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Old 13th Sep 2017, 11:11   #1 (permalink)

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Flight safety

I'm writing a piece for a business magazine on applying flight safety principles of learning from mistakes to the world of business leaders. You many have noticed that they also make mistakes - even leaders of airlines.

I plan to use G-BJRT's loss of its windshield (1990) as a story to illustrate how aviation investigators have long been getting to root causes. In reading the AAIB report I've come across an (old?) acronym that Google can't decode for me: "QMDR". It is clearly some kind of report of a problem but I'd be most grateful for an accurate translation into words.
Thank you
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Old 13th Sep 2017, 12:18   #2 (permalink)
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Do you have a page reference?
QM = quality management normally.
DR = could be any number of things depending on context.

Actually Ive just opened the report and it's on page viii.
Quality Monitoring Deficiency Report.
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Old 13th Sep 2017, 12:23   #3 (permalink)
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Quality Monitoring Deficiency Report - it's in the AAIB report's glossary, page viii (which, confusingly, is page 7 of 62; they seem to have skipped page iv)...
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Old 13th Sep 2017, 12:55   #4 (permalink)
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Ops, you might wish to research more recent views on the limitations of safety investigations, particularly as industries become increasingly complex.
Investigators may be well qualified, but experience from previous investigations might not relate to new or novel situations.
With human interaction there may be several viewpoints; reports constrained by ‘factual’ reporting, opposed to speculative, probabilistic views of human performance which are required for learning.

The transformation of accident investigation. A lengthy view, the case studies can be skipped; if nothing else see the summary and conclusions, page 168.


Quality is not safety; safety is what you do, quality is only one possible outcome.

Last edited by safetypee; 13th Sep 2017 at 16:18.
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Old 13th Sep 2017, 15:52   #5 (permalink)

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Many thanks to all. I should have realised there would be a glossary.

And thank you for the pointer to Pupulidy. A quick look at his conclusions suggests that he has reached conclusions similar to those in "Rethinking Reputational Risk" and earlier research, particularly a report from the Cass Business School called "Roads to Ruin". Between them about 30 case studies of major corporate disasters and analysis of the multiple causes involved in most of the failures.

In a nutshell their conclusions can be reduced to two main points. First, most major failures have people-system failures at their roots, which means that to fix the problem you have to fix the people-system weaknesses, which may be multiple and complex in nature and origin.

Second, people systems are driven by successive layers of leaders, which means that to fix it you may have to 'fix' leaders, often top leaders, too. This presents practical problems outside aviation safety which, from the outside, looks like a particularly enlightened community.
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Old 13th Sep 2017, 17:51   #6 (permalink)
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Ops, there are hazards in most approaches to ‘improvement’, particularly in attempting to fix humans.
Those at the workfare could benefit from improvements to the working environment, procedures, knowledge, protection from harm, but those at the top need to understand the ill defined processes to achieve that.

The danger in these views is first believing that there is a solution, there isn’t it's a process of continuous change, and second that humans are the hazard - see Safety 1 vs Safety 2, humans as a help, focus on the success not the failures; resilience.
Management might be attracted to some of these new ideas - particularly if they can be convinced that they thought of them.

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Old 13th Sep 2017, 20:08   #7 (permalink)
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Other areas for management types are the costs associated with getting things wrong, even if there isn't a smoking hole in the ground. Wrong decisions are made by everyone and each of these has an associated cost. The clever bit is identifying potentially bad ones before they are made. Pilots do this by thinking about what they are going to do beforehand and then briefing their colleague so they know what's going to happen next. The more interesting briefs are met with a raised eyebrow and the impending process maybe amended as a result. It is also important to discuss how we keep on the "straight and narrow". We have limits, expectations and ways of measuring what we do. We monitor this as we go along and well after the event have the opportunity to review what we have done using QAR data. The same should exist in business - performance indicators based on measurable parameters.
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Old 14th Sep 2017, 11:02   #8 (permalink)

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Safetypee thanks.
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Old 14th Sep 2017, 12:48   #9 (permalink)
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FYI. Interesting idea:

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