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Monday, January 28, 2019

On SAF's Safety Culture making things less safe

On Aloysius Pang:

"After every serious incident, a safety time out is always called; it was called after Gavin Chan's death, it was called after Dave Lee's death, it was called after Liu Kai's death. After some time, the safety time out will end, then what happens?

The safety time out is called also to review safety protocols. But it's not that safety protocols aren't there or not robust—the problem is that they are TOO robust, to the point that they are so onerous that people don't take them seriously. This is basic human factors and is a problem that Singapore in general has—in trying to cover backside so much, people get tired of all the hassle and find short-cuts.

The safety time out will work for a while because the onerous safety protocols will be re-emphasised and ensured. Even more protocols will be imposed. Then over time, people will forget, find short-cuts, and then something will happen again. It's a vicious circle."

Related (and previously linked):

How Technology Led a Hospital To Give a Patient 38 Times His Dosage

""The warnings in cockpits now are prioritized so you don’t get alarm fatigue,” he told me. “We work very hard to avoid false positives because false positives are one of the worst things you could do to any warning system. It just makes people tune them out.” He encouraged me to visit Boeing’s headquarters to see how its cockpit engineers manage the feat of alerting pilots at the right time, in the right way, while avoiding alert fatigue...

Like many of aviation’s safety solutions, the parsimonious approach to alerts came from insights born of tragedies. “The original ‘gear down’ warning was linked to the throttle,” recalled Myers, meaning that it went off, falsely, every time the pilot slowed the plane. “So the pilots’ learned response was throttle back, disconnect the alert.” Predictably, this led to accidents when pilots ignored this alert even when there truly was a problem. Another example: in the early days of the Boeing 727, some alerts were so frequent and wrong that pilots yanked the circuit breakers to quash them."
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