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System Safety ManagementThe Basic Need For SafetyHierarchy of Needs (cont.)Human Need for SafetyHuman Needs Based on DeficitIndustrial RevolutionAnonymous Safety Professional statement:History of Safety ProcessAviation Safety Process - 1908First Aviation FatalityMishap InvestigationFly-Fix-Fly Approach to SafetyScience of Accident InvestigationThe Need for System SafetyAviation Safety ProgramsChief of Air Service 1921 Report:Systematic ApproachOrganizational Best PracticesTechnical Report - 1927NACA Report -1928Challenges To Improving The Safety RecordArmy Air Corps Accident Investigation Goals -1930Reactive Safety ProgramAir Commerce Act - 1926Public Confidence ErodedU.S. Army Safety SectionSafety Section DutiesU.S. Army Air Corps Safety CultureSafety Objectives - 1941U.S. Army Air Force - 1942Office of Flying Safety - 1945Modern Day U.S. Air ForceThe Key to Program SuccessSystem Safety in the Civilian SectorEngineering For System SafetyEngineering For System Safety (cont)Slide 37System Safety – An Interdisciplinary PracticeAir Force Performance MetricsPublic Expectations of High StandardsSystems Safety in Acquisition ProgramsIndustry “Best Practice”Industrial System SafetyIndustrial System Safety (cont)North American X-15System Acquisition SpecificationsSystem Safety CultureAcquisition StandardsSlide 49System Safety ManagementThe Basic Need For Safety•Originates as a fundamental human need•Dr. Abraham Maslow outlined a hierarchy•States that humans are motivated to action by unsatisfied needs •Physiological needs are first:–Air, Water, Food, etc.•Basic requirement must be fulfilled before there is interest in a higher functionHierarchy of Needs (cont.)•After Physiological needs are met Safety concerns are second•At this level humans seek stability in their lives•Freedom from hazards or potential threats•In this layer humans predominantly seeks structure and order•Comfort zones are developed based on boundaries and known parametersHuman Need for Safety•Safety needs are mostly psychological in nature and difficult to quantify•Perception of safety is often based on false assumption and intuition•Once the “feeling” of safety is achieved humans can move on to the next tier•Higher tiers relate to increased efficiency and higher personal performancesHuman Needs Based on Deficit•Homeostasis principal (deficit needs)–Thermostat / Furnace relationship•Human needs are essential to survival and instinctive or instinctoid•Needs are Prepotent -- our actions are influenced by our greatest needIndustrial Revolution•Significant steps in structured safety efforts evolved during this period (19th Century)•Safer practices met personal needs and was eventually considered “Good Business” as it protected skilled laborers and valuable equipment •Safety Programs proved to be a Win-Win solutionAnonymous Safety Professional statement: ““It is immoral to design a It is immoral to design a product or system for mankind product or system for mankind without recognition and without recognition and evaluation of the hazards evaluation of the hazards associated with that product or associated with that product or system”system”History of Safety Process•To best enable users of system safety practices to understand the process of safety, placing today’s programs in context to their historical predecessors helps maintain the lessons learned of their “safety forefathers” •System safety began within the context of looking for safe resultsAviation Safety Process - 1908•Aviation safety processes can be traced back to the earliest days of aviation when a mishap occurred during flight demonstration of a new aerospace system (Wright Flyer) at Fort Myer, Virginia•The investigation revealed that an untested sub-system (propulsion) component (propeller), failed causing subsequent damage to the other propeller and structural supporting guy wiresFirst Aviation FatalitySeptember 17, 1908Mishap Investigation•The sub-system, which had performed reliably, was modified in order to successfully meet and exceed US Army speed specifications •The designer (Orville Wright) had extended the previously proven propeller design by approximately 4 inches •This untested modification failed, striking the other propeller and a wire bracing the tail section causing it to collapse and pitch into a fatal plungeFly-Fix-Fly Approach to Safety•This type of flight research was consistent with the approach that produced a functional aircraft •The Wright Brothers had successfully accomplished powered flight with a trial and error approach to flight testing their new designs •There were few previous studies for them to review -- Each flight was an experiment, if a new design worked, they would fly it to gather data. If it failed, they studied the deficiencies; performed modifications and flight-tested the new designScience of Accident Investigation•Early flight posed new challenges, which shaped safety programs that grew to address hazards •During these formative years the complexities of aircraft and the effects of the environment in which they operated were not fully understood •Inquiries into aircraft accidents were not specialized enough to capture information in a fashion that identified all the hazards, eliminated them or reduced them to acceptable levelsThe Need for System SafetyThe first fatal powered-aircraft accident investigation pointed to the need for system safety practices – the formal recognition of this holistic approach came decades laterAviation Safety Programs•The US Army Air Service took the first steps toward a formal aviation safety program in 1921•The Chief of the Medical Division --Air Service reviewed all accidents that caused injury to people or equipment during the previous year•In that report the first soundings for a formal safety program were heardChief of Air Service 1921 Report:“…that the Air Service desires to perfect preventive accident measures to the fullest possible may be readily appreciated from the fact that during the calendar year 1920, 51 officers and enlisted men of the Air Service lost their lives in airplane accident, [and] 312 airplanes were damaged or destroyed...”Systematic Approach•In December 1925, the Commander of the Information Division of the Air Service, Major Henry H. “Hap” Arnold, identified the need for a systematic approach to aircraft maintenance and operations •His


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O-K-State ETM 5471 - System Safety Management

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