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perceived absence of threat.
Fatigue
The progressive decrement in performance due to prolonged
or extreme mental or physical activity, sleep
deprivation, disrupted diurnal cycles, or life event
stress.
Illusion
An erroneous perception of reality due to limitations of
sensory receptors and/or the manner in which the information
is presented or interpreted.
Judgement
Assessing the significance and priority of information
in a timely manner. The basis for DECISION.
Aircraft Accident Investigation 28
Motivation
A person’s prioritized value system which influences
his or her behavior.
Peer Pressure
A motivating factor stemming from a person’s perceived
need to meet peer expectations.
Perception
The detection and interpretation of environment cues by
one or more of the senses.
Perceptual Set
A cognitive or attitudinal framework in which a person
expects to perceive certain cues and tends to search for
those cues to the exclusion of others.
Situational Awareness
The ability to keep track of he prioritized significant
events and conditions in one’s environment.
Spatial Disorientation
Unrecognized incorrect orientation in space. This can
result from a illusion, or an anomaly of attention, or an
anomaly of motivation.
Stress
Mental or physical demand requiring some action or
adjustment.
SYSTEM SAFETY AND THE SAFETY
ORDER OF PRECEDENCE
For every incident, there are many near accidents.
H.W. Heinrich’s Accident Safety Triangle projects that
for every 300 hazards present, there are 29 incidents,
and 1 accident. According to this, there are numerous
hazards that could potentially develop into the cause of
an incident or accident. The key is to identify these
hazards in the system and assess them so that a solution
may be determined.
System Safety is the application of special technical
and managerial skills to the systematic, forward-looking
identification and control of hazards throughout the life
cycle of a project, program, or activity. Simply stated,
system safety involves the identifying, evaluating, and
addressing of hazards or risk. Its sole purpose is to prevent
accidents.
The causes of an accident are factors, events, acts, or
unsafe conditions which singly, or in combination with
other causes, result in the damage or injury that occurred
and, if corrected, would have likely prevented or
reduced the damage or injury. A hazard is any condition,
event, or circumstance, which could induce
(cause) an accident. Risk is defined as the probability
that an event will occur.
There are two major types of risks that are involved in
system safety. An informed risk is a risk that has been
corrected and assessed, whereas an uninformed risk is a
risk that was not identified or was incorrectly measured.
The objective of risk management is to obtain an understanding
of how to access the various levels of hazards
and to gain an insight on logical approaches to deal
with those hazards. In order to control these risks, risk
management techniques must be enforced. The first
step of managing risks is to collect data. Once data is
collected, accident precursors (hazards) are identified
and evaluated. Finally, countermeasures (solutions) are
developed, communicated throughout the organization,
and are then implemented in the system.
An internal reporting system is an effective way of collecting
information about what is going on with respect
to safety within an organization. Employees involved
in an event report the hazard in the organization’s internal
reporting system. From there, hazards can be prioritized,
and risk can be assessed and analyzed.
Rank each hazard from 1 to 5, with 1 being the most
severe and 5 being the least severe.
Hazards can be prioritized according to the probability
of an accident occurring, and by the severity of an accident
that may occur due to the hazard. In order to prioritize
hazards, each hazard is ranked according to the
most severe or the least severe outcomes. Rankings are
assigned with the numbers 1 through 5, 1 being the
Aircraft Accident Investigation 29
most severe and 5 being the least severe. It must be
understood that we anticipate hazards, not discover
them.
The Safety Order of Precedence is the hierarchy of
solutions that may be implemented to eliminate, control,
or reduce a hazard. The highest, most efficient
solution is to design for minimum risk or the engineering
solution. According to this, the hazard is corrected
　
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