The Role of Lessons Learned in the System Safety Cycle for Commercial Aviation

摘要

The safety of large transport airplanes operating in commercial service throughout the world has steadily improved over the last several decades. Nevertheless, accidents still occasionally occur. When they do occur, it is important to identify the root causes, precursors, and lessons learned of these accidents so that appropriate steps may be taken to reduce the risk of their recurrence. Safety lessons learned from aviation now spans several generations of safety managers and engineers. It is no longer possible for comprehensive knowledge to be exchanged from experienced safety individuals to the next generation of safety personnel through on-the-job training alone. The system is so complex that it is unlikely any one individual can possess truly comprehensive system safety understanding. It is necessary to adopt a more rigorous and systematic approach to lessons learned safety training and management. When presented with the data, facts, and histories available, it becomes painfully obvious that most, if not all, accidents followed one or more precursors or previous accidents that were not acted on for several reasons. The predominant reason is that those involved were unaware of the significance of what they had observed. This lack of awareness was due to a failure to view the event from the airplane-level rather than the system, subsystem, or component-level. Another reoccurring reason is that those involved were unaware of the existence of critical relevant information. These reasons are actually common throughout many industries and tolerated or accepted by most. It is unacceptable in commercial aviation. To begin addressing some of these issues, the FAA Aircraft Certification office has created an internet based course covering Aircraft Accidents Lessons Learned. This course is based around the study of ten significant transport category aviation accidents. In addition, an introduction to system safety concepts is provided. This paper shares some valuable guidance on how to develop and deploy a lessons learned course.