Diapositive 1

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Diapositive 1

Anatomía de un Accidente
Parte 1.
Lecciones Aprendidas durante la
Investigación de Accidentes
Aéreos.
Eduard M. Ricaurte, M.D.
1er Congreso Internacional de Seguridad y
Salud en el Trabajo.
Bogotá - Colombia, 16 de Julio 2014
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Disclosure Information
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
I have no financial relationships to disclose

Views and opinions expressed in this presentation are those of the
presenter and DO NOT necessarily represent official policy or position
of my employer
1er Congreso Internacional de Seguridad y Salud en el Trabajo.
Civil Aerospace Medical Institute
Oklahoma City, OK
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Mike Monroney Aeronautical Center
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CAMI Facilities and Training Opportunities
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Greetings from Oklahoma!
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References
Drs. Eduard Ricaurte and Stephen Veronneau
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Aviation Operations: 24/7
The blind men and the elephant
“We have to remember that what we observe is not nature in itself,
but nature exposed to our method of questioning.”
-Werner Heisenberg
Risk Space Perception Graph by Slovic 1987
c
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Definitions
ac·ci·dent
Aviation Accident – NTSB
From: http://www.merriam-webster.com/dictionary/accident
https://www.ntsb.gov


: a sudden event (such as a
crash) that is not planned or
intended and that causes
damage or injury
 : an event that occurs by
chance
 Chance: the possibility that something will happen.
: the way that events happen when they are not planned or
controlled by people
: an occurrence associated with the
operation of an aircraft that takes
place between the time any person
boards the aircraft with the intention
of flight and all such persons have
disembarked,
 and in which any person suffers
death or serious injury, or in which
the aircraft receives substantial
damage.

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An incident is an occurrence other than
an accident that affects or could
affect the safety of operations
The Epidemiological Triangle
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The Concept of Accident Causation
http://www.icao.int/safety/SafetyManagement/Documents/Doc.9859.3rd%20Edition.alltext.en.pdf
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The Haddon Matrix
William Haddon Jr., M.D.
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The Haddon matrix and pedestrian injury from
automobiles.
Influencing factors
Phase
Pre event
Host
Agent/vehicle
Physical environment
Social environment
Intoxicated driver
Speeding automobile
Poor street lighting
Unenforced speed limit laws
Fatigued driver
Worn tires
Slick pavement
Inadequate investment in
crosswalks
Pedestrian crossing street
Worn brakes
Potholes
Inadequate signage
Nighttime
Intoxicated pedestrian
Elderly pedestrian
Pedestrian with osteoporosis
Event
Pedestrian wearing
headphones
Hearing-impaired pedestrian
Part of pedestrian’s body
struck by vehicle
Post event
Ability of victim to recover
Post injury care received
Momentum of automobile
Hospitals nearby with
specialty in trauma care
Impact of automobile with
pedestrian
Portion of vehicle impacting
pedestrian
Severity of physical injuries
Good samaritan laws
Part of body impacting ground
Rehabilitation facility
Health insurance
Severity of postevent
psychological impact
Access to rehabilitation
services
Family and social support
Psychological coping of victim
in aftermath of event
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Source: Barnett DJ et al., The Application of the Haddon Matrix to Public Health Readiness and Response Planning
Environ Health Perspect. May 2005; 113(5): 561–566.
Children falling on playgrounds:
The Haddon Matrix Applied
Host (children on the
playground)
Agent/vehicle (specific
playground equipment and
devices)
Physical environment
(overall playground design)
Social environment
(community norms,
policies, rules)
Teach children to follow
safety rules on the
playground (e.g., no
crowding on the climbing
equipment)
Construct equipment with
tacky grips, sized to
children’s hands, to reduce
the risk of hands slipping
Build sliding boards into
hillsides so children do not
have to climb to heights
Foster social norms that
encourage adults to help
maintain orderly play on the
playground
Event (during the fall and
time of impact)
Teach children to fall in
ways that reduce injury
Reduce the number of
protrusions on equipment
so falling children do not hit Ensure the presence of
resilient surfacing
sharp components
Post-event (after the child
is injured by the fall)
Teach children how to
summon help when injuries
occur (e.g., using
emergency call boxes)
Avoid equipment in which
children can fall into areas
not easily reached by
rescue personnel
Pre-event (before the fall)
Provide benches for
supervisors that afford good
visibility of all playground
areas to facilitate noticing
when children are injured
Source: Carol W. Runyan, Introduction: Back to the Future—Revisiting Haddon’s Conceptualization of Injury Epidemiology and
Prevention. The University of North Carolina Injury Prevention Research Center.
Oxford Journals. Epidemiologic Reviews (2003) Volume 25, Issue 1: 60-64.
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Organize community-watch
systems to monitor
playground safety (e.g.,
maintaining surfacing)
Ensure funding for
adequate emergency
personnel appropriately
equipped to deal with
pediatric emergencies
Source: Runyan C W Epidemiol Rev 2003;25:60-64. ©2003 by Oxford University Press
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Modified Haddon Matrix in 3-D
Occupant
Pre-Crash
Vehicle Environment
Medical
Records
Crash
Post-crash
Autopsy
Hosp.records
Toxicology
Source: Runyan, C., Injury Prevention 1998;4:302-307
FAA Action
taken
References
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Safety Management System
 FOUR
PILLARS OF SAFETY MANAGEMENT:
►Safety Policy – Clearly defined policies, procedures, and
organizational structure
►Safety Risk Management – Formal system of
hazard identification, risk assessment, resource allocation,
and system monitoring
►Safety Assurance – Continuous quality improvement of
processes and products
►Safety Promotion – Continuous communication of safety
values and practices that support a sound safety culture
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The Evolution of Safety
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The Shell Model
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
Software (S): procedures,
training, support, etc.

Hardware (H): machines and
equipment

Environment (E): the working
environment in which the rest
of the L-H-S system must
function

Liveware (L): humans in the
workplace.
The Management Dilemma
Source: James Reason on ICAO Safety Management Manual (SMM)
http://www.icao.int/safety/SafetyManagement/Documents/Doc.9859.3rd%20Edition.alltext.en.pdf
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Understanding Hazards and Safety Risk
Hazard

A hazard is a condition or an
object with the potential to cause
death, injuries to personnel,
damage to equipment or
structures, loss of material, or
reduction of the ability to perform
a prescribed function
 Could cause or contribute to
unsafe operation of aircraft or
aviation safety-related equipment,
products and services
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Safety Risk





Safety risk is the projected
likelihood and severity of the
consequence or outcome from
an existing hazard or situation
Safety risk probability
Safety risk severity
Safety risk tolerability
Safety risk management

Risk = Probability + Severity
Hazards are inevitable in aviation activities
A
hazard is a prerequisite to
an accident or incident
 The
Key: Mitigation
strategies to contain the
potential for a hazard to
result in unsafe aircraft or
aviation equipment
operations
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Hazard Identification / Mitigation
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Hazard Identification / Mitigation
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Other Hazards in Aviation:
Birds Vs Airplanes
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Stowaway
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“If you are looking for perfect
safety, you will do well to sit on a
fence and watch the birds; but if
you really wish to learn, you must
mount a machine and become
acquainted with its tricks by
actual trial”
— Wilbur Wright, from an address to the
Western Society of Engineers in Chicago, 18
September 1901.
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Safety Risk Probability Table
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The Human Factors Analysis and Classification
System (HFACS)
http://hfacs.com/about-hfacs-framework
HFACS Taxonomy – S. Shappell & D. Wiegmann, 1997
[email protected]
405-954-2099

Diapositive 1

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