Active failures by operational personnel take place in an operational context which includes latent conditions. Latent conditions are conditions present in the system well before a damaging outcome is experienced, and made evident by local triggering factors. The consequences of latent conditions may remain dormant for a long time.

Individually, these latent conditions are usually not perceived as harmful, since they are not perceived as being failures in the first place.


Latent conditions become evident once the systemís defenses have been breached. These conditions are generally created by people far removed in time and space from the event. Front-line operational personnel inherit latent conditions in the system, such as those created by poor equipment or task design; conflicting goals (e.g. service that is on time versus safety); defective organizations (e.g. poor internal communications); or management decisions (e.g. deferral of a maintenance item). The perspective underlying the organizational accident aims to identify and mitigate these latent conditions on a system-wide basis, rather than by localized efforts to minimize active failures by individuals. Active failures are only symptoms of safety problems, not causes.

Even in the best-run organizations, most latent conditions start with the decision-makers. These decision makers are subject to normal human biases and limitations, as well as to real constraints such as time, budgets, and politics. Since downsides in managerial decisions cannot always be prevented, steps must be taken to detect them and to reduce their adverse consequences.


Decisions by line management may result in inadequate training, scheduling conflicts or neglect of workplace precautions. They may lead to inadequate knowledge and skills or inappropriate operating procedures. How well line management and the organization as a whole perform their functions sets the scene for error- or violation-producing conditions. For example: How effective is management with respect to setting attainable work goals, organizing tasks and resources, managing day-to-day affairs, and communicating internally and externally? The decisions made by company management and regulatory authorities are too often the consequence of inadequate resources. However, avoiding the initial cost of strengthening the safety of the system can facilitate the pathway to the organizational accident.


ACCIDENT CAUSATION ó THE REASON MODEL




RASO-WA AVIATION SAFETY PROGRAM

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