Lecture 6: Safety Analysis/Integrated Investigation Process Flashcards
SOE
common time base
synchronized time sources
every event has (3)
actor(s)
event
source/provenance
identifying safety significant events (SSE)
event that is either
____
undesirable
antecedent
non-standard
one of other alternative safer options
slip
exmaple
attention/perception
pilots gets message of non urgent system inologies -> troubleshoots and loses situational awareness of what is going on infront of him -> aircraft goes in unusual attitude
lapse
lack of memory/skill
mistake
misapplication of good rule or application of bad rule
adaptation/violation
modified rules
defense analysis
defence against an unidentified hazard that did/did not exist @time of event
defence effective/used
practical
defence causation model
(pyramid -see notes)
listed in increasing order
- personal protective equipment
administrative and work practice controls
engineering controls
risk matrix (see notes)
risk control
propose further defences
must not be presciptive
new risk controls/defence must have:
chane agents:
operations
management
regulatory
manufactured
when proposing new risk control
must be evaluated for :
feasibility
residual risk
new hazards/risks
must not be prescriptive
safety deficiency statement (SDS)
as show in int this occurrence, without (insert ___) the (insert ___/___) may continue, increasing the risk of (insert___)
defence
unsafe condition/underlying factor
adverse consequence (risk)
safety deficiency statement
3 elements
inadequate/missing deficiencies
unsafe condition/underlying factors
adverse consequences
safety deficiency statement
see pyramid in slide
finding statements
findings as to __ and __
cause and risk
see examples in slides
