Safe limits, mindful organizing and loss of control in commercial aviation

摘要

In commercial aviation, loss of control (LOC) incidents are currently the single biggest cause of accident fatalities. Although LOC incidents typically have multiple causes, inappropriate flight crew responses to unfamiliar conditions are a major contributor. It has been suggested that restricted exposure to unusual aircraft behavior and limited manual flying are partly responsible for this, both of which are aggravated by high levels of flight deck automation. In this paper, we draw on ideas from human-automation interactions, organizational limits, mindful organizing and sensemaking to explore how systems that are very safe by design may subtly undermine mindful organizing, reducing the ability of operators to handle unusual and expected situations. We discuss "the paradox of almost totally safe systems" (Amalberti, 2001) and argue that as systems become safer by design it is increasingly difficult for operators to handle unusual, extreme events, partly due to an erosion of mindful organizing and partly to the limitations of existing training and simulation.