Adverse events only occur after a chain of events have formed to break through an organization's system defenses. If you are looking to reduce or eliminate adverse events, you must identify what defense mechanisms your organization has designed into its systems and associated working-level processes. As a high-risk, high-reliability industry, commercial aviation learned decades ago that a reactive approach to accident prevention is no longer acceptable or profitable. A "ny-fix-fly" philosophy of operation was no longer affordable or tolerable. Today, commercial airlines and aircraft manufacturers operate under an umbrella of safety that employs strict operational control and system safety. Commercial airlines and aircraft manufacturers work together with the Federal Aviation Administration (FAA) to ensure that a systems approach to safety oversight is continuously achieved.
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