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Old 19th Aug 2014, 09:59
  #278 (permalink)  
PJ2
 
Join Date: Mar 2003
Location: BC
Age: 76
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I think he has everything to do with aviation, but of course he woudn't have known it! It shows that the human and corporate behaviours and the principles that govern success and failure are the same.

One of the most significant insights developed in aviation safety came from Charles Perrow, when he wrote "Normal Accidents" in 1984. The process of changing our notions about "pilot error" and our notions of cause and blame began with Perrow and today are an integral part of SMS.

The other very significant change that arose out of the Dryden Inquiry, (as well as out of other industries such as coal mining - ...yes, there is a connection!), and which became a crucial part of SMS from the start, was the notion of the "Accountable Executive". In Canada it was called the "Westray Law" after a mining accident killed 26 miners and the courts held the executives accountable because they knew of the dangers and ignored them.

The notion of normal accidents is in contrast to the notion of "pilot error". The understanding that accidents occurred when people thought they were doing exactly the right thing opened the door to new understandings of why accidents occur. The concept of "organizational accidents" arose out of Perrow's work.

Although preceded by Bill Starbuck's paper, "Challenger: Fine-tuning the Odds Until Something Breaks", the finest explication of these notions is, in my view, Diane Vaughan's seminal sociological work, "
The Challenger Launch Decision The Challenger Launch Decision
".

There is a tremendous history behind the spectacular drop in fatal accidents and hull losses seen in the Airbus paper posted by A33Zab, (it should be noted that Boeing has been doing this same kind of study for a long time; the latest issue can be found here), began to change with the emergence of these important, broader notions about why machines and people fail. It is only the lawyers who seem to continue to focus on those who arrived at the accident site first...the pilots.

It is getting easier to make the business case so that shareholders, management and lawyers alike see that spending money on "nothing happening", (i.e., no accidents), is a good thing. These enlightened approaches, still resisted by corporate interests and their lawyers, are gradually showing that there is profit in operating safely, mainly because these days accidents do indeed cost far more than their prevention.
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