Modeling the Linate Runway Incursion: Questioning Managerial and Operator Tolerance for Degraded Technical Infrastructures
نویسنده
چکیده
This paper uses Events and Causal Factors charts to reexamine the ANSV’s report into the Linate runway incursion. The intention is not directly to identify new findings but to use the graphical formalism to trace the technical and managerial context for the errors made by individual air traffic controllers and aircrew. The analysis, therefore, looks beyond operator error as a cause of major accidents. However, the analysis also suggests that it is time to question the ‘can do’ attitude of air traffic personnel who are willing to find ‘work arounds’ even when technical changes remove critical elements of their safety infrastructure.
منابع مشابه
Understanding the interaction between public policy, managerial decision-making and the engineering of critical infrastructures
Failures in national and international infrastructures have causes that stretch well beyond the specific events that trigger an accident or incident. The following pages argue that these latent causes can be traced back through the decisions of local management teams to higher-levels of public policy. For example, the 2003 blackout of areas in Canada and the USA was triggered by ‘flash overs’ t...
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