Inter-Organizational Safety Debate: The Case of an Alarm System from the Air Traffic Control Domain

Inter-Organizational Safety Debate: The Case of an Alarm System from the Air Traffic Control Domain

Paola Amaldi, Simone Rozzi
DOI: 10.4018/jskd.2012010103
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The management of safety critical operations cannot be left to the initiative of those individuals directly in contact with the production processes. Society as a whole has a role. This paper explores the interface between societal components having a direct active role in the “safety debate”. The reference domain is air traffic management and the interface is among air traffic controllers and pilots – as directly involved in the management of the air traffic – and two agencies, the NTSB (responsible for safety investigation after an accident) and FAA (responsible for regulating, upgrading and training of the workforce). Recent debates in safety management highlight that safe practice is a control problem: the result of effective hierarchical transmissions of safety constraints and making the boundaries of acceptable performance visible. This work analyzes how safety constraints related to an alarm system are represented, transmitted and interpreted by several parties – all committed to safety of operations in air traffic management. A “miscalibration” pattern has emerged where the tendency to ignore the alarm was initially addressed at higher hierarchical levels in relation to alarm design, and only in 2006 was addressed in relation to the core issue of nuisance or false alerts (FA).
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In the Western world, every transport accident is followed by an investigation carried out by a Safety Board whose aim is not to identify “legal” responsibilities but to identify areas where operations could be improved. The present study focuses on the debate developed around safety recommendations following an accident involving aircraft flying into terrain or hitting an obstacle. We shall outline a general framework for analyzing accidents with a focus on safety issues.

The analysis of an accident should be informed by four dimensions including the cover story, the targets of the hazards, in our case human life and technical equipment, the nature of the hazard, in our case the spatial and temporal relationship between aircraft and obstacles, and the control strategy which can address one or more of the phases characterizing the adverse event. Such event or rather “flow of effects” can be causally linked to at least three preceding conditions: the root cause, the casual chain, the critical event itself. Safety control depends on means to break or to deviate the flow of events leading to the accident. A consensus should ideally be reached among decision makers at all levels of the socio-technical system with respect to the hazard sources and their control requirements. Following the representation of the accidental event, two main strategies can be identified: either blocking those events close to the critical ones or stepping backwards towards the “root causes” (Rasmussen et al., 2000).

Given a simplified representation of a sequence of events leading to an accident (Table 1), the following represents a schematic view of events in the worst scenario of Controlled Flight Into Terrain (CFIT).

Table 1.
Root causes and flow of events leading to the crash of Korean Flight 901, at Guam in 1997 (NTSB, 2000)

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