مهندس عبدالصمد احمدوند

وب سایت تخصصی ایمنی، بهداشت ، محیط زیست (HSE)

مهندس عبدالصمد احمدوند
خانه | موضوعات | موضوعات ايمني | ايمني صنعتي | دستورالعمل مديريت ايمني

دستورالعمل مديريت ايمني

نویسنده
دستورالعمل مديريت ايمني دستورالعمل مديريت ايمني

According to modern thinking, accidents require the coming together of a number of enabling factors — each one necessary but in itself not sufficient to breach system defences. Major equipment failures or operational personnel errors are seldom the sole cause of breaches in safety defences.

 (Safety Management Manual (SMM

  4.4.8 According to modern thinking, accidents require the coming together of a number of enabling factors — each one necessary but in itself not sufficient to breach system defences. Major equipment failures or operational personnel errors are seldom the sole cause of breaches in safety defences. Often these breakdowns are the consequence of human failures in decision-making. The breakdowns may involve active failures at the operational level, or latent conditions conducive to facilitating a breach of the system’s inherent safety defences. Most accidents include both active and latent conditions. 4.4.9 Figure 4-2 portrays an accident causation model that assists in understanding the interplay of organizational and management factors (i.e. system factors) in accident causation. Various “defences” are built into the aviation system to protect against inappropriate performance or poor decisions at all levels of the system (i.e. the front-line workplace, the supervisory levels and senior management). This model shows that while organizational factors, including management decisions, can create latent conditions that could lead to an accident, they also contribute to the system’s defences. 4.4.10 Errors and violations having an immediate adverse effect can be viewed as unsafe acts; these are generally associated with front-line personnel (pilots, ATCOs, AMEs, etc.). These unsafe acts may penetrate the various defences put in place to protect the aviation system by company management, the regulatory authorities, etc., resulting in an accident.

 

These unsafe acts may be the result of normal errors, or they may result from deliberate violations of prescribed procedures and practices. The model recognizes that there are many error- or violation-producing conditions in the work environment that may affect individual or team behaviour. 4.4.11 These unsafe acts are committed in an operational context which includes latent unsafe conditions. A latent condition is the result of an action or decision made well before an accident. Its consequences may remain dormant for a long time. Individually, these latent conditions are usually not harmful since they are not perceived as being failures in the first place. 4.4.12 Latent unsafe conditions may only become evident once the system’s defences have been breached. They may have been present in the system well before an accident and are generally created by decision-makers, regulators and other people far removed in time and space from the accident. Front-line  

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