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Circular 247. Издание 1

Документ обновлён на дату:01.01.1993

Human Factors Digest No. 10 - Human Factors, Management and Organization

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CIRCULAR 247-AN/1481993HUMAN FACTORS DIGESTNo. 10HUMAN FACTORS,MANAGEMENT AND ORGANIZATIONApproved by the Secretary Generaland published under his authorityI C A OCIRCULARINTERNATIONALCIVIL AVIATIONORGANIZATIONMONTREALCANADA

iTABLE OF CONTENTSPage Introduction................................................................1Chapter 1. From Individuals to Organizations....................................4Chapter 2. Safe and Unsafe Organizations......................................10Introduction...........................................................10Corporate culture......................................................11Safe and unsafe corporate cultures........................................12The structure of organizations............................................14Regulatory compliance..................................................16Allocation of resources..................................................17Accidents in complex technological systems.................................18The traits of a safe organization...........................................22Chapter 3. Managements Contribution to Safety.................................24Introduction...........................................................24Why management should take an active stance on safety......................25What management can do to take an active stance on safety...................26Chapter 4. Organizational Accidents A Case Study..............................33Introduction...........................................................33The events...........................................................34Failed defences........................................................37Unsafe acts...........................................................39Error-producing conditions...............................................40Latent organizational failures.............................................42Conclusion...........................................................44

2ICAO Circular 247-AN/1481.National Transportation Safety Board, Aircraft Accident Report 93/02 NTSB/AAR-93/02.2.Within the context of this digest, organization is defined as a body of persons organized for some specific purpose.5.Consider the probable cause statement in the aircraft accident report following a twin jetlinercrash during an attempted take-off in icing conditions The National Transportation Safety Board determines that the probablecauses of this accident were the failure of the airline industry and the FederalAviation Administration to provide flight crews with procedures, requirementsand criteria compatible with departure delays in conditions conducive toairframe icing and the decision by the flight crew to take off without positiveassurance that the airplane wings were free of ice accumulation after 35minutes of exposure to precipitation following deicing. The ice contaminationon the wings resulted in an aerodynamic stall and loss of control after liftoff.Contributing to the cause of the accident were the inappropriate proceduresused by, and inadequate coordination between, the flightcrew that led to arotation at a lower than prescribed airspeed. 1While acknowledging the role the operational personnel played in triggering the accident, the analysis looksfor system deficiencies and recognizes that the root causes of the accident can be traced back to flaws in theaviation system design and operation.6.This digest, therefore, addresses the influence of management factors in aviation safety, fromthe perspective of organizational accidents. Its contents, like any changes or new approaches in aviation, areevolutionary rather than revolutionary. Management factors in accident prevention go back to some of theearliest industrial safety texts, forty or more years ago they have been the subject of prevention courses forover thirty years Advanced Safety Management and System Safety Factors, C. O. Miller, University ofSouthern California, 1965. This digest builds on the ICAO Accident Prevention Manual Doc 9422. Thismanual, first published in 1984, clearly indicates that the responsibility for safety in any organization2 restsultimately with management and advocates a broadened approach to accident prevention. This digest picksup where the Prevention Manual left off, but from the perspective of Human Factors and with the obviousbenefit of the wealth of knowledge accrued through the intensified research in the intervening years. In duetime, this material will be incorporated in a revision to the Prevention Manual. 7.The objective of this digest is to provide the participants in the decision-making process in theaviation industry including corporate management, regulatory authorities, manufacturers and professionalassociations with an awareness of the impact of their actions or inactions on aviation safety. Throughoutthe digest, numerous examples are included for clarification purposes. The examples are excerpted fromaccident investigation reports produced by relatively few States and their inclusion should by no means beconstrued as a negative reflection on the safety record of those States or as an unwarranted criticism of theiradministrations or aviation systems. On the contrary, it is an implicit recognition of a progressive attitudetowards safety, since by virtue of being pioneers in the application of the perspective advanced by this digest,those States are among those at the leading edge of the international communitys safety endeavours. 8.This digest comprises the followingChapter 1 includes an introduction to contemporary safety thinking, presenting the shift fromindividuals to organizations.

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