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Normal Operations Monitoring Normal Operations Monitoring A New Approach to Measuring and Managing Human and Safety Performance Tested in Aviation Ground Handling Louise Raggett A thesis in fulfilment of the requirements for the degree of Doctor of Philosophy School of Aviation University of New South Wales September 2016 1 PLEASE TYPE THE UNIVERSITY OF NEW SOUTH WALES Thesis/Dissertation Sheet Surname or Family name: Raggett First name: Louise Other name/s: Claire Abbreviation for degree as given in the University calendar: AVIAAR1900 -Aviation, Doctor of Philosophy (PhD) School: Aviation Faculty: Science Title: Normal Operations Monitoring - A new approach to measuring and monitoring human and safety performance - tested in aviation ground operations Abstract 350 words maximum: (PLEASE TYPE) Unlike flight operations, which is now regarded as an 'Ultra-safe system' (Amalberti 2001, p. 109) aviation ground safety has languished behind the rest of the industry (Verschoor and Young 2011), with activities on the ramp now accounting for more than a quarter of all incidents (Balk and Bossenbroek 2010). In recent years, both 'damage to aircraft and harm to ground personnel have escalated' (Passenier 2015 p. 38) costing air carriers more than USD10 billion annually (GAO 2007) Models and measures influential to aviation safety are reviewed for their possible contribution to the ground safety problem. The Threat and Error Management Model (TEM) and line Operation Safety Audit (LOSA) method (Klinect, Murray, Merritt and Helmreich 2003) were identified as potential candidates and critically examined for their suitability. The aim of the current research was to develop an approach that builds on the existing benefits of LOSA, whilst incorporating contemporary theories of safety science, and improving data reliability and validity where possible. A new method is proposed named 'Normal Operations Monitoring' (NOM). NOM is an observation methodology which codes and measures human and safety performance in routine operations. NOM attempts to measure the gap between the system as designed and the system as actually operated (Hollnagel 2007). Identifying this variance provides novel insights into factors which influence safety performance and suggest new opportunities for interventions and improvement. NOM was customised for application in the ground handling industry. Data was collected and analysed from over 1300 observations of aircraft turnarounds. Implications for ground safety are explored as well as the potential applications and benefits of NOM to other domains. The final discussion explores how the current research and NOM tools could be taken forward as a method for informing and improving safety management in other high-hazard industries. Declaration relating to disposition of project thesis/dissertation I hereby grant to the University of New South Wales or its agents the right to archive and to make available my thesis or dissertation in whole or in part in the University libraries in all forms of media, now or here after known, subject to the provisions of the Copyright Act 1968. I retain all property rights, such as patent rights. I also retain the right to use in future works (such as articles or books) all or part of this thesis or dissertation. I also authorise University Microfilms to use the 350 word abstract of my thesis in Dissertation Abstracts International (this is applicable to doctoral thesesooly) �� � , � Date �f/ The University recogni6's t;at there may be exceptional circumstances requiring restrictions on copying or conditions on use. Requests for restriction for a period of up to 2 years must be made in writing. Requests for a longer period of restriction may be considered in exceptional circumstances and require the aooroval of the Dean of Graduate Research. FOR OFFICE USE ONLY Date of completion of requirements for Award: THIS SHEET IS TO BE GLUED TO THE INSIDE FRONT COVER OF THE THESIS THE UNIVERSITY OF NEW SOUTH WALES Thesis/Dissertation Sheet Surname or Family name: Raggett First name: Louise Other name/s: Claire AVIAAR1900 – Aviation Doctor of Philosophy (PHD) School: Aviation Faculty: Science Title: Normal Operations Monitoring - A New Approach to Measuring and Monitoring Human and Safety Performance – Tested in Aviation Ground Operations 1 TABLE OF CONTENTS THE UNIVERSITY OF NEW SOUTH WALES ..................................................................................... 1 Thesis/Dissertation Sheet ............................................................................................................. 1 Acknowledgements ........................................................................................................................ 6 TABLE OF CONTENTS ...................................................................................................................... 2 List of Figures ................................................................................................................................. 7 Glossary ......................................................................................................................................... 9 List of Acronyms ........................................................................................................................... 11 Abstract ....................................................................................................................................... 12 Chapter 1: Overview of Thesis ...................................................................................................... 14 Chapter 2: Safety and Human Performance in Ground Operations .............................................. 21 2.1 The Ground Safety Problem ..................................................................................................... 21 2.2 Ground Safety Incidents ........................................................................................................... 23 2.2.1 Safety-of-flight impacts ...................................................................................................... 23 2.2.2 Injury to ramp personnel ................................................................................................... 25 2.2.3 Damage to aircraft ............................................................................................................. 27 2.2.4 Calculating the cost to industry ......................................................................................... 27 2.2.5 Identifying the causes of ramp incidents ........................................................................... 28 2.3 Understanding the Ground Handling Task ............................................................................... 29 2.3.1 The ground servicing task .................................................................................................. 29 2.3.2 The need for new research in ground safety ..................................................................... 33 Chapter 3: Accidents and Models ................................................................................................. 36 3.1 Models and Metaphors of Accident Causation ........................................................................ 36 3.1.1 Accident chains and dominoes .......................................................................................... 37 3.1.2 The pyramid model ............................................................................................................ 38 3.1.3 The energy-damage model ................................................................................................ 41 3.2 Models of Human Performance ............................................................................................... 44 3.2.1 The information processing model .................................................................................... 44 3.2.2 The SHELL model ................................................................................................................ 47 3.2.3 The Threat and Error Management (TEM) model .............................................................. 49 3.3 System Models ......................................................................................................................... 53 3.3.1 Reason’s ‘Swiss Cheese’ model .......................................................................................... 54 3.3.2 Safety management system models .................................................................................. 57 3.3.3 Models of safety culture .................................................................................................... 59 3.3.4 High Reliability Organisation (HRO) model ........................................................................ 62 3.3.5 Models of organisational resilience ................................................................................... 64 3.4 Summary and Implications for the Current Research .............................................................. 67 Chapter 4: Methods for Measuring Safety ................................................................................... 71 4.1 Incidents, Indicators and Measures of Safety Systems............................................................. 71 4.1.1 Accident and incident data ................................................................................................ 71 4.1.2 Leading indicators of safety ..............................................................................................
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