@WillowRun, even with some heartening views expressed at the symposium there are few indications that the industry is changing, excepting perhaps some aspects of SMS.
The reluctance to change could represent the difficulty in changing culture, which conventionally might take a generation. In that respect 15 yr old thoughts could still be valid, more likely they represent exceptional forward thinking. For more recent views see Cook and Hollnagel, refs.
Ah, Annex 13 ‘Oversight’ – perhaps ‘Overarching Standards and Practices’ is better.
One ‘change’ initiative, amongst others is the awkwardly termed ‘Resilient Engineering’ - to build resilience (and how to spring forward, not back to an original positon).
The fundamental concept seeks a different way of thinking about safety – safety is not something to have, but that which is done. Furthermore, safety thinking should be against the backdrop of what happens in every-day situations – the successes, and most importantly to view humans as an asset, not as a hazard. Also, by comparing ‘work as done’ against ‘work as imagined’, any gaps in safety assumptions could be understood.
With understanding and improving the ‘successes’ there should be less opportunity for the failures. Unfortunately this assumes that the industry does not demand more activity, in more complex operational system, and the need to work near to the edge of established safety boundaries.
Distantly this can reflect the gap between researches seeking to better understand human behaviour (know-what) vs the industry’s need for the ‘know-how’ to enable current academic views to be implemented, an aspect which is reflected in some symposium presentations (inconsistent HF, CRM, TEM, training).
The change of view above is often defined as ‘Safety 2’, unfortunately with the potential for misinterpretation as a replacement for what we do now – Safety 1. I subscribe to the concept of “Safety 1
and Safety 2”. S1 has enabled today’s successes and should not be totally rejected, but in order to progress – high reliability organisation, complex operations, etc, S1 and S2 could provide the means for managing the uncertain nature of modern operations and reducing the potential for major accidents. Additionally, S2 thinking in areas of S1 may add unseen safety advantage, particularly in the ‘safety – commerce’ balance which could be overly subjected to S1 type commercial thinking.
A practical aspect RE starts with Learning, and then cycling though Responding, Monitoring, and Anticipating. The cycle can be entered at any point, i.e. Learn from accidents, Monitor the Responses made based on what has been learnt, which could provide the Anticipation to avoid or minimise the effect of future events, even to the point in not being exposed to situations which could not have been foreseen – we never know - uncertainty.
The points of learning should not require massed evidence or deep understanding; they could be questions about what is done ‘normally’, individually or collectively. Thus relating to this accident
‘what is the normal cruise seat positon’, ‘can full control be achieved from this position’, ‘is the SOP to follow the FD overstated’, ‘how is the FD interpreted’, ‘should we leave our seat to switch systems’, trim, etc.
With answers to these then the responses the required safety activity should be clearer, quicker, and pertinent to operations opposed to time-delaying regulation and training.
Resilience Engineering.
Introduction to S-I and S-II.
Resilience Analysis Grid.
The Resilient Organisation.
From Safety 1 to Safety 2
and for roulishollandais, et al;
Non-Newtonian View of Accidents.