Improving Air Safety through Organizational Learning


Book Description

The key theme of this book is organizational learning and its consequences for the field of aviation safety. Air safety rates have been improving for a long time, demonstrating the effects of a good learning model at work. However, the pace of improvement has almost come to a standstill. Why is this? Many safety improvements have been embodied in technology. New devices and procedures appear almost daily, yet the rate of air safety improvement has dragged in recent years. Improving Air Safety through Organizational Learning explains this situation as being the consequence of a development model supported chiefly by information technology being introduced as an alternative to human operators. This is not a book about the convenience of including or not including IT in aviation, but an open discussion about the adequacy and risks of some practices in the field. Two different but complementary issues emerge. Firstly, a real improvement in air safety requires a different approach, since the present one seems now to be exhausted. Secondly, the current approach has powerful economic roots, and any new approach must deal with this fact, improving safety rates without becoming financially damaging. Consequently the book is divided into two parts. Part one deals with the issue of the present learning model organizing the conclusions around accident reports that show themselves the existence of a problem: the present use of technology makes the system better at doing things already known, while at the same time it makes the whole system worse at dealing with unplanned situations. Part two suggests a new development model, one that makes strong use of technology but at the same time questions every step: what knowledge will disappear from the system and what is the potential effect of that loss?




Improving Air Safety through Organizational Learning


Book Description

The key theme of this book is organizational learning and its consequences for the field of aviation safety. Air safety rates have been improving for a long time, demonstrating the effects of a good learning model at work. However, the pace of improvement has almost come to a standstill. Why is this? Many safety improvements have been embodied in technology. New devices and procedures appear almost daily, yet the rate of air safety improvement has dragged in recent years. Improving Air Safety through Organizational Learning explains this situation as being the consequence of a development model supported chiefly by information technology being introduced as an alternative to human operators. This is not a book about the convenience of including or not including IT in aviation, but an open discussion about the adequacy and risks of some practices in the field. Two different but complementary issues emerge. Firstly, a real improvement in air safety requires a different approach, since the present one seems now to be exhausted. Secondly, the current approach has powerful economic roots, and any new approach must deal with this fact, improving safety rates without becoming financially damaging. Consequently the book is divided into two parts. Part one deals with the issue of the present learning model organizing the conclusions around accident reports that show themselves the existence of a problem: the present use of technology makes the system better at doing things already known, while at the same time it makes the whole system worse at dealing with unplanned situations. Part two suggests a new development model, one that makes strong use of technology but at the same time questions every step: what knowledge will disappear from the system and what is the potential effect of that loss?




Keeping Patients Safe


Book Description

Building on the revolutionary Institute of Medicine reports To Err is Human and Crossing the Quality Chasm, Keeping Patients Safe lays out guidelines for improving patient safety by changing nurses' working conditions and demands. Licensed nurses and unlicensed nursing assistants are critical participants in our national effort to protect patients from health care errors. The nature of the activities nurses typically perform â€" monitoring patients, educating home caretakers, performing treatments, and rescuing patients who are in crisis â€" provides an indispensable resource in detecting and remedying error-producing defects in the U.S. health care system. During the past two decades, substantial changes have been made in the organization and delivery of health care â€" and consequently in the job description and work environment of nurses. As patients are increasingly cared for as outpatients, nurses in hospitals and nursing homes deal with greater severity of illness. Problems in management practices, employee deployment, work and workspace design, and the basic safety culture of health care organizations place patients at further risk. This newest edition in the groundbreaking Institute of Medicine Quality Chasm series discusses the key aspects of the work environment for nurses and reviews the potential improvements in working conditions that are likely to have an impact on patient safety.




Advances in Patient Safety


Book Description

v. 1. Research findings -- v. 2. Concepts and methodology -- v. 3. Implementation issues -- v. 4. Programs, tools and products.




Why Airplanes Crash


Book Description

This work examines the causes of airplane accidents and what private and public policies are needed to improve aviation safety. It begins by examining the safety record of the United States commuter airline industry in the post-deregulation era characterized by increased emphasis by airlines on cost control and growing pressures on the air traffic control and airport system. The authors go beyond the safety of the scheduled airlines to examine the reasons for accidents in the nonscheduled and general aviation segments of the United States industry, where the bulk of fatalities occur and where airline pilots increasingly receive most of their training and experience. They then turn to an examination of aviation safety throughout the world, first with a detailed comparison of Canadian and American aviation safety, and then with a look at air safety in all regions of the world and the safety performances of all the world's major airlines. Three emerging issues are then examined in greater detail: assessing the margin of safety, worldwide aging of all airline fleets, and terrorism.




Cockpit Resource Management


Book Description

Cockpit Resource Management (CRM) has gained increased attention from the airline industry in recent years due to the growing number of accidents and near misses in airline traffic. This book, authored by the first generation of CRM experts, is the first comprehensive work on CRM. Cockpit Resource Management is a far-reaching discussion of crew coordination, communication, and resources from both within and without the cockpit. A valuable resource for commercialand military airline training curriculum, the book is also a valuable reference for business professionals who are interested in effective communication among interactive personnel. Key Features * Discusses international and cultural aspects of CRM * Examines the design and implementation of Line-Oriented Flight Training (LOFT) * Explains CRM, LOFT, and cockpit automation * Provides a case history of CRM training which improved flight safety for a major airline







Conference Proceedings


Book Description




Flying the Line


Book Description




Beyond Aviation Human Factors


Book Description

The authors believe that a systematic organizational approach to aviation safety must replace the piecemeal approaches largely favoured in the past, but this change needs to be preceded by information to explain why a new approach is necessary. Accident records show a flattening of the safety curve since the early Seventies: instead of new kinds of accident, similar safety deficiencies have become recurrent features in accident reports. This suggests the need to review traditional accident prevention strategies, focused almost exclusively on the action or inaction’s of front-line operational personnel. The organizational model proposed by the authors is one alternative means to pursue safety and prevention strategies in contemporary aviation; it is also applicable to other production systems. The model argues for a broadened approach, which considers the influence of all organizations (the blunt end ) involved in aviation operations, in addition to individual human performance (the sharp end ). If the concepts of systems safety and organizational accidents are to be advanced, aviation management at all levels must be aware of them. This book is intended to provide a bridge from the academic knowledge gained from research, to the needs of practitioners in aviation. It comprises six chapters: the fundamentals, background and justification for an organizational accident causation model to the flight deck, maintenance and air traffic control environments. The last chapter suggest different ways to apply the model as a prevention tool which furthermore enhances organizational effectiveness. The value of the organizational framework pioneered by Professor Reason in analyzing safety in high-technology production systems is felt by his co-authors to have an enduring role to play, both now and in coming decades. Applied now in this book, it has been adopted by ICAO, IFATCA, IMO, the US National Transportation Safety Board, the Transportation Safety B