Fast Pragmatic Safety Decisions: Analysis of an Event Review Team of the AviationSafety Action Partnership

摘要

Commercial aviation has become safe as a result of procedures and technologiesthat control well known hazards. Further safety improvements will require the identification of subtle and changing hazards in the combined realm of airspace, technology, commerce, and human behavior. The preconditions for a disaster may arise from the combined effects of a particular airport approach, air traffic control policies, and aircraft crew training. The potential may be revealed just once, in a near-miss that a highly skilled pilot is able to avert. Yet, because such discoveries are often related to human error, personnel are reluctant to come forward for fear of blame and punishment. With the Aviation Safety Action Programs (ASAP), the Federal Aviation Administration (FAA) is developing a nonpunitive collaborative approach that supplements traditional regulatory actions. An ASAP team is a triad composed of air carrier (corporate), pilot association (union), and FAA (regulatory) personnel who meet to review, discuss, and analyze event reports submitted voluntarily by flight personnel. The team is required to reach 'unanimous consensus' on the event report and the corrective actions to be taken. Our analysis suggests they do so through a hierarchy of shared values, a working buffer to exclude distractions, and sideband communications that build trust. ASAP appears to be a highly effective cultural mechanism for identifying novel and subtle hazards, and designing rapid, mutually acceptable corrective actions.