Organisational Human Factors and Safety in the News - Investigations to the Crashes - Assignment Example

Analysis of organizational human factors and safety in the news 1.1. The first instance is that of the report on the investigations to the crash in June, 2008. the report is clear on the fact that evidences have been gained through a process of specialist investigation wherein specialists removed nine "pitot tubes" out of a total of 84 seized from Air France and found that some were either slightly or highly degraded pointing to a doubt on them not being cleaned often enough (Telegraph Report, 2010). The jet's speed probes the report states, gave faulty readings and were "one of the factors" in the crash but "not the sole cause". This is a manifestation of the systems approach which states in essence that accidents are a manifestation of a manifold chain of events with the incident/accident/injury as the end point (Friend and Kohn, 2007). Danger develops or is minimised due to interaction between the elements of the machine such as hardware, the people and the manner in which the interaction takes place between the two, the procedures within which people are bound, organizational rules and the environment (Goetsch, 2002). The theory conceptualises incidents of air crash as manifestations of not just an event, but a chained process which have a succession of events and conditions. These differ in terms of the location of the sequence and the manner in terms of the availability of information, likelihood of changing the event or condition, and the political or social ramifications that characterise the event (Elvik, Hoye and and Tru Vaa, 2009). In the context of this case the dominoes theory again finds application given the fact that Heinrich’s Domino Theory states that accidents result from a chain of sequential events, metaphorically like a line of dominoes falling over.  When one of the dominoes falls, it triggers the next one, and the next…but removing a key factor (such as an unsafe condition or an unsafe act) prevents the start of the chain reaction. This was further developed in the multiple causation models by Bird and Loftus (1983) wherein it was tat stated behind any given accident there would be many contributing factors causes and subcasuses. The theory is basically states that these factors combine together in random fashion, causing accidents. These are made up of the unsafe act, the unsafe condition and the correction. If the correction does not indeed take place then an accident is bound to occur. The idea essentially is based on the concept that it is a lack of management control that leads to the basic cause of an accident, which could be a job factor such as unguarded machinery or a person factor such as lack of adequate training. This would then lead to the intermediate cause which is the unsafe act or condition which would in turn cause the accident (Banfield and Kay, 2008). 1.2. The second report focuses on the crash that killed the Indian chief minister for the state of Andhra Pradesh in the southern part of the country. The report focused on the cause of the crash outlining the fact that the probable cause of the accident was that it “occurred due to loss of control resulting in uncontrolled descent in the terrain at a very high rate of descent due to entry into severe down draught”. It was again focused principally on the human reasons for the crash stating that the time that the pilots spent going over the manual proved to be fatal. The search for cause in the context of this particular investigation is largely hindered by the reductionism trend that seeks to explain every7thing in terms of neurological functions. There is a certain logic to that in the sense that human functioning is based on what went on in the brain of the pilot while he wasted time in reading and rereading the manual. One sees in this report the need to know it all, not because we have a thirst for pure knowledge but because of the fact that we want to drive out the demons of uncertainty (Hollnagel, 2004). Although it might be assumed by many that what we report, we look for the meaning in the sense of an explanation of the accident, we are in fact more often looking for certainty in the form of cause. No wonder then that a death like this one gives birth to many conspiracy theories on the cause of death, creating political overtones where none exist. The accident on the face of it seems to fit into a simple category that has come to dominate recent accident statistics: mechanical failures as a result of poor maintenance (Dekker, 2004). He suggests that in trade-offs between safety and efficiency there is a feedback imbalance. Information on whether is a decision is cost effective or efficient can be easy to get. The fact that one would have to conclude this discussion with is that deviances in management of machines was normal earlier but by the present crop of reporting it is no longer normal but something that is to be studied. 1. 3. The third report focuses on the cause of the air crash that killed the Polish president. The circumstances surrounding the incident had led people to question the pilot’s judgment to fly that day making people question if the pilot had been in fact been pressured by his superiors to land at Smolensk rather than diverting. airlines and aircraft owners sometimes pressure pilots to fly or to land against their better judgment. The report clarified that in general, though, it would be unusual for an airline or an aircraft owner in the U.S. or most other Western countries to attempt to override a pilot's judgment. It concludes on the note that while pressure on pilots is often subtle, it is a contributing factor in several air crashes over the years. This report focuses on the domino theory of accident and prevention outlining the fact that the accident was a fall out of the social environment that resulted in the fault of the pilot, impacting unsafe act ultimately causing accident and injury (Ridely and Channing, 2003). In this context the report also has a manifdestaion of the aciident sequence model where it is suggested that an occupational accident may be regarded as an abnormal or unwanted effect of the process in an industrial system or something that does not work as planned (Stellman, 1998, Surry, 1969). In Surry’s view, an accident could be described as a series of questions, forming a sequential hierarchy of levels, where the answers to each question determine whether an event turns out as an accident or not. The model is reflective of the principles of human information processing, and is based upon the notion of an accident as a deviation from an intended process. It has three principal stages, linked by two similar cycles. The report and the manner in which it suggests the accident took place suggest more than once that the accident was direct manifestation of a flouting of norms that are related to the manner in which the flying was supposed to commence. This in turn is a direct implication of human factors to the same. The accident sequence model as outlined by Kjellen define norm as a system with specified requirements (rules, regulations etc), with a view to the planned sequence of events, a consideration for what is usual and accepted. The model to be fair has a consideration outlined for the fact that a clearly define model for what would constitute a norm is not always definable therefore it is often tough to tell when deviation has happened specially between levels in the organisation, e.g.: employee, supervisor, customer, manufacturer etc. this also has manifestation in the demand for a crime probe where the search would be to find motive. In this case however, the deviation is clear in as much as it is ultimately a pilot’s responsibility to take the call on whether or not conditions are suitable for flying but the fact that other factors override this judgment lead to accident such as this one resulting in catastrophic conclusions. 1.4. A Reuters report stated recently that a Bulgarian national had died in an airplane crash in the Philippines on April 22, 2010, caused by an electrical fire. The fire was attributed primarily to technical causes. The report also quoted the local police in as much as the plane had electric circuit trouble about an hour into the flight, and a fire that broke out forced him to make an emergency landing on the open field. The report works on the Common cause analysis (CCA) method- used in the identification of that lead up to an aircraft accident. The method outlines the usefulness in the extraction of the common causes in airplane accidents and crashes. The idea is to divide the machine (in this case the airplane) into zones that imply that the intricacies characterizing the system and working of the various elements of the zones are ultimately independent. As a result therefore, it is possible to identify the common causes of failures of particular components of such independent systems (Netjasov and Janic, 2008). In addition, the method enables identifying and assessing hazard from external causes that might compromise independency between particular systems and components and cause their failures due to the same (common) causes. The other method that is used in this case report is the Event tree analysis (ETA) which is used in the modeling of successive events that arise from a singular dangerous event thereby helping the description of the seriousness of the results of these events. The two things that this places under consideration is the echanical failure and the failure of the human being controlling the aircraft in preventing the accident (Blom, Stroeve, and de Jong, 2006). In very stage aviation incidents would not precede accidents, but normal work would. In these systems the common cause hypothesis is false and the value of the incident reporting for making even greater progress on safety is dubious. 1.5. The final report focuses on the 2007, Kenya Airways plane crash in Cameroon in which all 114 passengers and crew perished (Daily Nation report, 2010). The incident took place when a Kenya Airways Boeing 737-800 plunged into a swamp shortly after take-off from Doula International Airport. It was the airline’s second disaster in seven years. The report is probably a case in instance for the arguments being presented in this context given the fact that it highlights the vision of the CCAA in terms of wanting to highlight solutions and not just finding the culpable people. Accidents are different in nature from those occurring in safe systems. in this case accidents usually occur in the absence of serious breakdowns or even of serious error. They result from a combination of factors, none of which can alone cause an accident or even a serious incident; therefore these combinations remain difficult to detect and to recover using traditional safety analysis logic (Luxhoj and Coit, 2006). For the same reason therefore reporting would become less relevant in predicting major disasters. In spite of the relevance of this particular insight, independent errors are still major return of any accident investigation today (Harris and Muir, 2005). Failures of human performance defined by the situation (errors in these cases are not always erroneous). These could even be understood in the context of the failure of human performance are often produced by the situation. Even without sounding philosophical about this we can state that where there is a cause there would be an effect (Geisinger, 1985). Where this has a manifestation in terms of absence of training or even of incompetencies these need to be highlighted in reporting by the media but in cases where these are a simple fact of the person not being able to control the incident, the reporting needs to make allowances for error instead of trying and single-handedly testing and convicting the case as well. What one concludes from the discussion is that there is a need bringing about an improvement in accuracy in setting up the thresholds for third-party risk around given airport. References: Telegraph Report, (2010). Air France crash may have had maintenance problems. Published April 25, 2010. Retrieved April 26, 2010, < http://www.telegraph.co.uk/news/worldnews/europe/france/7632542/Air-France-crash-may-have-had-maintenance-problems.html> Ridely, J., and Channing, J. R., (2003). Safety at work. Butterworth Heinanman. P199-200 Goetsch, D. L., (2002). Occupational safety and health for technologists, engineers, and managers. A1 Books. p43 Elvik, R., Hoye, A., and and Tru Vaa, M., (2009). The Handbook of Road Safety Measures. Emerald Book Publishing. pp90-92 Friend, M. A, and Kohn, J. P, (2007). Fundamentals of occupational safety and health. A1 Books. pp72-74 Anderson, O., and Lagerlof J., (1983). Soil Fauna (Microanthropods and nematodes) in Swedish agriculkture cropping system. Acta Agric. Vol.33. pp33-52 Surry, J., (1969). Accident Sequence Model. Retrived April 26, 2010, < http://www.ilo.org/safework_bookshelf/english?content&nd=857170646> Kjellen, U., (2003). Prevention of accidents through experience feedback. CRC Press. Bird and Loftus, (1982). F.E. Bird and R.G. Loftus, Loss Control Management, Institute Press. Loganville Banfield, P., and Kay, R., (2008). Introduction to Human Resource Management. A1 Books. p173 Agency press Report (2010). Polish air crash puts spotlight on pilots' duties. Published, April 12, 2010. retrieved April 26, 2010, < http://www.google.com/hostednews/ap/article/ALeqM5isrxBJc6Ubjk_FaaevaXNRhqjr_QD9F1RGH00> Hollnagel, E. (2004). Barriers and accident prevention (Chapter 2: Thinking about accidents). Aldershot, UK: Ashgate Dekker, S. W. A. (2004). Why we need new accident models. Human Factors and Aerospace Safety, 4 (1), 1-18 Economic Times Report (2010). Pilot error cause of YSR helicopter crash, says probe report. Published January 20, 2010. retrieved April 26, 2010, < http://economictimes.indiatimes.com/news/politics/nation/Pilot-error-cause-of-YSR-helicopter-crash-says-probe-report/articleshow/5481791.cms> Blom, H.A.P., Stroeve, S.H., de Jong, H.H., 2006. Safety risk assessment by montecarlo simulation of complex safety critical operations. In: Proceedings of the 14th Safety Critical Systems Symposium. Bristol Daily Nation report, (2010). Douala plane crash report out this week. Retrieved April 26, 2010, < http://www.nation.co.ke/News/Douala%20plane%20crash%20report%20out%20this%20week/-/1056/906600/-/e3i0hjz/-/> Netjasov, F. & Janic, M. (2008). A review of risk and safety modelling in civil aviation. Journal of Air Transport Management, 14, 213-220 Geisinger, K., 1985. Airspace conflict equations. Transportation Science 19, 139–153 Luxhoj, J., Coit, D., 2006. Modeling low probability/high consequence events: an aviation safety risk model. In: Proceedings of the 2006 Reliability and Maintainability Symposium (RAMS), Newport Beach. Reuters Report (2010). Cargo plane crashes, bursts into flames in rice field in the Philippines; 3 dead, 3 rescued. Retrieved April 26, 2010, < http://calamities.gaeatimes.com/2010/04/21/cargo-plane-crashes-bursts-into-flames-in-rice-field-in-the-philippines-3-dead-3-rescued-17993/> Read More