Fred Brisbois, Sikorsky Aircraft Corp. and Larry Buehler, FAA ... - IHST

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ACTIVE vs. LATENT FAILURES*OrganizationalFactorsLatent Conditions•Procedures incomplete•Poor layout/configurationUnsafeSupervisionLatent Conditions•Poor task planning•Parts/tools improperly labeledPreconditionsforUnsafe ActsLatent Conditions•Inadequate lighting•Equipment inappropriate for taskFailed orAbsent Defenses* Reason, 1990IHSS – September, 2009IHST.orgUnsafeActsActive Conditions•Omitted procedural step•Distraction/Interruption•Inadequate task knowledge•Poor techniqueAccident & Injury• Maintenance problem• Aircraft crashed24
RECOGNIZING RISKIHSS – September, 2009IHST.org25
Page 3 and 4: IHST MODELBased On Proven CAST Proc
Page 6 and 7: U.S. JHSIT PROCESS MODELReview JHSA
Page 8 and 9: JHSIT EVALUATION MATRIXExampleJHSAT
Page 10 and 11: U.S. JHSIT CORE MEMBERSHIPLarry Bue
Page 12: IMPROVING PERFORMANCEPROBABILITY⇒
Page 16 and 17: IHSS - September, 2009IHST.org16
Page 20: U.S. JHSIT CORE MEMBERSHIPLarry Bue
Page 26 and 27: WHO APPROVES CONFIGURATION?4 Point
Page 28 and 29: CHALLENGER ACCIDENT INVESTIGATION
Page 32 and 33: CULTURAL CHANGENearly every states/
Page 34 and 35: SAFETY MANAGEMENT SYSTEMFramework F
Page 36 and 37: SAFETYResponsibility & Accountabili
Page 40 and 41: SMS IWG ACTIVITIES2007• Sep SMS T
Page 42 and 43: SYSTEMS, EQUIPMENT & INFORMATION200
Page 44 and 45: TRAINING IWG ACTIVITIES2008Nov Educ
Page 46 and 47: INFRASTRUCTURE IWG ACTIVITIES2008:C

Fred Brisbois, Sikorsky Aircraft Corp. and Larry Buehler, FAA ... - IHST

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