Serious Accidents and Human Factors - Aviation Safety Through Incident Reporting Analysis

Informationen zum Autor Masako Miyagi is Executive Director of the Japan Research Institute of Air Law. An earlier edition of her book is previously published in the Japanese language under the title Seeking Out the Signs of Major Accidents. She has presented her work at numerous academic meetings for the benefit of mechanical engineers and scientists! reliability engineering associations! aeronautical societies! health and safety organizations! and the chemical! process! and power industries. Klappentext There is growing concern globally over issues of aviationsafety. Awareness of previous failures and their causes isone of the most important factors in determining risks and hazardsin any new operational systems. This requires experience ofaccidents and failures across a broad spectrum of complex systems.Every accident occurs as a result of a chain of errors! and ifone of the 'links' making up that chain can be broken!the accident might be prevented - and becomes merely an'incident'. If you collect detailed data from a rangeof 'incidents'! relating to how they occurred! anddevelop a consistent method for analysing that data! you can createa potentially valuable resource to assist in accidentprevention.This interesting publication proposes an original and structuredapproach to accident prevention. In an interesting and readablecollection of accounts of major accidents! drawn mainly from theaviation industry! the author investigates incident reportsanalytically and reveals the critical information hidden thereinthat could avert a full-blown accident or disaster. She applies aninnovative analytical technique - multi-dimensional analysis ofincident reports (MAIR)! using a particular model (QuantificationMethod III) to validate the results and focus upon individualcomponents identified within the causal chain of events thatprecede an accident. She advocates wider acceptance and use of IRAS(Incident Report Analysing System)! ideally administered by aneutral and independent body! to help prevent accidents not only inaviation but in relation to all complex systems! such as nuclearpower plants.This comprehensive text offers aviation industry personnel! aswell as those involved more generally with safety! risk assessment!and accident prevention in other industries! an inclusiveunderstanding of the accident causation chain! events contributingto that chain! and a method for identifying and eliminating causalfactors in a pro-active way.Features:* Provides a comprehensive explanation of the accident causationchain! events contributing to that chain! and methods foridentifying & eliminating causal factors in a pro-activeway* Proposes an original and structured approach to accidentprevention* Presents case studies from a wide range of internationallyinfamous aviation accidents* Discusses and advocates the wider acceptance and use of IRAS(Incident Report Analysing System) Zusammenfassung Proposes an approach to accident prevention. This book investigates incident reports analytically and reveals the critical information hidden there in that could avert a full-blown accident or disaster. It discusses and advocates the acceptance and use of IRAS (Incident Report Analysing System)....

List of contents

Acknowledgements.
List of Figures and Tables.

Foreword.

Introduction.

Chapter 1 Presence of accident warning signs inall incidents.

1.1 The great losses that result fromaccidents in large-scale systems.

1.2 The limits of safety measures based onaccident investigations.

1.3 The social impact of the Osutaka MountainJAL plane crash accident.

1.4 Overconfidence in safety measures as acause of accidents.

1.5 Humility with respect to the facts.

1.6 The unrecovered vertical tailplanefragment of the Japan Airlines aircraft.

1.7 Incidents and the structure of anaccident.

1.8 Errors made by a veteran pilot.

1.9 Background to mistakes made by the airtraffic controller.

1.10 Improper instructions by the air trafficcontroller.

1.11 Unbroken chain of events leading to the accident.

1.12 Lessons not applied.

1.13 Differences in understanding between pilot andcopilot.

1.14 Matters not clarified by the accidentinvestigation.

1.15 Accident investigations conducted by reverselogic.

1.16 Forward-looking information obtained by IRAS.

1.17 Disasters preventable through conveyance ofinformation.

1.18 Advances in science and technology and new kinds ofdanger.

1.19 The pitfalls of computer control.

1.20 Where do the relevant danger factors lie?

1.21 The phase that determines the occurrence of anincident.

1.22 Evaluating the degree of danger.

1.23 Breaks in the chain of events leading to anaccident.

1.24 An overall picture of the danger factors.

1.25 IRAS and quantification method III.

1.26 Searching for incident patterns.

1.27 Why take up the field of aviation?

1.28 Meaning of Dr Shigeo Okinaka's document'Medical Record'.

Chapter 2 Pre-accident situations experienced bypilots.

2.1 The work of a pilot.

2.2 Take-off and reject take-offprocedures.

2.3 New emphasis on high-techinformation-processing tasks.

2.4 Landings require extra care.

2.5 Fatigue as a major factor in errors.

2.6 Impatience, fluster, and carelessnessafter stressful periods.

2.7 Mistakes caused by much or littleexperience and knowledge.

2.8 Danger arising from interpersonalrelationships among crew.

2.9 The dangers of the missed approach.

2.10 Heavy rain causing poor visibility.

2.11 Danger caused by snow.

2.12 Snow and ice build-up on the plane as a factor posingthe most

danger.

2.13 Danger of wind at take-off and landing.

2.14 Pitfalls of good weather conditions.

2.15 Latent danger in ever-advancing aviation safetyfacilities and instruments.

2.16 Airport markings and landmarks as importantfactors.

2.17 Importance of weather information.

2.18 Close relationship between weather forecasts and fuelon board.

2.19 Point where mechanical problems develop into anaccident.

2.20 Pilot training or check flights that increase stressand workload.

2.21 Unexpected changes of instructions as a cause ofmistakes.

2.22 Accidents averted by good fortune.

2.23 Improvements and countermeasures uncovered byanalysis.

2.24 Degree of danger in 'hard factors' and'soft factors'.

2.25 Urgently needed response to 'hardfactors'.

2.26 Danger factors increasing in importance and targetedfor improvement.

Chapter 3 Imminent danger experienced by airtraffic controllers.

3.1 Air traffic control space and various airtraffic control services.

3.2 Flight rules: Visual Flight Rule (VFR) andInstrument Flight Rule (IFR) aircraft.

3.3 Air traffic control service work flow andwork assignment.

3.4 Peculiarity of air traffic controlservice.

3.5 Mishearing in communications withpilots.

3.6 Danger created by inappropriateterminology.

3.7 Discrepancies in recognition between airtraffic controllers and pilots.

3.8 Problems near the boundaries between airtraffic controlled airspaces.

3.9 Oceanic control service via radiostation.

3.10 Highly dangerous incidents due to cumulonimbus.

3.11 Danger due to poor visibility within clo

Product details

• Authors: M Miyagi, Masako Miyagi, Masako (Japan Research Institute of Air La Miyagi, Miyagi Masako
• Publisher: Wiley, John and Sons Ltd
• Languages: English
• Product format: Hardback
• Released: 11.03.2005
• EAN: 9781860584732
• ISBN: 978-1-86058-473-2
• No. of pages: 320
• Subjects: Natural sciences, medicine, IT, technology > Technology > Mechanical engineering, production engineering; Social sciences, law, business > Business > Individual industrial sectors, branches; Maschinenbau, Luftfahrt, Flugsicherheit, Flugunfall, Mechanical Engineering, Electrical & Electronics Engineering, Elektrotechnik u. Elektronik, Aeronautic & Aerospace Engineering, Luft- u. Raumfahrttechnik, Quality & Reliability, Qualität u. Zuverlässigkeit, Spezialthemen Elektrotechnik, Electrical Engineering Special Topics, Menschlicher Faktor