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AVSC 2130 Module 3 & 4
Terms in this set (16)
What does S.T.A.M.P. mean?
Systems Theoretic Accident Model & Process
What is the of the S.T.A.M.P. Accident theory?
STAMP aims to develop an organization-specific (system specific) approach rather than laying out general ideas for safety and analysis of accident. A system may create pressure to work faster, and cut costs, but in aviation, those kinds of savings often come at a high price.
What does the term "normalization of deviance" mean?
occur when several conflicting goals have to be juggled, such as safety and productivity. People start taking short cuts to meet deadlines and enhance effectiveness of their work.
What does "practical drift" mean?
Practical drift is when people adapt their actions to the real life context at work and drift towards a way to practically solve problems while bypassing the written standards. There is often a mismatch between the practical ways of accomplishing a task and how it is described in rules and regulations, directives, SOPs, etc.
According to Leveson what is the focus of the S.T.A.M.P. accident perspective?
STAMP focuses particular attention on the role of constraints in safety management. Instead of defining safety in terms of preventing component failure events, it is defined as a continuous control task to impose the constraints necessary to limit system behavior to safe changes and adaptations. Accidents are seen as resulting from inadequate control or enforcement of constraints on safety-related behavior at each level of the system development and system operations control structures. STAMP helped us to separate factual data from the interpretations of that data: While the factors involved in accidents may be clear, their importance and the explanations for why the factors were present are often subjective. Our models were also more complete than the causal factors cited in the official government accident reports associated with these accidents.
How is ethics defined?
"set of moral principles"
How a company reacts to safety related issues can influence what?
The foundation for further safety improvement or instill a fear of punishment that discourages conversation and prevents real solutions from being implemented. It is within these reactions that a company begins to build the "culture" of their organization.
One important aspect of a systems approach is?
Safety and developing a Safety Culture.
A Safety Culture is comprised of what several smaller cultures?
informed, flexible, reporting, learning, and just.
What tends to be the main focus following an accident and during an accident investigation?
Holding those who were at fault accountable.
When people are INFORMED they have a better understanding of the system as a...
whole or they know where to access necessary information.
Flexibility implies that people are willing to adapt themselves and the process they work in to...
A reporting culture implies that everyone is willing to...
Report on their own mistakes, errors, and experiences for the benefit and learning of the whole.
A reporting culture is necessary in order to create a...
Learning culture where people and a system as a whole can draw important conclusions from past experiences and implement the necessary reforms.
A just culture is needed in order to encourage continued reporting. A just culture is a set of paradigms that seeks to find that difficult balance between...
accountability, forgiveness, and learning
Although most organizations communicate their vision of Just Culture in one form or another, there may be an unconscious drift towards...
"Unethical" ways of doing business that leads to short cuts and accidents.
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