above may fail or be bypassed The surgeon may meet the patient for the first time in the operating room A hurried xray technologist might mislabel a film or simply hang it backwards and a hurried surgeon not notice signing the site may not take place at all eg if the patient is unconscious or if it takes place be rushed and offer no real protection In the technical parlance of accident analysis the different barriers may have a common failure mode in which several protections are lost at once ie several layers of the cheese line up In health care such failure modes in which slices of the cheese line up more often than one would expect if the location of their holes were independent of each other and certainly more often than wings fly off airplanes occur distressingly commonly In fact many of the systems problems discussed by Reason and otherspoorly designed work schedules lack of teamwork variations in the design of important equipment ... blur-text-image