In conformity with the principles laid down in article 26 of the Chicago Convention and its Annex 13 concerning technical aircraft accident investigations, the United States and France respectively set up and developed their own investigation Boards, the NTSB and the BEA, which may be different by their organization and functioning but both aim at the same objective: the promotion of Air Safety. / To fulfil their complex mission in the best possible conditions and despite eventual pecuniary constraints, the pressure of the media, or the occasional tensions which may arise in case of concomitance with other investigations, the NTSB and the BEA rely on the renowned professionalism and high technical skills of their employees as well as on the participation in the investigation of members of the aeronautical industry who bring their expertise and contribute to the improvement of air safety.

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Αντικείμενο της διατριβής είναι η έρευνα των παραγόντων πρόκλησης των εργατικών ατυχημάτων με το σχεδιασμό και την ανάλυση μιας ολοκληρωμένης μεθόδου διερεύνησης, περιορίζοντας τους παράγοντες σε συγκεκριμένες κατηγορίες με τις αλληλεπιδράσεις τους και την ποσοτικοποίηση των σχέσεών τους. Από την ανάλυση των μοντέλων πρόκλησης, προσδιορίζονται τρεις ομάδες μοντέλων (διαδοχικά, επεξεργασίας της ανθρώπινης πληροφορίας και συστημικά), αναδεικνύεται η αντιστοιχία τους με τις μεθόδους διερεύνησης και προτείνεται ολοκληρωμένο πλαίσιο αξιολόγησης των μεθόδων διερεύνησης με συγκεκριμένα κριτήρια. Παράλληλα, οι έρευνες πεδίου σε διαφορετικά δείγματα εργατικών ατυχημάτων ταυτοποιούν παράγοντες πρόκλησης επιβεβαιώνοντας τη σημερινή έρευνα για άμεσους και έμμεσους παράγοντες χωρίς να λαμβάνεται υπόψη το συνολικό πλαίσιο πρόκλησής τους. Η αξιολόγηση των μεθόδων διερεύνησης και τα αποτελέσματα των ερευνών πεδίου, οδήγησαν στο σχεδιασμό μιας νέας μεθόδου διερεύνησης, η οποία στηρίζεται σε συνδυαστικό μοντέλο πρόκλησης εμπλουτίζοντάς το με τη νομική διάσταση. Η μέθοδος λαμβάνει υπόψη τέσσερις ομάδες παραγόντων: εργασιακούς, ανθρώπινους, οργανωτικούς και νομικούς, οι οποίες διακρίνονται σε υποομάδες με τη βοήθεια σχεδίων ταξινόμησης στοχεύοντας σε μια ολοκληρωμένη διερεύνηση του ατυχήματος. Τα πρώτα αποτελέσματα από την επικύρωση της προτεινόμενης μεθόδου, όσον αφορά στην αξιοπιστία της και την εγκυρότητά της, είναι ενθαρρυντικά για την εφαρμογή της μεθόδου. Ο έλεγχος των υποθέσεων για τη διασφάλιση της εγκυρότητας της μεθόδου, με την ποσοτικοποίηση των σχέσεων των παραγόντων πρόκλησης, όπως ο σχεδιασμός της εργασίας με την κατάρτιση καθώς και η παροχή ανασφαλούς εξοπλισμού με την έλλειψη συμμετοχής των εργαζομένων σε θέματα σχετικά με την εργασία και τα καθήκοντά τους οδηγεί στην πληρέστερη απεικόνιση της πρόκλησης. / This thesis concerns the identification of accident causation factors and their interrelationships with the design and analysis of a structured accident investigation method. The main contribution of the research reported is the development of an evaluation framework of accident investigation methods in terms of their alignment with accident causation models, the design of an investigation method based on the evaluation results and covering the descriptive, revealing, qualitative, quantitative and legal requirements of the investigation and the quantification of the relation between accident causation factors aiming at a more precise structural equation model explaining the occupational accident causation phenomenon. Preliminary research on various samples of accidents identified accident causation factors confirming the current research on immediate and underlying factors without taking into account the whole context of accident causation. The proposed method takes into account four areas: workplace, human, management and legal factors. The method process breaks down the four areas into simpler components with the aid of classification schemes aimed at an integrated accident reconstruction. Results from the application of the proposed method can reveal patterns of associations between factors such as work design and training as well as between provision of unsafe equipment and employee involvement which form the basis to understand complex accident causation mechanisms.

This work describes general view of a traffic accident in order to introdukce non-specific features of traffic accidents. The objective of this work is deeper understanding of this issue, of the difference between the need for improving the participants skills and the repressive measures introduced in the attempt to guarantee the observance of fundamental legal standards.

Orientador: Saide Jorge Calil / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Engenharia Elétrica e de Computação / Made available in DSpace on 2018-08-14T06:19:25Z (GMT). No. of bitstreams: 1 Morita_PlinioPelegrini_M.pdf: 1995472 bytes, checksum: 044db36e3175f261486233283a234b7d (MD5) Previous issue date: 2009 / Resumo: Com o crescente aumento do parque tecnológico dentro das instituições de saúde, são crescentes os perigos inseridos no ambiente hospitalar. Conseqüentemente, medidas de gerenciamento de riscos precisam ser adotadas para garantir tanto um ambiente de trabalho seguro para os funcionários como uma maior segurança aos pacientes, familiares e visitantes que transitam diariamente por estas instituições. Uma das possíveis medidas de gerenciamento de risco é a investigação de incidentes, onde informações de ocorrências na instituição são coletadas e analisadas para gerar possíveis modificações de procedimentos e estruturas da instituição, reduzindo assim a probabilidade de ocorrências futuras. Neste trabalho, o desenvolvimento do material apresentado foi baseado em técnicas já amplamente disseminadas em diversos setores da indústria as quais possuem avançadas metodologias de investigação de incidentes. Este trabalho não só propõe um guia completo para a investigação de qualquer tipo de incidente em uma instituição de saúde, como também provê o suporte necessário ao desenvolvimento de uma cultura de segurança que, ao longo do tempo, aumente a segurança dos pacientes e a qualidade do serviço oferecido por essas instituições. Tem ainda como objetivo preencher a lacuna existente nos programas de gerenciamento de riscos de instituições de saúde, uma vez que as metodologias de investigação de incidentes ou não são específicas à investigação em instituições de saúde, ou não abordam adequadamente todas as atividades necessárias, impossibilitando a investigação de todos os tipos de ocorrências em instituições de saúde. O processo investigativo é estruturado de acordo com a teoria de gerenciamento de projetos onde as atividades necessárias foram divididas em dois grandes blocos: um para a Estruturação Inicial e um bloco composto de quatro fases para o processo investigativo. No bloco para estruturação inicial são abordados todos os requisitos necessários em uma instituição de saúde para a implementação de um sistema de investigação de incidentes, variando desde a equipe a ser utilizada até a cultura da instituição. No bloco do Processo Investigativo, a Fase 1 - Inicialização da Investigação descreve as atividades a serem realizadas entre a notificação de uma ocorrência e a chegada da equipe investigativa à cena da ocorrência; na Fase 2 - Coleta de Evidências são detalhadas as atividades que a equipe investigativa irá conduzir enquanto na cena da ocorrência e anteriormente à análise das evidências; na Fase 3 - Análise de Evidências são apresentados os processos de análise e quais os procedimentos a serem tomados com estas evidências para que seja possível determinar os cenários envolvidos e as causas raízes destes cenários; e na Fase 4 - Recomendações e Relatório são fornecidas instruções de como desenvolver recomendações adequadas à instituição e de como apresentá-las de forma a obter o melhor resultado possível. Esta divisão tem como objetivo tornar o material mais fácil de ser seguido e dividir o árduo processo investigativo em sub-atividades menores. Este trabalho resultou em um guia claro, completo, de fácil utilização e que possibilita a investigação de qualquer tipo de ocorrência, fornecendo mais uma ferramenta para auxílio de um sistema de gerenciamento de riscos em instituições de saúde. / Abstract: The hazards inside a healthcare institution are increased by the growth in the use of more technological equipments. Consequently, risk management measures must be taken to ensure both a safe workplace and an improved safety for the patients, family and visitors that transit daily by these institutions. One possible risk management measure is the incident investigation, in which information from occurrences are gathered and analyzed to generate possible procedural and structural modifications in the institution, therefore reducing the probability of future occurrences. The development of the methodology presented in this work was based on techniques widely spread in several industry sectors that already have highly developed incident investigation methodologies. This work proposes a complete incident investigation methodology for the investigation of any type of incident in a healthcare institution, as well as the necessary support for the development of a safety culture that, through time, increases the safety of the patients and the quality of the service offered by these institutions. It also has the objective of filling an existing gap in healthcare institutions risk management programs, since the available incident investigation methodologies are not specific to investigations in healthcare institutions nor cover adequately all the activities inside the incident investigation process. Consequently, it's not possible to investigate all types of occurrences in healthcare institutions. The investigative process here presented is structured according to the project management theory in which the necessary activities were divided into two big blocks: one for initial foundation and one consisting of four phases for the investigation process. In the Initial Foundation block are presented and discussed all the necessary requirements in a healthcare institution for the implementation of an incident investigation system, varying from the team to be used to investigate to the institution's culture. In the Investigative Process block, the Phase 1 - Investigation Initialization describes the activities to be performed between the occurrence notification and the arrival of the team at the incident site. In the Phase 2 - Evidence Collection are described the activities that the investigation team will conduct while in the scene and prior to the evidence analysis. In the Phase 3 - Evidence Analysis are discussed the analyses processes and procedures to be undertaken on the collected evidences so that it becomes possible to determine the involved scenarios and the root causes of such scenarios. In the Phase 4 - Recommendations and Report, instructions are presented regarding the development of recommendations that are adequate to the characteristics of the institution and how to present them in order to achieve the best results. This division has the objective of making this methodology easier to be followed and to divide the arduous investigation process into smaller sub-activities. This work resulted in a clear, complete and easy-to-use guide that allows the investigation of any type of incident, providing another helpful tool for the healthcare institutions risk management system. / Mestrado / Engenharia Biomedica / Mestre em Engenharia Elétrica

No description available.

The general purpose of this study was to determine whether a relationship exists between emotional awareness and human error in aviation. A quantitative analysis approach was used to explore this by means of a cross-sectional survey design. The independent variable emotional awareness and the dependent variable human error were contextualised and operationalised. During the empirical phase, biographical information was collected and the Hartmann Emotional Boundary Questionnaire was administered to a purposive sample consisting of 173 aircrew members within the South African Air Force. Factor analysis revealed an eight-factor structure: involved; exactness; blend; openness; structured; unstructured; flexibility; and imagination. No differentiation was found between the mustering groups in relation to emotional awareness and human error. However, correlations differentiated between aircrew with zero human error and aircrew with “more than ten years’ aviation experience”. The test for differences between human error and the emotional awareness sub-construct "imagination" indicated a medium significance. From this relationship, the researcher deducted that “imaginative aircrew are prone to err”. / Industrial and Organisational Psychology / M. Com. (Industrial and organisational Psychology

In December 1978, United Airlines Flight 173 arriving in Portland from Denver with 189 people aboard crash-landed in a suburb at 157th and East Burnside. Ten people were killed and dozens more were injured. The jet ran out of fuel after it had circled for an hour while the crew tried to determine what was wrong with the right main landing gear, which had fallen with a huge double jolt on extension. The investigation that followed the crash placed the blame squarely on the pilot for his negligence in failing to monitor his fuel supply, and secondarily on his crew members, who failed to adequately communicate their concerns about it. The accident was a watershed event in what would become known in the airline industry as crew resource management, a communication model designed to reduce human error by fostering collaborative decision-making and assertiveness training. In the years that have followed the accident, very little has changed in the narrative surrounding it. Articles and docudramas on the plane crash consistently repeat the tale as is, blaming the pilot and shedding no light on the factors that led to the in-flight emergency or on United's role in contributing to the crash. This thesis is a "cold-case" investigation that reveals those contributing factors, which have been so thoroughly ignored. In the words of renowned attorney F. Lee Bailey, "The rule of law requires that all parties who contribute to an accident share in the responsibility for whatever harm has been caused." This is the untold story of all the decisions that brought down United Flight 173, and of the responsibilities heretofore overlooked.