Patterns In Safety Thinking

A Literature Guide to Air Transportation Safety

Geoffrey R. McIntyre

• Publisher: Routledge
• Year: 2017
• ISBN:
  9781351912587
• Edition: 1
• Topic: Politics & International Relations
• Subtopic: Labour & Industrial Relations
• Index: Politics & International Relations

Safety is more than the absence of accidents. Safety has the goal of transforming the levels of risk that are inherent in all human activity, while its interdisciplinary nature extends its influence far into most corporate management and government regulatory actions. Yet few engineers have attended a safety course, conference or even a lecture in the area, suggesting that those responsible for the safe construction and operation of complex high-risk socio-technical systems are inadequately prepared. This book is designed to meet the expressed needs of aviation safety management trainees for a practical and concise education supplement to the safety literature. Written in a highly readable and accessible style, its features include: ¢ detailed analysis of the forward-looking System Safety approach, with its focus on accident prevention; ¢ classification of transportation safety literature into distinct schools of thought (Tort Law, Reliability Engineering, System Safety Engineering); ¢ real world, practical, illustrations of the theory; ¢ the history, theory and practice of safety management; ¢ inter-disciplinary thinking about safety. The flying public is faced with a bewildering array of aviation safety data from a diverse and ever increasing number of sources. This book is an essential guide to the available information, and a major contribution to the international public debate on aviation safety.

1 Introduction

This essay will examine and classify the major air transportation safety related books and select journals on transportation safety and where appropriate, provide real world, practical illustrations of the theoretical concerns. The essay is primarily designed to educate aviation transportation safety practitioners and aviation university students on the broad outlines of the history, theory and practice of "safety management" in the United States. Several aviation safety trainees under the time-sensitive pressure of typical training programs have expressed the need for concise reference material that would provide a broad orientation and conceptual overview of the safety management discipline without having to resort to an entire shelf of books.¹ As such, Patterns In Safety Thinking: A Literature Guide To Air Transportation Safety, meets that requirement. Many of the textbooks and reports that were reviewed for this essay ranged in size from 260 pages to in excess of 600 pages. Within the confines of this survey, a full and comprehensive literature review to include scholarly journals is neither practical nor desirable. In part this would have resulted in an overly ambitious project that could easily exceed 1,500 pages-defeating the original purpose and intent of this essay, as well as the fact that not all of the risk management issues addressed by researchers are germane to aviation safety. The safety literature has drawn from among many disciplines including the behavioral and natural sciences and these incorporations are continuing to enrich its intellectual evolution and how we think about "safety management." As an educational supplement for engineering students, the essay may serve as a guide to stimulate interdisciplinary thinking about safety. The book may also partially meet public policy objectives to further educate air travelers about safety and further aviation safety risk communication. Transportation has an enormous impact on the U.S. economy. According to one estimate, in 1995, transportation-related goods and services accounted for approximately 11 percent of United States Gross Domestic Product.²

The safety management literature has evolved from several incorporations from the behavioral sciences, engineering and mathematical sciences/quantitative methods. These disciplines have clearly defined various "emphases" or "schools" within the boundaries of the safety discipline and have led the author to create a taxonomy of key literary contributions. Such a classification of the books on safety that is relevant to its teaching has never been undertaken.³ Research into the related books on safety indicated that there are good reasons why a study such as this had never been undertaken. For certain, regardless of how one were to qualify or hedge an approach such as this, it is axiomatic that, this is at best a perilous undertaking since there appears to be no one best way to view the literature. Many persons populate the safety literature and naturally, in describing the citations from the literature it does not necessarily mean that controversial views are shared. Rather, its purpose is to educate and provide concise reference material on the well-documented historical progression of the major scholarly safety literature as it relates to the theory and practice of U.S. transportation safety management.

"Safety" as a discipline has evolved from several divergent and conflicting paths and disciplines that were the result of polar patterns of thought and actions. From this omni-disciplinary character, this essay identifies various intellectual emphases or "schools of thought" - a "Tort Law School," the "Reliability Engineering School," and the "System Safety Engineering School." There is also extensive literature concerning Occupational Safety Law, Insurance, Risk Management, Product Liability, Environmental Law and Safety, and Security. However, to keep within the purpose and scope, those subject areas are only referenced insofar as they impact the aviation transportation safety emphasis. It appears that a concise summary of the historical origins and development of this "practical discipline" should help students and practitioners understand the philosophical context and the often-confusing viewpoints and the uses of terminology. Aviation safety practitioners seeking to gain a wider appreciation of the System Safety Engineering discipline and how it has evolved from "Reliability Engineering" should find this textbook useful.

A Century of Safety Concerns

This essay spans over a century of U.S. societal thought, actions and concerns over transportation safety. We begin our study with the activities of Lorenzo Coffin, the 19^th century railroad safety advocate and champion of the Railroad Safety Appliance Act, 1893. As early as 1874, his was the pioneering voice for the merging of the two streams of safety technology and government policy control. Chapter Two also includes the activities of Ralph Nader, the 20^th century's celebrated crusader for automobile, highway and, increasingly, air safety and the "Tort Law School" of transportation safety and government regulation. Chapter Three progress to the newly emerging post Second World War "Reliability Engineering" profession. We also examine the rise of Probabilistic Risk Assessment and Human Reliability Assessment with its emphasis that human behavior can be mechanically modeled, analyzed and understood. The apparently inwardly regenerative nature of safety further gave rise in Chapter Four to the emergence in 1962 of the "System Safety Engineering School." The concerns of this school are over our ability to safely design software-intensive, electro-mechanical systems that characterize the modern air and space transportation era, and the overall safety of complex, socio-technical systems.

We begin with our classification of the literature of the "Reliability Engineering School" with publication in 1968 of Martin Shooman of Brooklyn Polytechnic Institute, landmark text, Probabilistic Reliability: An Engineering Approach. The book was designed for college and industrial courses in what was then the newly emerging field of Reliability Engineering. However, it should be emphasized that the roots of "Reliability" go further back to the early (1911) work of Frederick W. Taylor's: The Principles of Scientific Management. He is often called the "Father of Scientific Management." Taylor's dominant concern was efficiency and the best and cheapest way of accomplishing routine work. Also the experiences of America's early industrial assembly line production methods are rooted in reliability. For Shooman, the need for reliable equipment and reliability analysis became apparent at the close of the Second World War. The problems of maintenance, repair, and field failures became severe for the military equipment used during the War. In the late 1940s and early 1950s, Reliability Engineering became the newest engineering field. This new field came about primarily due to the complexity, sophistication, and automation inherent in modern technology. The fields of communication and transportation were the first to witness rapid growth in complexity as equipment manufacturers adapted advances in electronics and control systems. The field came to a focus and began to develop when people agreed that the proper definition of reliability was in terms of the probability of success. This decision marshaled the powerful techniques of modern probability theory behind the growing field of reliability.⁴ It is beyond the scope of this text for a treatment of the complex subject of the laws of probability. However, Shooman's early text does contain explanations on its analytical tools as well as an excellent bibliography.

One consequence of this new pattern in safety thinking was the further evolutionary spiral to a new branch of Probabilistic Risk Assessment (PRA) within the "Reliability Engineering School." By 1975, in a continuing evolutionary spiral, the drive to an understanding of the likelihood of hardware malfunctions and errors led to the adoption of PRA (pioneered by the commercial aviation industry) by the nuclear and other high-risk industries. Then there was a natural migration to focus attention on Human Reliability Analysis. Suffice it to say that for the "Reliability Engineering School," the circle appeared completed with the migration from mechanical reliability to perfected methods and techniques for predicting human reliability.

According to Roland and Moriarty,⁵ the modern discipline of System Safety evolved in 1962, with the dawn of the space transportation era. The growth and development of the System Safety approach to accident prevention was created by the publication of safety standards, specifications, and requirements, as well as operating instructions. The System Safety concept calls for safety analyses and hazard control actions beginning with the conceptual phase of a system and continuing through the design, production, testing, use, and disposal phases, until the activity is retired.

A Golden Decade

The period, 1965-1975, was truly a Golden Decade for safety. During that period, there was a profound experience in the demand for "safety" and the laying of a broader legal and theoretical framework for transportation safety in particular. The emergence of Ralph Nader as the undisputed leader of the public safety advocacy movement with publication in 1965 of his book, Unsafe At Any Speed, focused national attention on the issue of automobile safety defects, regulatory inaction and the potential for further increasing the carnage on the Nation's highways.⁶ An updated version of Unsafe At Any Speed, was published in 1972. For Nader, the experience of the mounting four decade-statistics on automobile deaths and the lack of accountability and publicly available information or regulatory requirements for a safe, non-polluting automobile, meant that it was time to "bring the industry to justice."

During the Golden Decade, air transportation safety also came under scrutiny. However, it should be emphasized that air safety concerns go back further to the Air Commerce Act of 1926 that in effect introduced the regulatory role of the Federal government. During the 1930s, the emphasis on industry-government cooperation on the standards for civil aviation intensified. For example, in 1935, in a remarkable development of industry-government cooperation, the Radio Technical Commission for Aeronautics (RTCA) was organized as a forum where government and aviation industry representatives gathered to develop consensus performance standards for "black box" airborne equipment. Armed with those "Minimum Operation Performance Standards," manufacturers were now able to build a product with the assurance of obtaining regulatory certification. The June 30'" 1956 mid-air crash over the Grand Canyon was the first commercial aviation disaster to claim more than 100 lives. It exposed the safety inadequacies of the air traffic control system and ultimately led to the Federal Aviation Administration (FAA) Act, 1958.

In 1967, the book, Airline Safety Is A Myth, was published by Captain Vernon W. Lowell, a command pilot with Trans World Airlines for over 22 of his 28 years of airline piloting. Captain Lowell, in cooperation with the Airline Pilots Association, provided readers with actual case histories that in effect called for the need for preventive action by the airlines, aircraft manufacturers, the federal agencies with responsibility in this area and the congress. One case study in Captain Lowell's book is of the Boeing 727, which had been involved, in four fatal accidents within six months. The book documents the misguided role of the then investigative Civil Aeronautics Board in placing blame on "Pilot Error" for those accidents, notwithstanding the fact that there had been known problems with asymmetric reverse thrust on that type aircraft.⁷

John Godson's 1970 book, Unsafe at Any Height, called attention to the increasing number of air crashes and a public perception that air crashes were "unavoidable." The author cited the "culpably neglected" standards of air safety, ineffective accident inquiry boards that did nothing to avoid future accidents and "how tragically slow the aviation industry has been to learn from experience." The book contained ominous warnings about future accidents with the approaching era of jumbo jets. Godson acknowledged that a totally accident-free aviation world is not expected. However, his concern was "about those many areas of civil air transport where neglect and inadequacy are glossed over and condoned by inaction year after year... we are dealing not with merchandise but with human lives; and a company which takes part in this kind of business must expect to have to observe the most rigorous standards."⁸

The role of the electronic and print media further served to raise public consciousness about the terrible toll of accidents and the need for more atten...

Table of contents

• Cover
• Half Title
• Dedication
• Title
• Copyright
• Contents
• Preface
• Acknowledgements
• 1 Introduction
• 2 Transportation Tort Law School
• 3 Reliability Engineering School
• 4 System Safety Engineering School
• 5 Conclusion
• Bibliography