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Old 9th Nov 2008, 20:29
  #2397 (permalink)  
Rightbase
 
Join Date: Feb 2008
Location: UK
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An onlooker's observation:

A bold generalisation - if there were no accidents - ever - then safety provisions would lose credibility. It is the recurrence of accidents that maintains safety awareness. To keep the recurrence rate low, we need long memories.

We can artificially enhance safety awareness by adding 'near misses' to the accident pool. With credible extrapolation they can be as effective as accidents, but much less painful.

We can increase the value of each accident to safety awareness by publishing it widely discuss it at length and looking at what caused it. We get even more safety awareness by looking at what else might have caused the accident. In this way a safety hazard that might have but didn't cause the accident can surface without the need for it to cause an accident. So speculation magnifies the value of each accident to the safety awareness objective.

We get best value out of near misses and the speculation accidents that didn't happen. The killer accidents such as the one that prompted this thread are the expensive ones.

I suspect that the incidence of TOWS episodes has dropped recently, and awareness of the killer items is high at the moment. Paradoxically, over time, awareness will drop, TOWS episodes will begin to save the day again, and at some time in the future, another accident will remind us of these or other killer items.

Every time the TOWS goes off, it means that if a tiny transistor, a small sounder, one of a dozen connections, or a relay had failed to work, hundreds of lives could have been lost. It is a warning to the crew that (probably) a human procedure AND a human check have both failed, and only the last line of defence saved the day. It is a warning that for some reason the human systems are under performing, and that today is one of those days - a day to be extra careful...

The TOWS saves lives. Its contribution to safety awareness depends on whether the crew's response to it is simply to put the configuration right, or to register the TOWS event as a near miss, and add it to the safety awareness pool. Registering it mentally adds it to your own awareness pool. Registering it publically adds it to everybodys.

The TOWS saves lives. If pulling a breaker disables this or any other major warning system, it must be a major factor for the crew who would heed that warning. It cannot be difficult to produce and present to the crew a list of warnings any breaker disables. Knowing that they have no last line of defence against a killer mistake could make a useful difference, especially when today is one of those days...
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