By C. Macrae
Drawing on huge and particular fieldwork inside airlines—an that pioneered near-miss research— this booklet develops a transparent set of functional implications and theoretical propositions concerning how all enterprises can study from 'near-miss' occasions and higher deal with threat and resilience.
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Extra info for Close Calls: Managing Risk and Resilience in Airline Flight Safety
One of the defining characteristics of these organisations is how they monitor for disruptions and surprises and then rapidly organise resources to analyse and address them. In this way, high-reliability organisations (HRO) achieve reliable operational outcomes through continual adaptation to and correction of deviations and disruptions as they occur (Weick, 1987). Underpinning this are diverse social practices for communicating about what is going on, checking and cross-checking performance, and monitoring for problems or deviations from normal operations (Rochlin, 1989).
On this occasion, just as the aircraft reaches V1 engine number two fire warning goes off declaring a fire in the engine requiring immediate attention. The pilot in control takes an instant decision and elects to abort the take-off. Power is pulled back and brakes applied. The aircraft continues to accelerate for another 10 knots or so due to inertia and the downward-slopping runway, but finally lumbers to a stop just before the end of the tarmac. The aircraft is taxied back to stand and all passengers disembark safely.
The vignettes each show the particular complexities and challenges of investigators’ work, and a typical day might be made up of some combination of these activities, supplemented by a healthy serving of more routine and administrative activities. The latter are described later. Here, these three vignettes show some of the challenges of interpreting incidents, investigating risks and managing safety. They show the close calls that investigators must routinely make in their daily work, and how considerable attention and sensemaking efforts become organised around otherwise brief and transient fluctuations in operational activities.