Systems Thinking: Aviation Accidents, Complexity, and Cause
This paper distinguishes between two approaches to systems thinking in accident investigations: Systems Thinking 1.0 and Systems Thinking 2.0. The first approach, 1.0, focuses on identifying broken components, even those distantly related to the event, while the second, 2.0, considers the emergent properties and complex relationships within a system. Using the Alaska Airlines Flight 261 crash as a case study, the paper contrasts these perspectives. It argues that Systems Thinking 2.0, informed by complexity science, provides a more comprehensive understanding of accidents by acknowledging path-dependence, open systems, and the potential for small changes to have large effects. Ultimately, the piece advocates for a shift towards Systems Thinking 2.0 to improve aviation safety by addressing the normal social processes that can contribute to disaster.
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Pilot and ATC communication - Cushing 2
This July 1995 issue of Flight Safety Digest from the Flight Safety Foundation focuses on pilot-air traffic control (ATC) communication errors, analyzing various linguistic and non-linguistic factors contributing to miscommunication. The article examines specific incidents highlighting ambiguity, homophony, and code-switching, proposing solutions like improved training and technological interfaces to enhance clarity. Accompanying statistical data from Boeing shows flight crew error as a major cause of accidents, particularly during landing, despite overall accident rates decreasing. Finally, the publication includes summaries of recent aviation safety reports and publications, covering topics like weather service modernization and helicopter safety.
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The changing nature of risk
Problem solving and decision making
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Crews as Groups: Their Formation and their Leadership
Sverige