Root causes of engineering complacency on aviation and aerospace safety.

摘要

When engineers, maintenance personnel or operators in aviation and aerospace begin to settle into a complacent mindset they inherently accept a greater amount of risk, thus opening the door for the possibility of dangerous events to unfold. If a connection as to why engineers or operators settle into a complacent mindset is made, and consequently how the development of that attitude can be avoided, it is the author's opinion that catastrophic events can be avoided. This thesis identifies possible catalysts, in the form of complacency factors, that can make engineers and operators have high confidence in a system and cause them to accept a higher amount of risk. A total of six complacency factors were identified and include: discounting risk, ignoring warning signs, assuming risk decreases over time, over-reliance on redundancy or automation, unrealistic risk assessments, and ignoring high-consequence low probability events. This investigation into engineering complacency and the root cause of it occurring in aerospace and aviation safety relied on an analysis of historical accident investigation data and the circumstances involved. Case studies were pulled from the aerospace and aviation industry that involve both engineering and operator error. Catastrophic accidents within military aircraft, NASA systems including the Space Shuttles and Satellites, and commercial and private aviation were explored. Analysis was conducted to look at the system safety programs, risk management, and corrective action procedures for each organization. Through case study analysis it was apparent that one or more of the identified complacency factors were present in all cases. Complacency is a substantial risk throughout any human oriented task or engineering centric organization, not just aerospace. Complacency can be evaluated in the oil industry, nuclear industry, manufacturing and everyday tasks such as operating an automobile. Focusing on a particular failure mode in a single organization would allow for concentrated analysis and corporate culture specific trending. Implementation of trending analysis to evaluate failure modes within all of the aforementioned organizations is imperative to identifying areas where complacent factors can occur.