Improving Air Safety Through Organizational Learning

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?

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?

In Safety Culture: Building and Sustaining a Cultural Change in Aviation and Healthcare, the four authors draw upon their extensive teaching, research and field experience from multiple industries to describe the dynamic nature of a culture-change process, particularly in safety-critical domains. They use a "stories to numbers" approach that starts with felt experiences and stories of certain change programs that they have documented, then proceed to describe the use of key measurement tools that can be used to analyze the state of a change program. The book concludes with a description of empirical models that illustrate the dynamic nature of change programs.

Air safety is right now at a point where the chances of being killed in an aviation accident are far lower than the chances to winning a jackpot in any of the major lotteries. However, keeping or improving that performance level requires a critical analysis of some events that, despite scarce, point to structural failures in the learning process. The effect of these failures could increase soon if there is not a clear and right development path. This book tries to identify what is wrong, why there are things to fix, and some human factors principles to keep in aircraft design and operations. Features Shows, through different events, how the system learns through technology, practices, and regulations and the pitfalls of that learning process Discusses the use of information technology in safety-critical environments and why procedural knowledge is not enough Presents air safety management as a successful process, but at the same time, failures coming from technological and organizational features are shown Offers ways to improve from the human factors side by getting the right lessons from recent events

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.

Pre-Accident Investigations: Better Questions - An Applied Approach to Operational Learning challenges safety and reliability professionals to get better answers by asking better questions. A provocative examination of human performance and safety management, the book delivers a thought-provoking discourse about how we work, and defines a new approach to operational learning. This is not a book about traditional safety. This is a book about creating "real" safety in your organization. In order to predict incidents before they happen, an organization should first understand how their processes can result in failure. Instead of managing the outcomes, they must learn to manage and understand the processes used to create them. Ideal for use in safety, human performance, psychology, cognitive and decision making, systems engineering, and risk assessment areas, this book equips the safety professional with the tools, steps, and models of success needed to create long-term value and change from safety programs.

Although aviation is among the safest modes of transportation in the world today, accidents still happen. In order to further reduce accidents and improve safety, proactive approaches must be adopted by the aviation community. The International Civil Aviation Organization (ICAO) has mandated that all of its member states implement Safety Management System (SMS) programs in their aviation industries. While some countries (the United States, Australia, Canada, members of the European Union and New Zealand, for example) have been engaged in SMS for a few years, it is still non-existent in many other countries. This unique and comprehensive book has been designed as a textbook for the student of aviation safety, and as an invaluable reference tool for the SMS practitioner in any segment of aviation. It discusses the quality management underpinnings of SMS, the four components, risk management, reliability engineering, SMS implementation, and the scientific rigor that must be designed into proactive safety. The authors introduce a hypothetical airline-oriented safety scenario at the beginning of the book and conclude it at the end, engaging the reader and adding interest to the text. To enhance the practical application of the material, the book also features numerous SMS in Practice commentaries by some of the most respected names in aviation safety. In this second edition of Safety Management Systems in Aviation, the authors have extensively updated relevant sections to reflect developments since the original book of 2008. New sections include: a brief history of FAA initiatives to establish SMS, data-driven safety studies, developing a system description, SMS in a flight school, and measuring SMS effectiveness.

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