Grappling with Complexity: Finding Core Problems from Safety Information

摘要

The Theory of Constraints is an analytical method which can handle complex information about undesirable effects within a system, and show how to make improvements. In the context of aviation safety, we can take data from an accident investigation, or from safety oversight activities, and devise safety recommendations. The method is unique in that it is able to identify one or a few core problems which underlie all of the undesirable effects. Our corrective efforts can thus be focussed on a few leverage points, instead of being spread over a plethora of recommendations. The application of the Theory of Constraints to aviation safety action is illustrated by reference to an accident investigation. It is shown that underlying causes of the accident can be identified, and corrective actions devised, both within the airline concerned, and in the regulatory authority.