Air Force System Safety Handbook - System Safety Society

with the missile, would inflict severe structural damage to
the wing and possibly the horizontal stabilizer.
• A safety engineer found in the PAVE LOW helicopter
system that loss of voltage in a radar circuit would cause
a command to the aircraft to fly at zero altitude with no
warning to the pilot. He also checked with personnel on
the RF-4C and A-7D programs, knowing they used the
same system. All aircraft were quickly prohibited from
flying certain low-level missions until the systems were
corrected.
Investments in system safety pay off. The cost of system
safety is not large compared to overall program costs or
compared to a weapon system’s cost. Preventing the loss of
one aircraft could pay for system safety for the entire
development effort of that system. Waiting for mishaps to
point out design problems is not economically, politically, and
ethically feasible. “Fly-fix-fly” has been replaced with
identify-analyze-control. (Figure 1-4)
1.5 Development of System Safety.
System safety as we know it today began as a grass roots
movement that was introduced in the 40s, gained momentum
during the 50s, became established in the 60s, and formalized
its place in the acquisition process in the 70s. The system
safety concept was not the brain child of one man but rather a
call from the engineering and safety community to design and
build safer equipment by applying lessons learned from our
accident investigations. It was an outgrowth of the general
dissatisfaction with the fly-fix-fly approach to systems design.
The first formal presentation of system safety was by Amos L.
Wood at the Fourteenth Annual Meeting of the Institute of
Aeronautical Sciences (IAS) in New York in January 1946.
Titled “The Organization of an Aircraft Manufacturer’s Air
Safety Program,” Wood emphasized “continuous focus of
safety in design,” “advance and post-accident analysis,”
“safety education,” “accident preventive design minimize
personnel errors,” “statistical control of post-accident analysis.”
(14:18)
Wood’s paper was referenced in another landmark paper by
William I. Stieglitz entitled “Engineering for Safety,” presented
in September 1946 at a special meeting of the IAS and finally
printed in the IAS Aeronautical Engineering Review in
February 1948. Mr. Stieglitz’ farsighted views on system
safety are evidenced by a few quotations from his paper:
“Safety must be designed and built into airplanes, just as are
performance, stability, and structural integrity. A safety group
must be just as important a part of a manufacturer’s organization
as a stress, aerodynamics, or a weights group....”
“Safety is a specialized subject just as are aerodynamics and
structures. Every engineer cannot be expected to be thoroughly
familiar with all developments in the field of safety any
more than he can be expected to be an expert
aerodynamicist.”
“The evaluation of safety work in positive terms is extremely
difficult. When an accident does not occur, it is impossible to
prove that some particular design feature prevented it.”
(14:18-19)
The Air Force was an early leader in the development of
system safety. In 1950, the USAF Directorate of Flight Safety
Research (DFSR) was formed at Norton AFB, California. It
was followed by safety centers for the Navy in 1955 and Army
in 1957. The DFSR began in 1954 sponsoring Air
Force-industry conferences to address safety issues of various
aircraft subsystems by technical and safety specialists. In
1958, the first quantitative system safety analysis effort was
undertaken with the Dyna-Soar X-20 manned space glider.
3
This significant approach to hazard prevention was required
because of the unique emergency, rescue, and survival
problems of the X-20. (14:21-22)
FLY
Figure 1-3
The Fly-Fix-Fly Approach to Safety
FIX
FLY
In July 1960, a system safety office was established at the
USAF Ballistic Missile Division (BMD) at Inglewood, California.
BMD facilitated both the pace and direction of system safety
efforts when it published in April 1960 the first system-wide
safety specification titled BSD Exhibit 62-41, “System Safety
Engineering: Military Specification for the Development of Air
Force Ballistic Missiles.” The Naval Aviation Safety Center
was among the first to become active in promoting an
interservice system safety specification for aircraft, using BSD
Exhibit 62-41 as a model. (17:4-6) In the fall of 1962, the
Minuteman program director, in another system safety first,
identified system safety as a contract deliverable item in
accordance with BSD Exhibit 6282. (39:11)
The early 1960s saw many new developments in system
safety. In 1963, the Aerospace System Society was formed in
the Los Angeles area. The University of Southern California’s
Aerospace Safety Division began in 1964 a master’s degree
program in Aerospace Operations Management from which
specific system safety graduate courses were developed. In
1965, the University of Washington initiated a short course in
system safety analysis. (14:22-23) System safety had
become institutionalized.
1.6 Evolution of System Safety
Principles. (41:3-7)
MIL-STD-882 is the primary reference for system safety
program information for Department of Defense weapon
systems. Its evolution from BSD Exhibit 62-41 documents the
development of vital system safety principles.
By studying the early documents, basic concepts begin to
emerge. These founding principles include:
a. Safety must be designed in. Critical reviews of the
system design identify hazards that can be
controlled by modifying the design. Modifications
are most readily accepted during the early stages of
design, development, and test. Previous design
deficiencies can be exploited to prevent their recurrence.
b. Inherent safety requires both engineering and management
techniques to control the hazards of a
system. A safety program must be planned and
implemented such that safety analyses are