Multimodal Safety Management and Human Factors: Crossing the Borders of Medical, Aviation, Road and Rail Industries

357 Pages·2007·2.584 MB·English

by  José M. Anca Jr

MULTIMODAL SAFETY MANAGEMENT AND
HUMAN FACTORS
To the Youth, who can teach all of us to discern meaning and to my
co-pilgrims in the journey: Luisa, Athena, Sophia, Aletheia, Federico and
Inigo
Multimodal Safety Management
and Human Factors
Crossing the Borders of Medical, Aviation,
Road and Rail Industries
Edited by
JOSÉ M. ANCA JR
Swinburne University, Australia
© José M. Anca Jr 2007
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system
or transmitted in any form or by any means, electronic, mechanical, photocopying, recording
or otherwise without the prior permission of the publisher.
José M. Anca Jr has asserted his right under the Copyright, Designs and Patents Act, 1988, to
be identifi ed as the editor of this work.
Published by
Ashgate Publishing Limited Ashgate Publishing Company
Gower House Suite 420
Croft Road 101 Cherry Street
Aldershot Burlington, VT 05401-4405
Hampshire GU11 3HR USA
England
Ashgate website: http://www.ashgate.com
British Library Cataloguing in Publication Data
Multimodeal safety management and human factors : crossing
the borders of medical, aviation, road and rail industries
1. Transportation - Safety measures 2. Transportation
accidents 3. Risk-taking (Psychology) 4. Accident
investigation
I. Anca, José M.
363.1'207
Library of Congress Cataloging-in-Publication Data
Anca, José M.
Multimodal safety management and human factors : crossing the borders of medical,
aviation, road and rail industries / by José M. Anca, Jr.
p. cm.
Includes index.
ISBN 978-0-7546-7021-6
1. Traffi c safety--Case studies. 2. Traffi c engineering--Case studies. 3. Human
engineering--Case studies. I. Title.
HE5614.A59 2007
363.12--dc22
2006034813
ISBN-13: 978 0 7546 7021 6
Printed and bound in Great Britain by TJ International Ltd, Padstow, Cornwall.
Contents
List of Figures ix
List of Tables xiii
Foreword xv
Preface xvii
Acknowledgements xix
List of Abbreviations xxi
PART 1 MULTIMODAL CHARACTERISTICS OF SAFETY
MANAGEMENT SYSTEMS 1
1 Can Simply Correcting the Defi ciencies Found through Incident
Investigation Reduce Error? 3
Gerry Gibb, Safety Wise Solutions Pty Ltd
2 Moving Up the SMS Down Escalator 13
Bruce Tesmer, Continental Airlines
3 Unsafe or Safety-Signifi cant Acts? 17
David McNair, Transportation Safety Board of Canada
4 The Calgary Health Region: Transforming the Management
of Safety 31
Jack Davis, Calgary Health Region, Jan M. Davies, University
of Calgary and Ward Flemons, Calgary Health Region
5 Governance and Safety Management 41
Greg Marshall, National Air Support
6 Overcoming the Short-Medium-Term Problems of Fleet
Transition: The Expectation and Achievement of Economic Gains 51
Boyd Falconer and Christopher Reid, University of
New South Wales and Jetstar Airways
PART 2 SAFETY MANAGEMENT METRICS, ANALYSIS AND
REPORTING TOOLS 59
7 A New Reporting System: Was the Patient Harmed or Nearly
Harmed? 61
Jan M. Davies, University of Calgary
Carmella Duchscherer and Glenn McRae, Calgary Health Region
vi Multimodal Safety Management and Human Factors
8 Using Aviation Insurance Data to Enhance General Aviation
Safety: Phase One Feasibility Study 73
Michael Lenné, Paul Salmon, Michael Regan, Narelle Haworth
and Nicola Fotheringham, Monash University Accident Research
Centre
9 Grappling with Complexity: Analysing an Accident with the
Theory of Constraints 83
Dmitri Zotov, Alan Wright and Lynn Hunt, Massey University
10 Drought in Safety Management – More Tools, Less Theory 107
Steve Tizzard, Civil Aviation Safety Authority (CASA), Australia
11 Aerial Agriculture Accidents 2000–2005: The Human Factors
and System Safety Lessons 113
Geoff Dell, Protocol Safety Management Pty Ltd and the Safety
Institute of Australia
12 Learning from Accidents and Incidents 131
Joanne De Landre, Safety Wise Solutions Pty Ltd
Miles Irving, Iaen Hodges and Bruce Weston, RailCorp
13 Managing Road User Error in Australia: Where Are We Now,
Where Are We Going and How Are We Going to Get There? 143
Paul M. Salmon, Michael Regan and Ian Johnston, Monash
University Accident Research Centre
PART 3 NORMAL OPERATIONS MONITORING AND
SURVEILLANCE TOOLS 157
14 Performance and Cognition in Dynamic Environments:
The Development of a New Tool to Assist Practitioners 159
Jemma M. Harris and Mark W. Wiggins, University of Western
Sydney, Scott Taylor, Eastern Australia Airlines
Matthew J.W. Thomas, University of South Australia
15 Error Management Training: Identifi cation of Core Cognitive
and Interpersonal Skill Dimensions 169
Matthew J.W. Thomas and Renée M. Petrilli, University of
South Australia
16 Confi dential Observations of Rail Safety (CORS):
An Adaptation of Line Operations Safety Audit (LOSA) 179
Allison McDonald and Brett Garrigan, Queensland Rail
Lisette Kanse, University of Queensland
Contents vii
17 Human Factors in Air Traffi c Control: An Integrated Approach 189
Christine C. Boag-Hodgson, Airservices Australia
PART 4 THE MODALITY OF HUMAN FACTORS:
EXPLORING THE MANAGEMENT OF HUMAN ERROR 197
18 Human Factors at Railway Level Crossings: Key Issues and
Target Road User Groups 199
Jeremy Davey, Nadja Ibrahim and Angela Wallace,
Queensland University of Technology
19 Attitudes to Safety and Teamwork in the Operating Theatre, and
the Effects of a Program of Simulation-Based Team Training 211
Brendan Flanagan, Michele Joseph and Michael Bujor,
Southern Health Simulation and Skills Centre, Victoria
Stuart Marshall, The Alfred Hospital
20 Human Factors and the QFI: Developing Tools through
Experience 221
Boyd Falconer, University of New South Wales
21 Advanced Driver Assistance Systems and Road Safety:
The Human Factor 233
Michael A. Regan and Kristie L. Young, Monash University
Accident Research Centre
22 Recovery of Situational Awareness Using Operant Conditioning
Techniques 245
Peter N. Rosenweg, Psyfactors Pty Ltd
23 Effects of Flight Duty and Sleep on the Decision-Making of
Commercial Airline Pilots 259
Renée M. Petrilli, Matthew J.W. Thomas, Nicole Lamon, Drew
Dawson and Gregory D. Roach, University of South Australia
24 Medical Team Resource Management and Error Prevention
Training 271
David G. Newman, Flight Medicine Systems Pty Ltd
25 Driver Distraction: Review of the Literature and Suggestions for
Countermeasure Development 279
Kristie L. Young and Michael A. Regan, Monash University
Accident Research Centre
viii Multimodal Safety Management and Human Factors
26 Assessing and Managing Human Factors Risks –
Practical Examples in the Australian Rail Context 291
Julia Clancy, Lloyd’s Register
27 Anaesthetic Registrars’ Stress Mediators in a Simulated
Critical Incident 301
Kate Fraser, Matthew J.W. Thomas and Renée Petrilli,
University of South Australia
28 Trying Before Buying: Human Factors Evaluations of New
Medical Technology 315
J.M. Davies, J.K. Caird and S. Chisholm
University of Calgary, Canada
Index 325
List of Figures
3.1 The Reason Model (A) 19
3.2 The Reason Model (B) 20
3.3 Sequence of events diagram 21
3.4 Investigation process from TSB manuals 22
3.5 DC-10 Chicago sequence of events example 24
3.6 Swissair 111 sequence of events example 25
3.7 Medical incident sequence of events 26
3.8 B767 Gimli fuel exhaustion sequence of events example 27
3.9 Air Transat A330 Azores fuel exhaustion sequence of events
example 28
3.10 A slight revision of the Reason Model 29
4.1 The Patient Safety Framework 35
7.1 Manufacturer’s boxes of sodium chloride (NaCl) and
potassium chloride (KCl), in which the bottles of NaCl and
KCl were transported and stored 63
7.2 Manufacturer’s vials of sodium chloride (NaCl) and potassium
chloride (KCl) 63
7.3 The Calgary Health Region’s safety framework 64
8.1 Potential data sources for accidents and incidents in general
aviation (for operations covered in the BTRE defi nition of GA) 77
9.1 Undesirable effects in the Ansett Dash 8 accident 85
9.2 Connections between undercarriage latch design and potential
to strike terrain 86
9.3 Financial stress and emergency training 87
9.4 Lack of continuation training – approach procedure 89
9.5 Maintenance aspects 89
9.6 Undercarriage failures 90
9.7 Absence of safety manager 91
9.8 Shortness of GPWS warning 92