APPROACHES TO MANAGING OF SYSTEM PERFORMANCE
Aviation workplaces are multi-component, multi-feature, complex operational contexts. Their functions and performance involve complex relationships among their many components in order for the system to achieve its production goals.
It is thus evident that proper consideration and analysis of the operational context is a source of valuable information in order to understand operational performance, to support it and to enhance it.
There may be 2 different approaches to managing of system performance:
1. One option is to follow the traditional perspective — produce hollow reminders to staff to do what they know and have been trained to do and allocate blame and punish the staff for failing to perform as expected.
2. The other option is to analyze the operational context to see if there are components and features of the context that might be the source of adverse interactions with the staff.
In following the second option, valuable information about certain components and features within the context will be acquired, which will allow for the readjustment of design assumptions and the development of mitigation strategies for the safety risks of the consequences of unforeseen components and features of the context. In other words, by acquiring information on hazards in the operational context and understanding their interactions with people, system managers can bring the system back under organizational control.
It is proposed that a proper understanding of operational performance and operational errors cannot be achieved without a proper understanding of the operational context in which operational performance and errors take place. This understanding cannot be achieved unless a clear differentiation is made between processes and outcomes.
There is a tendency to allocate symmetry to causes and consequences of operational errors which, in real practice, does not exist. The very same error can have significantly different consequences, depending upon the context in which the operational error takes place. The consequences of operational errors are not person-dependent but context dependent.
This concept has a significant impact in mitigation strategies: efficient and effective error mitigation strategies aim at changing those features and components of the operational context that magnify the consequences of errors, rather than changing people.
RASO-WA AVIATION SAFETY PROGRAM