Inter-Organizational Safety Debate: The Case of an Alarm System from the Air Traffic Control Domain

摘要

The management of safety critical operations cannot be left to the initiative of those individuals directly in contact with the production processes. Society as a whole has a role. This paper explores the interface between societal components having a direct active role in the "safety debate ". The reference domain is air traffic management and the interface is among air traffic controllers and pilots - as directly involved in the management of the air traffic - and two agencies, the NTSB (responsible for safety investigation after an accident) and FAA (responsible for regulating, upgrading and training of the workforce). Recent debates in safety management highlight that safe practice is a control problem: the result of effective hierarchical transmissions of safety constraints and making the boundaries of acceptable performance visible. This work analyzes how safety constraints related to an alarm system are represented, transmitted and interpreted by several parties - all committed to safety of operations in air traffic management. A "miscalibration " pattern has emerged where the tendency to ignore the alarm was initially addressed at higher hierarchical levels in relation to alarm design, and only in 2006 was addressed in relation to the core issue of nuisance or false alerts (FA).