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By definition, errors occur within the rules and regulations espoused by an organization; typically dominating most accident databases. In contrast, violations represent a willful disregard for the rules and regulations that govern safe flight and, fortunately, occur much less frequently since they often involve fatalities (Shappell et al., 1999b).
2.1.2.1 Routine violations
固然有很多方法来区分不同范例的违规举动，两种不同的形式已被确定，根据其病因，这将有助于安全专业职员确定事故的因果因素。第一种是日常违规举动，往往是风俗性的，往往被管理政府容忍（Rea son，1990）。例如，考虑一个人，他的驾驶速率不停比法律允许的速率快5-10英里/小时，或者一个人，当他只被授权在可视气象条件下飞行时，他经常在边缘天气飞行。固然两者都肯定违背了管理法规，但很多其他人也在做同样的事情。此外，在55英里/小时的地区中驾驶64英里/小时的人几乎总是在55英里/小时的地区中驾驶64英里/小时。也就是说，他们“经常”违背速率限制。同样的情况也可以典型地实用于那些经常飞进恶劣天气的飞行员。
While there are many ways to distinguish between types of violations, two distinct forms have been iden tified, based on their etiology, that will help the safety professional when identifying accident causal factors. The first, routine violations, tend to be habitual by nature and often tolerated by governing authority (Rea son, 1990). Consider, for example, the individual who drives consistently 5-10 mph faster than allowed by law or someone who routinely flies in marginal weather when authorized for visual meteorological conditions only. While both are certainly against the governing regulations, many others do the same thing. Further more, individuals who drive 64 mph in a 55 mph zone, almost always drive 64 in a 55 mph zone. That is, they “routinely” violate the speed limit. The same can typically be said of the pilot who routinely flies into mar ginal weather.
更糟糕的是，这些违规举动(通常被称为“弯曲”规则)通常是被容忍的，实际上是被监管政府批准的(也就是说，你不太可能收到交通罚单，除非你超过规定的限速10英里每小时)。然而，假如地方政府开始对高速公路上超过限速9英里或更低的速率开出交通罚单(就像在军事设施上经常做的那样)，那么个人违背规定的可能性就会降低。因此，从界说上讲，假如发现了日常违规举动，就必须进一步查看监管链，以确定那些没有执行规则的当权者。
What makes matters worse, these violations (com monly referred to as “bending” the rules) are often tolerated and, in effect, sanctioned by supervisory authority (i.e., you’re not likely to get a traffic citation until you exceed the posted speed limit by more than 10 mph). If, however, the local authorities started handing out traffic citations for exceeding the speed limit on the highway by 9 mph or less (as is often done on military installations), then it is less likely that individuals would violate the rules. Therefore, by definition, if a routine violation is identified, one must look further up the supervisory chain to identify those individuals in authority who are not enforcing the rules.
2.1.2.2 Exceptional violations
另一方面，与常规侵占举动不同的是，越权侵占举动表现为对权利的孤立背离，并不愿定表明个人的范例举动模式，也不被管理层所纵容(Reason，1990)。例如，一个孤立的例子，驾驶105英里每小时在55英里每小时的地区被以为是一个破例的违规。同样地，在桥下飞行或从事其他被克制的机动，如低空峡谷跑，将构成破例。但是，必须指出，固然大多数破例的违背举动令人震惊，但由于其极度性质，它们并不被视为“破例”。相反，他们被以为是特殊的，因为他们既不是典型的个人，也没有得到权威的宽恕。尽管如此，对于任何组织来说，特别难以处理的违规举动的原因是，它们并不代表一个人的举动，因此，特别难以猜测。事实上，当人们面对自己可骇举动的证据并要求他们做出解释时，他们往往得不到什么解释。事实上，那些从这种常规中幸存下来的人清楚地知道，假如被抓住，可骇的后果将随之而来。尽管如此，很多其他方面的模范公民照旧走上了这条潜在的悲剧之路。
On the other hand, unlike routine violations, exceptional violations appear as isolated departures from authority, not necessarily indicative of individual’s typi cal behavior pattern nor condoned by management (Reason, 1990). For example, an isolated instance of driving 105 mph in a 55 mph zone is considered an exceptional violation. Likewise, flying under a bridge or engaging in other prohibited maneuvers, like low-level canyon running, would constitute an exceptional viola tion. However, it is important to note that, while most exceptional violations are appalling, they are not consid ered “exceptional” because of their extreme nature. Rather, they are considered exceptional because they are neither typical of the individual nor condoned by au thority. Still, what makes exceptional violations par ticularly difficult for any organization to deal with is that they are not indicative of an individual’s behavioral repertoire and, as such, are particularly difficult to predict. In fact, when individuals are confronted with evidence of their dreadful behavior and asked to explain it, they are often left with little explanation. Indeed, those individuals who survived such excur sions from the norm clearly knew that, if caught, dire consequences would follow. Still, defying all logic, many otherwise model citizens have been down this potentially tragic road.
LevelTieTypeContentUnsafe actsERRORSSkillbased ErrorsBreak down in visual scanUnsafe actsERRORSSkillbased ErrorsFailed to prioritize attentionUnsafe actsERRORSSkillbased ErrorsInadvertent use of flight controlsUnsafe actsERRORSSkillbased ErrorsOmitted step in procedureUnsafe actsERRORSSkillbased ErrorsOmitted checklist itemUnsafe actsERRORSSkillbased ErrorsPoor techniqueUnsafe actsERRORSSkillbased ErrorsOvercontrolled the aircraftUnsafe actsERRORSDecision ErrorsImproper procedureUnsafe actsERRORSDecision ErrorsMisdiagnosed emergencyUnsafe actsERRORSDecision ErrorsWrong response to emergencyUnsafe actsERRORSDecision ErrorsExceeded abilityUnsafe actsERRORSDecision ErrorsInappropriate maneuverUnsafe actsERRORSDecision ErrorsPoor decisionUnsafe actsERRORSPerceptual Errors (due to)Misjudged distance/altitude/airspeedUnsafe actsERRORSPerceptual Errors (due to)Spatial disorientationUnsafe actsVIOLATIONSFailed to adhere to briefUnsafe actsVIOLATIONSFailed to use the radar altimeterUnsafe actsVIOLATIONSFlew an unauthorized approachUnsafe actsVIOLATIONSViolated training rulesUnsafe actsVIOLATIONSFlew an overaggressive maneuverUnsafe actsVIOLATIONSFailed to properly prepare for the flightUnsafe actsVIOLATIONSBriefed unauthorized flightUnsafe actsVIOLATIONSNot current/qualified for the missionUnsafe actsVIOLATIONSIntentionally exceeded the limits of the aircraftUnsafe actsVIOLATIONSUnauthorized lowaltitude canyon runningUnsafe actsVIOLATIONSContinued lowaltitude flight in VMC 2.2 Preconditions for Unsafe Acts
Arguably, the unsafe acts of pilots can be directly linked to nearly 80 % of all aviation accidents. However, simply focusing on unsafe acts is like focusing on a fever without understanding the underlying disease causing it. Thus, investigators must dig deeper into why the unsafe acts took place. As a first step, two major subdi visions of unsafe aircrew conditions were developed: substandard conditions of operators and the substandard practices they commit .
2.2.1 Substandard Conditions of Operators
2.2.1.1 Adverse mental states
不良心理状态。精神上的预备在几乎全部的努力中都是至关告急的，但在飞行中可能更告急。因此，不良心理状态 这一种别被创建来解释那些影响表现的心理状态(表2)。其中主要包罗情境意识的丧失、任务固定、注意力分散和由于睡眠不足或其他压力源导致的心理疲劳。这一种别还包罗个性特征和有害的态度，如过度自信、自满和错误的动机。
Adverse mental states. Being prepared mentally is critical in nearly every endeavor, but perhaps even more so in aviation. As such, the category of Adverse Mental States was created to account for those mental conditions that affect performance (Table 2). Principal among these are the loss of situational awareness, task fixation, distraction, and mental fatigue due to sleep loss or other stressors. Also included in this category are personality traits and pernicious atti tudes such as overconfidence, complacency, and mis placed motivation.
可以预见的是，假如一个人由于某种原因感到精神疲劳，那么出错的可能性就会增加。同样，太过自信和其他有害的态度，如傲慢和冲动，也会影响违法举动的可能性。显然，任何人为错误的框架都必须解释事件因果链中预先存在的倒霉心理状态。
Predictably, if an individual is mentally tired for whatever reason, the likelihood increase that an error will occur. In a similar fashion, overconfidence and other pernicious attitudes such as arrogance and impulsivity will influence the likelihood that a violation will be committed. Clearly then, any framework of human error must account for preexisting adverse mental states in the causal chain of events.
2.2.1.2 Adverse physiological states
不良的生理状态。第二类，倒霉生理状态，是指那些妨碍安全操作的医学或生理状态。如前所述的视错觉、空间迷失以及身体疲劳等状态对航空特别告急。还有无数已知会影响表现的药理学和医学异常。
Adverse physiological states. The second category, adverse physiological states, refers to those medical or physiological conditions that preclude safe opera tions (Table 2). Particularly important to aviation are such conditions as visual illusions and spatial disori entation as described earlier, as well as physical fa tigue, and the myriad of pharmacological and medical abnormalities known to affect performance.
大多数飞行员都知道视觉错觉和空间定向障碍的影响。然而，飞行员们不太相识的是，经常忽视的是仅仅抱病对驾驶舱内性能的影响。我们几乎全部人都曾带着病去上班，服用了非处方药，而且通常表现精良。然而，考虑到飞行员正在遭受平常的头部感冒。不幸的是，大多数飞行员以为头部感冒只是个小贫苦，利用非处方的抗组胺药、对乙酰氨基酚和其他非处方药就能轻松治愈。事实上，劈面对鼻塞时，飞行员通常只关心随着机舱高度的变化而产生的鼻窦阻塞的影响。然而，这并不是本地飞行外科医生所关心的明显症状。更令人担心的是，当进入仪器气象条件时，伴随而来的内耳感染和空间定向障碍的可能性增加，更不用说抗组胺药的副作用、疲劳和飞行员决策的睡眠不足。因此，任何安全专业职员都有责任在事件的因果链中解释这些偶尔微妙的医疗条件。
The effects of visual illusions and spatial disorientation are well known to most aviators. However, less well known to aviators, and often overlooked are the effects on cockpit performance of simply being ill. Nearly all of us have gone to work ill, dosed with over-the-counter medications, and have generally performed well. Consider however, the pilot suffering from the common head cold. Unfortunately, most aviators view a head cold as only a minor inconvenience that can be easily remedied using over-the counter antihistamines, acetaminophen, and other non-prescription pharmaceuticals. In fact, when confronted with a stuffy nose, aviators typically are only concerned with the effects of a painful sinus block as cabin altitude changes. Then again, it is not the overt symptoms that local flight surgeons are concerned with. Rather, it is the accompanying inner ear infection and the increased likelihood of spatial disorientation when entering instrument meteorological conditions that is alarming - not to mention the side-effects of antihistamines, fatigue, and sleep loss on pilot decision-making. Therefore, it is incumbent upon any safety professional to account for these sometimes subtle medical conditions within the causal chain of events.
2.2.1.3 Physical/Mental Limitations
身体/精神的限制。第三种也是末了一种不合标准的情况涉及个人的身体/精神限制。详细地说，这一类是指任务须要超出控制职员本领的情况。例如，人类的视觉系统在夜间受到严峻限制;然而，就像开车一样，司机不愿定要减速或接纳额外的预防措施。在航空范畴，固然减速并不总是一种选择，但额外关注根本的飞行准则和增加飞行里程往往会增加安全边际。不幸的是，假如不接纳预防措施，效果可能是劫难性的，因为飞行员经常会由于视野中物体的大小或对比度而看不到其他飞机、障碍物或电线。
Physical/Mental Limitations. The third, and final, substandard condition involves individual physical/mental limitations. Specifically, this cat egory refers to those instances when mission requirements exceed the capabilities of the individual at the controls. For example, the human visual system is severely limited at night; yet, like driving a car, drivers do not necessarily slow down or take additional precautions. In aviation, while slowing down isn’t always an option, paying additional attention to basic flight instruments and increasing one’s vigi lance will often increase the safety margin. Unfortunately, when precautions are not taken, the result can be catastrophic, as pilots will often fail to see other aircraft, obstacles, or power lines due to the size or contrast of the object in the visual field.
雷同地，偶尔完成一项任务或举措所需的时间超出了个人的本领。每个人处理和回应信息的本领差异很大。然而，精良的飞行员通常以其快速准确的反应本领而著称。然而，有充分的证据表明，假如要求个人迅速作出反应(即，有更少的时间来彻底考虑全部的可能性或选择)，出错的可能性就会显著增加。因此，劈面对快速处理和反应时间的须要时，就像大多数航空紧急情况一样，全部形式的错误都会加剧，这一点也不奇怪。
Similarly, there are occasions when the time re quired to complete a task or maneuver exceeds an individual’s capacity. Individuals vary widely in their ability to process and respond to information. Nevertheless, good pilots are typically noted for their ability to respond quickly and accurately. It is well documented, however, that if individuals are required to respond quickly (i.e., less time is available to consider all the possibilities or choices thoroughly), the probability of making an error goes up markedly. Consequently, it should be no surprise that when faced with the need for rapid processing and reaction times, as is the case in most aviation emergencies, all forms of error would be exacerbated.
除了上述根本的感官和信息处理限制，至少还有两个额外的生理/心理限制须要解决，尽管它们经常被大多数安全专业职员忽略。这些限制包罗那些根本不得当飞行的人，因为他们要么身体不得当飞行，要么没有飞行的本领。例如，一些人根本没有足够的体力在潜在的高G情况下飞行，或者由于人体丈量的原因，根本无法到达控制。换句话说，驾驶舱的计划传统上并没有考虑到全部的形状、大小和物理本领。同样，并不是每个人都有驾驶飞机的智力或资质。正如不是全部人都能成为音乐会钢琴家或美国橄榄球联盟的中后卫一样，并不是每个人都有驾驶飞机的天赋——这一职业须要在生命受到威胁的情况下做出快速决策和准确反应的独特本领。对于安全专业职员来说，困难的任务是确定是否资质可能导致了事故的因果次序。
In addition to the basic sensory and information processing limitations described above, there are at least two additional instances of physical/mental limitations that need to be addressed, albeit they are often overlooked by most safety professionals. These limitations involve individuals who simply are not compatible with aviation, because they are either unsuited physically or do not possess the aptitude to fly. For example, some individuals simply don’t have the physical strength to operate in the potentially high-G environment of aviation, or for anthropometric reasons, simply have difficulty reaching the controls. In other words, cockpits have traditionally not been designed with all shapes, sizes, and physical abilities in mind. Likewise, not everyone has the mental ability or aptitude for flying aircraft. Just as not all of us can be concert pianists or NFL linebackers, not everyone has the innate ability to pilot an aircraft – a vocation that requires the unique ability to make decisions quickly and respond accurately in life threatening situations. The difficult task for the safety professional is identifying whether aptitude might have contributed to the accident causal sequence.
2.2.2 Substandard Practices of Operators
显然，很多不符合标准的操作职员的条件可以而且确实导致不安全的举动。然而，我们对自己做了很多事情，造成了这些不合标准的条件。一样平常来说，操作员的不标准做法可以归纳为两类:机组资源管理不善和个人预备停当。
Clearly then, numerous substandard conditions of operators can, and do, lead to the commission of unsafe acts. Nevertheless, there are a number of things that we do to ourselves that set up these substandard conditions. Generally speaking, the substandard practices of operators can be summed up in two categories: crew resource mismanagement and personal readiness.
2.2.2.1 Crew Resource Mismanagement
机组资源管理不善。几十年来，精良的沟通本领和团队协调不停是工业/组织和人事心理学的咒语。不足为奇的是，机组资源管理在过去几十年里不停是航空航天的基石(Helmreich & Foushee, 1993)。因此，就产生了机组资源管理不善这一种别，以解释职员之间缺乏协调的情况。在航空方面，这包罗飞机内部和与空中交通管制设施和维修管制之间的协调，以及须要时与设施和其他支助职员的协调。但是空勤职员之间的协调并不仅限于飞行中的空勤职员。它还包罗在飞行前后与机组职员的简要和报告举行协调。
Crew Resource Mismanagement. Good communication skills and team coordination have been the mantra of industrial/organizational and personnel psychology for decades. Not surprising then, crew resource management has been a cornerstone of aviation for the last few decades (Helmreich & Foushee, 1993). As a result, the category of crew resource mismanagement was created to account for occurrences of poor coordination among personnel. Within the context of aviation, this includes coordination both within and between aircraft with air traffic control facilities and maintenance control, as well as with facility and other support personnel as necessary. But aircrew coordination does not stop with the aircrew in flight. It also includes coordination before and after the flight with the brief and debrief of the aircrew.
不难想象，由于机组职员缺乏协调，导致驾驶舱内的混乱和决策失误，从而导致事故发生的情景。事实上，航空事故数据库中充斥着机组职员之间缺乏协调的例子。更悲惨的例子之一是1972年一架民用飞机在佛罗里达沼泽地的夜晚坠毁，当机遇组职员正忙着排除信号灯烧坏的原因。不幸的是，驾驶舱里没有人在监控飞机的高度，因为高度保持不警惕断开了。理想情况下，机组职员应该协调解决题目的工作，确保至少有一名机组职员在监控根本的飞行准则和“驾驶”飞机。然而，事实并非如此，因为他们进入了一个缓慢的、不为人所知的沼泽地，导致了大量的死亡。
It is not difficult to envision a scenario where the lack of crew coordination has led to confusion and poor decision making in the cockpit, resulting in an accident. In fact, aviation accident databases are replete with instances of poor coordination among aircrew. One of the more tragic examples was the crash of a civilian airliner at night in the Florida Everglades in 1972 as the crew was busily trying to troubleshoot what amounted to a burnt out indicator light. Unfortunately, no one in the cockpit was monitoring the aircraft’s altitude as the altitude hold was inadvertently disconnected. Ideally, the crew would have coordinated the trouble-shooting task ensuring that at least one crewmember was monitoring basic flight instruments and “flying” the aircraft. Tragically, this was not the case, as they entered a slow, unrecognized, descent into the everglades resulting in numerous fatalities.
2.2.2.2 Personal Readiness
个人预备。在航空行业，或者在任何职业情况中，员工都应该预备好以最佳程度工作。然而，在航空行业，就像在其他行业一样，当个人在身体或精神上没有做好执勤预备时，就会出现个人预备不足的情况。例如，违背乘务职员休息要求、从bottle-to-brief rules和自我治疗都会影响工作表现，在飞机上尤其有害。不难想象，当个体违背机组休息要求时，就碰面对精神疲劳等不良心理状态的风险，最终导致错误和事故的发生。然而，须要注意的是，影响个人预备状态的违例举动并不被以为是“不安全举动，违例举动”，因为它们通常不会发生在驾驶舱内，也不愿定是具有直接和直接后果的主动故障。
Personal Readiness. In aviation, or for that matter in any occupational setting, individuals are expected to show up for work ready to perform at optimal levels. Nevertheless, in aviation as in other profes sions, personal readiness failures occur when individuals fail to prepare physically or mentally for duty. For instance, violations of crew rest requirements, bottle-to-brief rules, and self-medicating all will af fect performance on the job and are particularly detrimental in the aircraft. It is not hard to imagine that, when individuals violate crew rest requirements, they run the risk of mental fatigue and other adverse mental states, which ultimately lead to errors and accidents. Note however, that violations that affect personal readiness are not considered “unsafe act, violation” since they typically do not happen in the cockpit, nor are they necessarily active failures with direct and immediate consequences.
然而，并不是全部的个人预备失败都是由于违背管理规则或条例造成的。例如，在驾驶一架飞机之前跑10英里可能并不违背任何现有的规定，但它可能损害个人的身体和精神本领，足以降低表现，并引发不安全举动。同样，现代贩子传统的“糖果和可乐”午餐可能听起来不错，但可能不足以在严格的情况中维持业绩。固然可能没有规定这种举动，但飞行员在决定自己是否“得当”驾驶飞机时，必须有精良的判断力。
Still, not all personal readiness failures occur as a result of violations of governing rules or regulations. For example, running 10 miles before piloting an aircraft may not be against any existing regulations, yet it may impair the physical and mental capabilities of the individual enough to degrade performance and elicit unsafe acts. Likewise, the traditional “candy bar and coke” lunch of the modern businessman may sound good but may not be sufficient to sustain performance in the rigorous environment of aviation. While there may be no rules governing such behavior, pilots must use good judgment when deciding whether they are “fit” to fly an aircraft.
LevelTieTypeContentPreconditions for Unsafe ActsSubstandard Conditions of OperatorsAdverse mental statesChannelized attentionPreconditions for Unsafe ActsSubstandard Conditions of OperatorsAdverse mental statesComplacencyPreconditions for Unsafe ActsSubstandard Conditions of OperatorsAdverse mental statesDistractionPreconditions for Unsafe ActsSubstandard Conditions of OperatorsAdverse mental statesMental fatiguePreconditions for Unsafe ActsSubstandard Conditions of OperatorsAdverse mental statesGet-home-itisPreconditions for Unsafe ActsSubstandard Conditions of OperatorsAdverse mental statesHastePreconditions for Unsafe ActsSubstandard Conditions of OperatorsAdverse mental statesLoss of situational awarenessPreconditions for Unsafe ActsSubstandard Conditions of OperatorsAdverse mental statesMisplaced motivationPreconditions for Unsafe ActsSubstandard Conditions of OperatorsAdverse mental statesTask saturationPreconditions for Unsafe ActsSubstandard Conditions of OperatorsAdverse physiological statesImpaired physiological statePreconditions for Unsafe ActsSubstandard Conditions of OperatorsAdverse physiological statesMedical illnessPreconditions for Unsafe ActsSubstandard Conditions of OperatorsAdverse physiological statesPhysiological incapacitationPreconditions for Unsafe ActsSubstandard Conditions of OperatorsAdverse physiological statesPhysical fatiguePreconditions for Unsafe ActsSubstandard Conditions of OperatorsPhysical/Mental LimitationsInsufficient reaction timePreconditions for Unsafe ActsSubstandard Conditions of OperatorsPhysical/Mental LimitationsVisual limitationPreconditions for Unsafe ActsSubstandard Conditions of OperatorsPhysical/Mental LimitationsIncompatible intelligence/aptitudePreconditions for Unsafe ActsSubstandard Conditions of OperatorsPhysical/Mental LimitationsIncompatible physical capabilityPreconditions for Unsafe ActsSubstandard Practices of OperatorsCrew Resource MismanagementFailed to back-upPreconditions for Unsafe ActsSubstandard Practices of OperatorsCrew Resource MismanagementFailed to communicate/coordinatePreconditions for Unsafe ActsSubstandard Practices of OperatorsCrew Resource MismanagementFailed to conduct adequate briefPreconditions for Unsafe ActsSubstandard Practices of OperatorsCrew Resource MismanagementFailed to use all available resourcesPreconditions for Unsafe ActsSubstandard Practices of OperatorsCrew Resource MismanagementFailure of leadershipPreconditions for Unsafe ActsSubstandard Practices of OperatorsCrew Resource MismanagementMisinterpretation of traffic callsPreconditions for Unsafe ActsSubstandard Practices of OperatorsPersonal ReadinessExcessive physical trainingPreconditions for Unsafe ActsSubstandard Practices of OperatorsPersonal ReadinessSelf-medicatingPreconditions for Unsafe ActsSubstandard Practices of OperatorsPersonal ReadinessViolation of crew rest requirementPreconditions for Unsafe ActsSubstandard Practices of OperatorsPersonal ReadinessViolation of bottle-to-throttle requirement 2.3 Unsafe Supervision
监督不足。任何主管的脚色都是提供成功的机会。要做到这一点，主管，无论在什么级别的操作，必须提供指导，培训机会，领导和动机，以及适当的脚色模型，以供模仿。不幸的是，情况并非总是如此。例如，不难想象这样一种情况，即没有为某一特定的机组职员提供充分的机组职员资源管理培训，或者没有为某一特定的机组职员提供参加这种培训的机会。可以想象，机组职员的协调本领将受到损害，假如飞机被置于倒霉的情况(例如紧急情况)，出错的风险将会加剧，发生事故的可能性将显著增加。
Inadequate Supervision. The role of any supervisor is to provide the opportunity to succeed. To do this, the supervisor, no matter at what level of operation, must provide guidance, training opportunities, lead ership, and motivation, as well as the proper role model to be emulated. Unfortunately, this is not always the case. For example, it is not difficult to conceive of a situation where adequate crew resource management training was either not provided, or the opportunity to attend such training was not afforded to a particular aircrew member. Conceivably, aircrew coordination skills would be compromised and if the aircraft were put into an adverse situation (an emer gency for instance), the risk of an error being com mitted would be exacerbated and the potential for an accident would increase markedly.
同样，精良的专业指导和监督是任何成功组织的根本要素。固然赋予个人独立决策和运作的权利固然是须要的，但这并不会使监督者脱离责任。缺乏指导和监督已被证实是繁殖很多违规举动的温床，这些违规举动已经伸张到驾驶舱内。因此，任何对事故原因的彻底调查都必须考虑到监管在人为错误发生过程中所扮演的脚色(即监管是否不当或根本没有发生)
In a similar vein, sound professional guidance and oversight is an essential ingredient of any successful organization. While empowering individuals to make decisions and function independently is certainly essential, this does not divorce the supervisor from accountability. The lack of guidance and oversight has proven to be the breeding ground for many of the violations that have crept into the cockpit. As such, any thorough investigation of accident causal factors must consider the role supervision plays (i.e., whether the supervision was inappropriate or did not occur at all) in the genesis of human error
2.3.2 Planned Inappropriate Operations
筹划外的不当操作。偶尔，操作节奏和/或空乘职员的调度是这样的，个人被置于不可接受的风险，机组职员休息受到危害，并最终性能受到倒霉影响。在紧急情况下，这样的举措固然是不可制止的，但在正常的举措中是不可接受的。因此，第二类不安全的监督，筹划不当的操作，被创建来解释这些失败
Planned Inappropriate Operations. Occasionally, the operational tempo and/or the scheduling of air crew is such that individuals are put at unacceptable risk, crew rest is jeopardized, and ultimately perfor mance is adversely affected. Such operations, though arguably unavoidable during emergencies, are unac ceptable during normal operations. Therefore, the second category of unsafe supervision, planned inap propriate operations, was created to account for these failures
以机组配对不当的题目为例。众所周知，当非常高级、专横的机长与非常低级、本领较弱的副机长搭档时，很可能会出现沟通和协调题目。通常被称为跨座舱权威梯度，这样的条件可能导致了1982年1月一架商业客机在华盛顿特区外的波托马克河的悲剧坠毁(NTSB, 1982)。在那次事故中，当副机长指出发动机准则好像不正常时，机长多次对副机长举行了重击。机长绝不悲观，在结冰的条件下，以不足的起飞推力继续了一次致命的起飞。飞机失速，坠入结冰的河中，机组职员和很多乘客遇难。
Take, for example, the issue of improper crew pairing. It is well known that when very senior, dictatorial captains are paired with very junior, weak co-pilots, communication and coordination prob lems are likely to occur. Commonly referred to as the trans-cockpit authority gradient, such conditions likely contributed to the tragic crash of a commercial airliner into the Potomac River outside of Washing ton, DC, in January of 1982 (NTSB, 1982). In that accident, the captain of the aircraft repeatedly re buffed the first officer when the latter indicated that the engine instruments did not appear normal. Un daunted, the captain continued a fatal takeoff in icing conditions with less than adequate takeoff thrust. The aircraft stalled and plummeted into the icy river, killing the crew and many of the passengers.
很明显，机长长和机组成员都有责任。他们死于事故，无法分析原因;但是，这个监督链的作用是什么呢?大概机组成员配对同样负有责任。固然在报告中没有详细论述，但在很多事故中，这些题目显然是值得探讨的。事实上，在那次事故中，还发现了其他几个培训和职员配备题目。
Clearly, the captain and crew were held account able. They died in the accident and cannot shed light on causation; but, what was the role of the supervi sory chain? Perhaps crew pairing was equally respon sible. Although not specifically addressed in the report, such issues are clearly worth exploring in many acci dents. In fact, in that particular accident, several other training and manning issues were identified.
2.3.3 Failure to Correct a Known Problem
未能纠正已知题目。已知不安全监管的第三类，未纠正已知题目，指的是那些个人、设备、培训或其他相关安全范畴存在缺陷的情况，这些缺陷被主管“知道”，但被允许继续存在。例如，事故调查职员在一次致命的坠机事故后采访飞行员的朋友、同事和主管，效果却发现他们“知道这事总有一天会发生在他身上”，这种情况并不少见。假如主管知道一名飞行员没有本领安全飞行，但照旧允许他飞行，他显然没有给飞行员任何好处。无论是通过补救性培训，照旧在须要时取消飞行资格，都未能纠正这种举动，这意味着该飞行员已被判处死刑，更不用说机上其他乘客了。
Failure to Correct a Known Problem. The third category of known unsafe supervision, Failed to Cor rect a Known Problem, refers to those instances when deficiencies among individuals, equipment, training or other related safety areas are “known” to the supervisor, yet are allowed to continue unabated (Table 3). For example, it is not uncommon for accident investigators to interview the pilot’s friends, colleagues, and supervisors after a fatal crash only to find out that they “knew it would happen to him some day.” If the supervisor knew that a pilot was incapable of flying safely, and allowed the flight anyway, he clearly did the pilot no favors. The failure to correct the behavior, either through remedial train ing or, if necessary, removal from flight status, essen tially signed the pilot’s death warrant - not to mention that of others who may have been on board.
同样地，假如不能始终如一地纠正或束缚不适当的举动，肯定会繁殖不安全的气氛，促进违背规则的举动。亚维亚航空的历史是丰富的，有飞行员的报告，他们讲述了令人毛骨悚然的故事，他们的功绩和巡回低空飞行(污名昭著的“到过那里，做过那件事”)。固然对一些人来说很有趣，但它们经常用来宣传一种宽容和“高人一等”的观念，直到有一天有人冲破了地面低空飞行的记录!事实上，未能报告这些不安全倾向并接纳纠正举措，是未能纠正已知题目的又一个例子。
Likewise, the failure to consistently correct or disci pline inappropriate behavior certainly fosters an unsafe atmosphere and promotes the violation of rules. Avia tion history is rich with by reports of aviators who tell hair-raising stories of their exploits and barnstorming low-level flights (the infamous “been there, done that”). While entertaining to some, they often serve to promul gate a perception of tolerance and “one-up-manship” until one day someone ties the low altitude flight record of ground-level! Indeed, the failure to report these unsafe tendencies and initiate corrective actions is yet another example of the failure to correct known problems.
2.3.4 Supervisory Violations
违背监管规定。另一方面，违背监管举动只实用于那些被监管者故意无视的现有规则和规章的情况。尽管可以说是稀有的情况，但监管者在管理资产时偶尔会违背规则和原则。例如，在某些情况下，个人可以在没有现有资格或执照的情况下驾驶飞机。同样，也可以以为，未能执行现有的规章制度或炫耀权威也是监管层面的违法举动。尽管这种做法很少见，而且可能很难被剔除，但它公然违背了规则，并为可以预见的随之而来的悲惨事件奠定了根本。
Supervisory Violations. Supervisory violations, on the other hand, are reserved for those instances when exist ing rules and regulations are willfully disregarded by supervisors (Table 3). Although arguably rare, supervi sors have been known occasionally to violate the rules and doctrine when managing their assets. For instance, there have been occasions when individuals were permitted to operate an aircraft without current quali fications or license. Likewise, it can be argued that failing to enforce existing rules and regulations or flaunt ing authority are also violations at the supervisory level. While rare and possibly difficult to cull out, such practices are a flagrant violation of the rules and invari ably set the stage for the tragic sequence of events that predictably follow.
LevelTieTypeContentUnsafe SupervisionInadequate SupervisionFailed to provide guidanceUnsafe SupervisionInadequate SupervisionFailed to provide operational doctrineUnsafe SupervisionInadequate SupervisionFailed to provide oversightUnsafe SupervisionInadequate SupervisionFailed to provide trainingUnsafe SupervisionInadequate SupervisionFailed to track qualificationsUnsafe SupervisionInadequate SupervisionFailed to track performanceUnsafe SupervisionPlanned Inappropriate OperationsFailed to provide correct dataUnsafe SupervisionPlanned Inappropriate OperationsFailed to provide adequate brief timeUnsafe SupervisionPlanned Inappropriate OperationsImproper manningUnsafe SupervisionPlanned Inappropriate OperationsMission not in accordance with rules/regulationsUnsafe SupervisionPlanned Inappropriate OperationsProvided inadequate opportunity for crew restUnsafe SupervisionFailed to Correct a Known ProblemFailed to correct document in errorUnsafe SupervisionFailed to Correct a Known ProblemFailed to identify an at-risk aviatorUnsafe SupervisionFailed to Correct a Known ProblemFailed to initiate corrective actionUnsafe SupervisionFailed to Correct a Known ProblemFailed to report unsafe tendenciesUnsafe SupervisionSupervisory ViolationsAuthorized unnecessary hazardUnsafe SupervisionSupervisory ViolationsFailed to enforce rules and regulationsUnsafe SupervisionSupervisory ViolationsAuthorized unqualified crew for flight 2.4 Organizational Influences
如前所述，上层管理职员的错误决定直接影响监督实践，以及操作职员的条件和举措。不幸的是，这些组织错误经常被安全专业职员忽视，这在很大程度上是由于缺乏一个明确的框架来研究它们。一样平常来说，最难以捉摸的潜在失败围绕着与资源管理、组织氛围和操作过程相关的题目，如下图所示。
As noted previously, fallible decisions of upper-level management directly affect supervisory practices, as well as the conditions and actions of operators. Unfor tunately, these organizational errors often go unnoticed by safety professionals, due in large part to the lack of a clear framework from which to investigate them. Gen erally speaking, the most elusive of latent failures revolve around issues related to resource management, organi zational climate, and operational processes, as detailed below in Figure 5.
2.4.1 Resource Management
资源管理。这一类包含了关于组织资产(如人力资源(职员)、钱币资产和设备/设施)的配置和维护的公司级决策范畴。一样平常来说，关于怎样管理这些资源的企业决策围绕着两个截然不同的目标——安全目标和准时高效运营目标。在繁荣时期，这两个目标很容易得到均衡和充分满足。然而，正如我们前面提到的，也可能会有财务紧缩的时候，这两者之间须要一些妥协。不幸的是，历史告诉我们，在这样的战斗中，安全往往是输家，一些人可以很好地证实，在有财务困难的组织中，安全和培训往往是第一个被削减的。假如在这些范畴的削减太过严峻，飞行熟练程度可能会受到影响，最好的飞行员也可能脱离组织去寻找更好的工作。
Resource Management. This category encompasses the realm of corporate-level decision making regard ing the allocation and maintenance of organizational assets such as human resources (personnel), monetary assets, and equipment/facilities (Table 4). Generally, corporate decisions about how such resources should be managed center around two distinct objectives – the goal of safety and the goal of on-time, costeffective operations. In times of prosperity, both objectives can be easily balanced and satisfied in full. However, as we mentioned earlier, there may also be times of fiscal austerity that demand some give and take between the two. Unfortunately, history tells us that safety is often the loser in such battles and, as some can attest to very well, safety and training are often the first to be cut in organizations having financial difficulties. If cutbacks in such areas are too severe, flight proficiency may suffer, and the best pilots may leave the organization for greener pastures.
过度削减本钱还可能导致新设备的资金淘汰，或可能导致购买的设备不是最优的，计划不适当，以满足公司飞行的业务范例。其他涓滴效应包罗设备和工作区维护不善，以及无法纠正现有设备的已知计划缺陷。其效果是，在最不理想的条件和时间安排下，飞行员驾驶的是一种非海上航行的、技术程度较低的老式和维护不良的飞机。这对航空安全的影响并不难想象。
Excessive cost-cutting could also result in reduced funding for new equipment or may lead to the pur chase of equipment that is sub optimal and inad equately designed for the type of operations flown by the company. Other trickle-down effects include poorly maintained equipment and workspaces, and the failure to correct known design flaws in existing equipment. The result is a scenario involving unsea soned, less-skilled pilots flying old and poorly main tained aircraft under the least desirable conditions and schedules. The ramifications for aviation safety are not hard to imagine.
2.4.2 Climate
气候。组织气候是指影响员工绩效的一大类组织变量。在形式上，它被界说为“组织对待个人时基于情境的一致性”(Jones, 1988)。然而，一样平常来说，组织气氛可以被视为组织内部的工作气氛。一个组织氛围的一个标记就是它的布局，这反映在指挥链、授权和责任、沟通渠道和正式的举措问责制(表4)。就像在驾驶舱一样，沟通和协调在一个组织中是至关告急的。假如组织内部的管理层和员工没有沟通，或者没有人知道谁在负责，那么组织的安全显然会受到影响，事故也会发生(Muchinsky, 1997)。
Climate. Organizational Climate refers to a broad class of organizational variables that influence worker performance. Formally, it was defined as the “situationally based consistencies in the organization’s treatment of individuals” (Jones, 1988). In general, however, organizational climate can be viewed as the working atmosphere within the organization. One telltale sign of an organization’s climate is its structure, as reflected in the chain-of-command, delegation of authority and responsibility, communication chan nels, and formal accountability for actions (Table 4). Just like in the cockpit, communication and coordi nation are vital within an organization. If manage ment and staff within an organization are not communicating, or if no one knows who is in charge, organizational safety clearly suffers and accidents do happen (Muchinsky, 1997).
一个组织的政策和文化也是其气候的精良指标。政策是官方的指导方针，指导管理层在雇用和解雇、晋升、留任、加薪、病假、吸毒和酗酒、加班、事故调查和安全设备的利用等方面做出决定。另一方面，文化是指一个组织中非官方的或不成文的规则、价值观、态度、生活和习俗。文化是“在这里做事的真正方式”。当政策界说不清、敌对或辩论时，或者当它们被非正式的规则和价值观所取代时，组织内部就会布满混乱。事实上，有一些公司司理在公共论坛上很快就会对官方的安全政策“口惠而实不至”，但在幕后操作时却忽视了这些政策。然而，热力学第三定律告诉我们，“秩序和调和不能由这样的混乱和不调和产生”。在这种情况下，安全必然受到影响。
An organization’s policies and culture are also good indicators of its climate. Policies are official guidelines that direct management’s decisions about such things as hiring and firing, promotion, reten tion, raises, sick leave, drugs and alcohol, overtime, accident investigations, and the use of safety equip ment. Culture, on the other hand, refers to the unofficial or unspoken rules, values, attitudes, be liefs, and customs of an organization. Culture is “the way things really get done around here.” When policies are ill-defined, adversarial, or con flicting, or when they are supplanted by unofficial rules and values, confusion abounds within the orga nization. Indeed, there are some corporate managers who are quick to give “lip service” to official safety policies while in a public forum, but then overlook such policies when operating behind the scenes. However, the Third Law of Thermodynamics tells us that, “order and harmony cannot be produced by such chaos and disharmony”. Safety is bound to suffer under such conditions.
2.4.3 Operational Process
操作过程。这一类是指管理组织内部日常活动的公司决策和规则，包罗建立和利用标准化的操作程序，以及维护员工和管理层之间的制衡(监督)的非正常方法。例如，诸如操作节奏、时间压力、激励系统和工作时间表等因素都是会对安全产生倒霉影响的因素(表4)。如前所述，可能会有这样的情况，当一个组织的上层决定有须要增加操作的速率，以超出主管的职员配备本领。因此，主管可能会诉诸于利用不适当的调度程序，这将危及机组职员的休息，并产生次优的机组职员配对，使机组职员面对更大的事故风险。然而，组织应该有适当的官方程序来处理这些意外事件，以及监督筹划来监测这些风险。
Operational Process. This category refers to corporate decisions and rules that govern the everyday activities within an organization, including the establishment and use of standardized operating procedures and for mal methods for maintaining checks and balances (over sight) between the workforce and management. For example, such factors as operational tempo, time pres sures, incentive systems, and work schedules are all factors that can adversely affect safety (Table 4). As stated earlier, there may be instances when those within the upper echelon of an organization determine that it is necessary to increase the operational tempo to a point that overextends a supervisor’s staffing capabilities. Therefore, a supervisor may resort to the use of inad equate scheduling procedures that jeopardize crew rest and produce sub optimal crew pairings, putting aircrew at an increased risk of a mishap. However, organiza tions should have official procedures in place to address such contingencies as well as oversight pro grams to monitor such risks.
遗憾的是，并不是全部的组织都有这些程序，他们也没有到场到通过匿名报告系统和安全审计来监测机组职员错误和人为因素题目的积极过程中。因此，主管和司理往往在事故发生前就没有意识到题目。事实上，有人说“事故是很多人的一个事件”(Reinhart, 1996)。任何组织都有责任在“奶酪上的洞”创造劫难来袭的机会之窗之前，积极地寻找并堵住它们。
Regrettably, not all organizations have these pro cedures nor do they engage in an active process of monitoring aircrew errors and human factor prob lems via anonymous reporting systems and safety audits. As such, supervisors and managers are often unaware of the problems before an accident occurs. Indeed, it has been said that “an accident is one incident to many” (Reinhart, 1996). It is incumbent upon any organization to fervently seek out the “holes in the cheese” and plug them up, before they create a window of opportunity for catastrophe to strike.
LevelTieTypeContentOrganizational InfluencesResource/Acquisition ManagementHuman ResourcesSelectionOrganizational InfluencesResource/Acquisition ManagementHuman ResourcesStaffing/manningOrganizational InfluencesResource/Acquisition ManagementHuman ResourcesTrainingOrganizational InfluencesResource/Acquisition ManagementMonetary/budget resourcesExcessive cost cuttingOrganizational InfluencesResource/Acquisition ManagementMonetary/budget resourcesLack of fundingOrganizational InfluencesResource/Acquisition ManagementEquipment/facility resourcesPoor designOrganizational InfluencesResource/Acquisition ManagementEquipment/facility resourcesPurchasing of unsuitable equipmentOrganizational InfluencesOrganizational ClimateStructureChain-of-commandOrganizational InfluencesOrganizational ClimateStructureDelegation of authorityOrganizational InfluencesOrganizational ClimateStructureCommunicationOrganizational InfluencesOrganizational ClimateStructureFormal accountability for actionsOrganizational InfluencesOrganizational ClimatePoliciesHiring and firingOrganizational InfluencesOrganizational ClimatePoliciesPromotionOrganizational InfluencesOrganizational ClimatePoliciesDrugs and alcoholOrganizational InfluencesOrganizational ClimateCultureNorms and rulesOrganizational InfluencesOrganizational ClimateCultureValues and beliefs 写在末了
