CHAPTER 2: BASIC SAFETY CONCEPTS

2.5: THE ORGANIZATIONAL ACCIDENT

For the aviation industry, the always top priority of everyone is safety. And the
Reason Model can be more understand through building block approach. This is
where the Organizational Accident comes through.
THE ORGANIZATIONAL PROCESSES
- in this block, the organization has the full or complete control. They are
the ones that have more responsibility towards the safety of their
operation. Usual examples include: policy making, which the rest of the
organization should follow always; planning, no action is done without
planning it first. Example is that in case of emergency, there is a SOP to
be done; communication, one of the important things in aviation
industry. Everyone involved should have clear feedback so no errors can
be made and if there are any, it can be resolved quickly; allocation of
resources, airline companies are spending a lot of fortunes to make their
services better, and for safety it is not excluded; supervision, every
action and work of every men and women who works in aviation should
always be supervised and take necessary actions if needed, and so forth.
Any deficiencies and irregularities in this part are a step closer towards
failure.
LATENT CONDITIONS
- not all the failures and errors can be avoided of course, but these can be
lessen. These are potential circumstances that can happen. Under latent
conditions are deficiencies in equipment design, the machines and
equipment didnt do sufficient work due to design errors;
incomplete/incorrect standard operating procedures, sometimes
personnel are misunderstood what they should do in case of an
emergency. Instead of doing right to assess the situation they can make it
worse due to misunderstanding of the so-called S.O.P; and training
deficiencies. Sometimes the employees have no adequate training in
their respective jobs, thats why they sometimes commit error.
In common terms, latent conditions can be grouped into two large
clusters. One cluster is inadequate hazard identification and safety
risk management, whereby the safety risks of the consequences of
hazards are not kept under control, but roam freely in the system to
eventually become active through operational triggers. Those risks that
are for some have no impact in major works, they let it pass through. Even
though the risks of some hazards are not going to have a major impact,
still these things should treated as a major hazard so that the sense of
safety cant be compromised.
- The second cluster is known as normalization of deviance, a notion
that, simply put, is indicative of operational contexts where the exception
becomes the rule. Sometimes due to lack of resources to do an important
procedure, some will get their resort through shortcut, meaning they
doing the necessary things out the book and they rely on what knowledge
they have, without even consulting.
DEFENCES

Typically, defences in aviation can be grouped under three large headings:

technology, training and regulations. These are usually the last resort
or precaution to contain latent conditions, as well as the consequences of
lapses in human performance.
If the latent conditions have lapses, the defence must do its job to
prevent the errors to occur. For example if human error is involved,
defences should act so that the mistake can be rectified immediately.

WORKSPACE CONDITIONS
- Workplace conditions are factors that directly influence the efficiency of
people in aviation workplaces. An organization cannot run without
someone that is moving and doing actions. Workplace conditions are
largely intuitive in that all those with operational experience have
experienced them to varying degrees. They should have the capability to
do what the company is asking you to do and be prepared to what things
that you must do. This include: workforce stability, which means an
organization should have enough personnel to do jobs; qualifications
and experience, being familiar and having experience in the aviation
industry are more hired than those who arent. People that are working at
the aviation should know what they need to do and act with decency;
morale, management credibility, not only the people who are working
in the aviation should do their job properly, they also need to be humane
to their co-workers so that a friendly environment can be established. And
traditional ergonomics factors such as lighting, heating and
cooling. The workplace of people should also be friendly to everyone
working so that smooth and uninterrupted work can be done and they
should also be safe to the workers.
ACTIVE FAILURES
- Active failures can be considered as either errors or violations. The
difference between errors and violations is the motivational component. A
person trying to do the best possible to accomplish a task, following the
rules and procedures as per the training received, but failing to meet the
objective of the task at hand commits an error. A person who willingly
deviates from rules, procedures or training received while accomplishing a
task commits a violation. Thus, the basic difference between errors and
violation is intent.
THE PERSPECTIVE OF THE ORGANIZATIONAL ACCIDENT
Monitoring the organizational processes is very important because this is the
primary body of the safety organization and for also to know the latent conditions.
And if there is a concern, defenses can be reinforced. Improving workplace
conditions is also a thing to do to monitor and contain active failures, because the
linkage of these factors will somehow produce safety breakdown.

THE PERSPECTIVE OF THE

ORGANIZATIONAL ACCIDENT