1、I C ICA0 CIRCULAR*247 * = it8414Lb O032379 3b3 W CIRCULAR 247-AW148 CAO IRCULAR 1993 HUMAN FACTORS DIGEST No. 10 HUMAN FACTORS, MANAGEMENT AND ORGANIZATION Approved by the Secretary General and published under his author INTERNATIONAL CIVIL AVIATION ORGANIZATION MONTREAL CANADA Copyright Internation
2、al Civil Aviation Organization Provided by IHS under license with ICAONot for ResaleNo reproduction or networking permitted without license from IHS-,-,-ICAO CIRCULAR*247 * 484141b 0032380 085 m I Published in separate English, French, Russian and Spanish editions by the Intemational Civil Aviation
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9、2BN. The Catalogue of ICAO Publications and Audio Visual Training Aids Issued annually, the Catalogue lists all publications and audio visual training aids currently available. Monthly supplements announce new publications and audio visual training aids, amendments, supplements, reprints, etc. Avail
10、able free from the Document Sales Unit, ICAO Copyright International Civil Aviation Organization Provided by IHS under license with ICAONot for ResaleNo reproduction or networking permitted without license from IHS-,-,-.;. - ICA0 CIRCULARf247 ft m 48434Lb 0032383 TLL TABLE OF CONTENTS Page Introduct
11、ion 1 . 4 Chapter 1. From Individuals to Organizations . Chapter 2. Safe and Unsafe Organizations 10 Introduction . Corporate culture Safe and unsafe corporate cultures The structure of organizations . Regulatory compliance Allocation of resources Accidents in complex technological systems . The tra
12、its of a safe organization . 10 11 12 14 16 17 17 22 24 Introduction 24 25 What management can do to take an active stance on safety 26 Chapter 3. Managements Contribution to Safety . Why management should take an active stance on safety . . 33 Introduction 33 Theevents 34 Faileddefences 37 Unsafeac
13、ts 39 40 Error-producing conditions 42 Latent organizational failures Conclusion . 44 Chapter 4. Organizational Accidents: A Case Study . . . Copyright International Civil Aviation Organization Provided by IHS under license with ICAONot for ResaleNo reproduction or networking permitted without licen
14、se from IHS-,-,-ICA0 CIRCULAR*247 * 48414Lb 0032382 958 INTRODUCTION 1. Since the beginning of aviation, human error has been recognized as a major factor in accidents and incidents. Indeed, one of aviations biggest challenges has been - and will continue to be - human error avoidance and control. T
15、raditionally, human error in aviation has been closely related to operational personnel, such as pilots, controllers, mechanics, dispatchers, etc. Contemporary safety views argue for a broadened perspective which focuses on safety deficiencies in the system rather than in individual performance. Evi
16、dence provided by analysis from this perspective has allowed the identification of managerial deficiencies at the design and operating stages of the aviation system as important contributing factors to accidents and incidents. 2. During the early years, aviation safety efforts were directed towards
17、improving the technology, with the main focus on operational and engineering methods for combating hazards. With admirable success, they sustained a reduced accident rate. When it became apparent that human error was capable of circumventing even the most advanced safety devices, efforts were then d
18、irected to the human element in the system. The late 70s and 80s will undoubtedly be remembered for the prevailing enthusiasm regarding aviation Human Factors. Cockpit (and then Crew) Resource Management (CRM), Line-Oriented Flight Training (LOFT), Human Factors training programmes, attitude-develop
19、ment programmes and similar efforts have multiplied, and a campaign to increase the awareness of the pervasiveness of human error in aviation safety has been initiated. Human error, however, continues to be at the forefront of accident statistics. 3. Statistics can be misleading in understanding the
20、 nature of accidents and devising prevention measures. Statistics reflect accidents as a series of cause and effect relationships grouped into discrete categories (flight crew, maintenance, weather, ATC, etc.). Errors are not registered as such but some of their effects are: controlled flight into t
21、errain, aborted take-off overrun, etc. Statistics then provide the answers when it is too late. They fail to reveal accidents as processes, with multiple interacting chains, which often go back over considerable periods of time and involve many different components of the over-all system. 4. The inv
22、estigation of major catastrophes in large-scale, high-technology systems has revealed these accidents to have been caused by a combination of many factors, whose origins could be found in the lack of Human Factors considerations during the design and operating stages of the system rather than in ope
23、rational personnel error. Examples of such catastrophes include the accidents at the Three Mile Island (Pennsylvania, USA, 28 March 1979) and Chernobyl (Ukraine, USSR, 26 April 1986) nuclear power plants, the Challenger space shuttle (Florida, USA, 28 January 1986), the double 6-747 disaster at Tene
24、rife (Canary Islands, Spain, 27 March 1977) and the Bophal (Bophal, India, 3 December 1984) chemical plant. Large-scale, high-technology systems like nuclear power generation and aviation have been called sociofechnicai systems, in reference to the complex interactions between their human and techno
25、logical components. Management factors and organizational accidents are key concepts in sociotechnical systems safety. The terms system accident and organizational accident reflect the fact that certain inherent characteristics of sociotechnical systems, such as their complexity and the unexpected i
26、nteraction of multiple failures, will inevitably produce an accident. In sociotechnical systems, remedial action based on safety findings goes beyond those who had the last opportunity to prevent the accident, .e. the operational personnel, to include the influence of the designers and managers, as
27、well as the structure or architecture of the system. In this approach, the objective is to find what, rather than who, is wrong. 1 Copyright International Civil Aviation Organization Provided by IHS under license with ICAONot for ResaleNo reproduction or networking permitted without license from IHS
28、-,-,-ICAO CIRCULARx247 * m 484141b 0032383 894 m 2 ICAO Circular 247-AN/148 5. crash during an attempted take-off in icing conditions: Consider the probable cause statement in the aircraft accident report following a twin jetliner “The National Transportation Safety Board determines that the probabl
29、e causes of this accident were the failure of the airline industry and the Federal Aviation Administration to provide flight crews with procedures, requirements and criteria compatible with departure delays in conditions conducive to airframe icing and the decision by the flight crew to take off wit
30、hout positive assurance that the airplane wings were free of ice accumulation after 35 minutes of exposure to precipitation following deicing. The ice contamination on the wings resulted in an aerodynamic stall and loss of control after liftoff. Contributing to the cause of the accident were the ina
31、ppropriate procedures used by, and inadequate coordination between, the flightcrew that led to a rotation at a lower than prescribed airspeed.” While acknowledging the role the operational personnel played in triggering the accident, the analysis looks for system deficiencies and recognizes that the
32、 root causes of the accident can be traced back to flaws in the aviation system design and operation. 6. This digest, therefore, addresses the influence of management factors in aviation safety, from the perspective of organizational accidents. Its contents, like any changes or new approaches in avi
33、ation, are evolutionav rather than revolutionary. Management factors in accident prevention go back to some of the earliest industrial safety texts, forty or more years ago; they have been the subject of prevention courses for over thirty years (Advanced Safety Management and System Safety factors,
34、C. O. Miller, University of Southern California, 1965). This digest builds on the ICAO Accident Prevention Manual (Doc 9422). This manual, first published in 1984, clearly indicates that the responsibility for safety in any organization* rests ultimately with management and advocates a broadened app
35、roach to accident prevention. This digest picks up where the Prevention Manual left off, but from the perspective of Human Factors and with the obvious benefit of the wealth of knowledge accrued through the intensified research in the intervening years. In due time, this material will be incorporate
36、d in a revision to the Prevention Manual. 7. The objective of this digest is to provide the participants in the decision-making process in the aviation industry - including corporate management, regulatory authorities, manufacturers and professional associations - with an awareness of the impact of
37、their actions or inactions on aviation safety. Throughout the digest, numerous examples are included for clarification purposes. The examples are excerpted from accident investigation reports produced by relatively few States and their inclusion should by no means be construed as a negative reflecti
38、on on the safety record of those States or as an unwarranted criticism of their administrations or aviation systems. On the contrary, it is an implicit recognition of a progressive attitude towards safety, since by virtue of being pioneers in the application of the perspective advanced by this diges
39、t, those States are among those at the leading edge of the international communitys safety endeavours. 8. This digest comprises the following: Chapter 7 includes an introduction to contemporary safety thinking, presenting the shift from individuals to organizations. 1. National Transportation Safety
40、 Board, Aircraft Accident Report 93/02 (NTSB/AAR-93/02). 2. Within the context of this digest, organization is defined as u.a body of persons organized for some specific purpose“. Copyright International Civil Aviation Organization Provided by IHS under license with ICAONot for ResaleNo reproduction
41、 or networking permitted without license from IHS-,-,-ICAO CIRCULARa247 * 4BLiL4Lb 0032384 720 = /CA O Circular 24 7-A NA48 3 Chapter2 elaborates the concepts presented in Chapter 1, provides examples of how system deficiencies whose roots can be found far away from the site contribute to accidents
42、and introduces the concept of safe and unsafe organizations. Chapter 3 is a “how to” to help decision-makers recognize why they should act upon safety; it provides details on and examples of what decision-makers can do to contribute to safety. Chapter 4 presents a case study to illustrate in practic
43、al terms the concepts discussed in the digest. 9. Factors Study Group and was developed from an outline prepared by Study Group Member Jean Paries. The sources of reference and additional reading material are included at the end of each chapter. The other digests in this series are: This digest was
44、produced with the assistance of the ICAO Flight Safety and Human Digest No. 1 - Fundamental Human Factors Concepts (Circular 21 6); Digest No. 2 - Flight Crew Training: Cockpit Resource Management (CM) and Line- Oriented Flight Training (LOFT) (Circular 21 7); Digest No. 3 - Training of Operational
45、Personnel in Human Factors (Circular 227); Digest No. 4 - Proceedings of the ICA0 Human Factors Seminar (Circular 229); Digest No. 5 - Operational Implications of Automation in Advanced Technology Flight Decks (Circular 234); Digest No. 6 - Ergonomics (Circular 238); Digest No. 7 - Investigation of
46、Human Factors in Accidents and Incidents (Circular 240); Digest No. 8 - Human Factors in Air Traffic Control (Circular 241); and Digest No. 9 - Proceedings of the Second ICA0 Flight Safety and Human Factors Global Symposium (Circular 243). Copyright International Civil Aviation Organization Provided
47、 by IHS under license with ICAONot for ResaleNo reproduction or networking permitted without license from IHS-,-,-ICA0 CIRCULARs247 * M 4843436 0032385 667 M 1.1 Chapter FROM INDIVIDUALS TO 1 ORGANIZATIONS “At O1 :24 on Saturday, 26 April 1986, two explosions blew off the 1000-tonne concrete cap sea
48、ling the Chernobyl-4 reactor, releasing molten core fragments into the immediate vicinity and fission products into the atmosphere. This was the worst accident in the history of commercial nuclear power generation. It has so far cost over 30 lives, contaminated some 400 square miles of land around t
49、he Ukrainian plant, and significantly increased the risk of cancer deaths over a wide area of Scandinavia and Western Europe . There are two immediate questions: (1) How and why did a group of well-intentioned, highly motivated and (by other accounts at least) competent operators commit just the right blend of errors and safety violations necessary to blow this apparently safe reactor? (2) Could something like it happen here?” (1) 1.2 The fi
