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Airline Safety Improvement Through Experience with Near-Misses: A Cautionary Tale

机译:通过近距离飞行体验改善航空安全:一个警告性的故事

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In recent years, the U.S. commercial airline industry has achieved unprecedented levels of safety, with the statistical risk associated with U.S. commercial aviation falling to 0.003 fatalities per 100 million passengers. But decades of research on organizational learning show that success often breeds complacency and failure inspires improvement. With accidents as rare events, can the airline industry continue safety advancements? This question is complicated by the complex system in which the industry operates where chance combinations of multiple factors contribute to what are largely probabilistic (rather than deterministic) outcomes. Thus, some apparent successes are realized because of good fortune rather than good processes, and this research intends to bring attention to these events, the near-misses. The processes that create these near-misses could pose a threat if multiple contributing factors combine in adverse ways without the intervention of good fortune. Yet, near-misses (if recognized as such) can, theoretically, offer a mechanism for continuing safety improvements, above and beyond learning gleaned from observable failure. We test whether or not this learning is apparent in the airline industry. Using data from 1990 to 2007, fixed effects Poisson regressions show that airlines learn from accidents (their own and others), and from one category of near-misses-those where the possible dangers are salient. Unfortunately, airlines do not improve following near-miss incidents when the focal event has no clear warnings of significant danger. Therefore, while airlines need to and can learn from certain near-misses, we conclude with recommendations for improving airline learning from all near-misses.
机译:近年来,美国商业航空业已实现了前所未有的安全水平,与美国商业航空有关的统计风险下降到每1亿乘客0.003例死亡。但是数十年来有关组织学习的研究表明,成功通常会滋生自满,失败会激发改进。将事故视为罕见事件,航空业能否继续提高安全水平?这个问题由于行业运作的复杂系统而变得复杂,在该系统中,多种因素的机会组合对很大程度上是概率性(而非确定性)结果做出了贡献。因此,由于运气好而不是好的过程,取得了一些明显的成功,并且本研究旨在引起人们对这些事件的关注,这几乎是失败的。如果多个促成因素以不利的方式结合在一起而没有好运的干预,那么造成这些未遂事件的过程可能会构成威胁。但是,从理论上讲,接近失误(如果被这样认出来)可以提供一种持续改进安全性的机制,超越了从可观察到的故障中学到的知识。我们测试这种学习在航空业中是否显而易见。使用1990年至2007年的数据,固定效应的Poisson回归表明,航空公司可以从事故(他们自己的事故和其他事故)以及一类未遂事故中吸取教训,这些事故的潜在危险性很明显。不幸的是,当焦点事件没有明显的重大危险警告时,航空公司在未遂事故后并没有改善。因此,虽然航空公司需要并且可以向某些未遂事件学习,但我们最后提出了一些建议,以改善所有未遂事件的学习。

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