 The Course Human error is the main factor in most accidents. It would be wrong to conclude that human error indicates carelessness or incompetence. It is necessary to understand the underlying causes for human error in order to prevent its potentially catastrophic consequences. In the early 90s, analysis of accidents in complex system found the origin of conditions which led to human errors in managing organizational policies. The term “organizational accident” was coined for catastrophic events where a sequence of latent failures breached the system defences and led to final wrong human outcome. Managers need information, tools, and procedures to find out system failure that may cause human errors, to understand how they can breech defences, how they can be predicted and what can be done to reduce or manage them. The answer is a well structured safety management system. • It is a systematic, explicit and comprehensive process for managing operational risks. • A safety management system is woven into the fabric of an organization. It becomes part of the culture; the way people do their jobs. • A safety management system will provide an organization with the capacity to anticipate and address safety issues before they lead to an incident or accident. • A safety management system also provides management with the ability to deal effectively with accidents and near misses so that valuable lessons are applied to improve safety and efficiency. • The safety management system approach reduces losses and improves productivity. • Safety management systems require that responsibility and accountability for safety occur within the management structure of an organization. Who may attend the course This course is essentially arranged for personnel assigned to safety and safety-related positions in an airline, an aerodrome, an air navigation service provider, or a government regulatory body who have a need to either review, evaluate, build, or improve upon a safety management plan. It is appropriate for safety officer who wants a more effective, realistic approach to safety program and for managers and supervisors who have responsibility for controlling risk in all complex systems. Lecturers James Reason – Professor Emeritus - University of Manchester Paul Louis Arslanian - Director Bureau d'Enquêtes et d'Analyses pour la sécurité de l'aviation civile (France) Frank Taylor – Director Emeritus of Cranfield Aviation Safety Centre, College of Aeronautics, University of Cranfield Gavin McKellar – IFALPA Accident Analysis Chairman Maurizio Catino - University of Milan Bicocca Carlo Conte – Consultant on Quality Systems Marco Consalvo - Airport Management Director - Aeroporto Internazionale di Napoli Anna Masutti – University of Bologna Vittorio Pimpinelli – Member of the Performance Review Commission-Eurocontrol Francesco Preti - Performance Review Unit-Eurocontrol Marcello Ralli – Ralli Associates, Rome Franco Lodi – Master in Flight Safety – University of Bologna Aldo Carlo Pezzopane – Master in Flight Safety – University of Bologna Silvano Silenzi – Master in Flight Safety – University of Bologna Course topics - Management of complex hazardous systems - Safety Culture and senior management commitment - Human and Organizational Factors in Safety Management - Hazard Identification and Risk Management - Accident and Incident Reporting and Investigation - Documentation and references Course Timetable Click here to see timetable>> Abstracts Unsafe Acts & Their Management (8 hours) Human error: models, mechanisms, varieties, provoking circumstances. Maintenance errors. Violations: distinctive features, mechanisms, varieties, provoking circumstances. Types of rule-related behaviour. Error management: tools and principles. Comparisons with quality assurance and safety management systems. Models of system breakdown. Sentinel events in aviation. Tensions between production and protection. Safety culture: just culture, reporting culture, learning culture. On the nature of safety and resilience. What does a resilient organization look like? French and European experience in air accident investigation (3 hours) May a wreckage tell its own story? (3 hours) The author was invited to join an international team for further investigation into “Ustica DC-9 accident” some 10 years after the in flight break-up. Recovering wreckage from the deep sea, looking at previous finding and reassessing earlier evidence. Discussing old theories against new evidence. Investigator’s self-critical attitude and scientific approach. The element of truth and the probable cause. Focusing on Accident Prevention including Flight Data Monitoring (3 hours) The focus and balance of accident prevention and risk. Investigating for cause or prevention. The non-punitive Flight Data Analysis experience. Making sure the FDA is used with crew input and part on the Accident Prevention Program. Identifying and implementing -plus monitoring-accident prevention measures. Principles of Operation and a Risk Management Model. If “human” is the problem factor, humans are the solution (4 hours) Since long, in aviation (and other fields) error inducing mental processes are studied, design is more technologically oriented, relationships are analysed and improved, effective communication is fostered, equipment ergonomics is refined, organisational liaison are held in due consideration. All this has produced extraordinary results. Yet, all of a sudden, and periodically, in the aftermath of an accident we are facing again fundamental questions. Perhaps, it should be considered that all the above described resources refer only to human “surface”, perhaps the “Whys” reside more in depth. Here, it is not a question of an undue and imprudent raid on psychoanalysis; notwithstanding it should unwise a priori excluding the idea of better evaluate the deeply hidden elements of the operating man, elements emerging in many, too many, apparently inexplicable cases. Organizational models and accident etiology in complex systems (4 hours) Beyond human error. Organizational factors of accidents in complex systems. Socio-technical approach. Normal Accidents Theory and High Reliability Theory. Error inducing systems and vulnerable systems. Models and methods of analysis of errors and accidents. Three levels of failures: human, organizational, network. A new accident model for organizing safer systems. Tensions between safety and reliability. The basic concept of constraints. Beyond the blame culture: the learning organization. The Linate disaster and other cases study. Safety Management System Risk Analysis (3 hours) Safety performance review in European Air Navigation Services (2 hours) Performance framework, indicators and data flow Current status of the European safety performance review Integrated Management Systems (2 hours) Health, Safety, Quality, Environmental Protection, Social Accountability. Guide line and standards for IMS. Business through IMS implementation. Ethics and social accountability. Organization and management. Occurrence reporting and accident investigations (2 hours) ICAO rules and EC regulations on accident report and analysis. Occurrence reporting in European civil aviation. EC Directive 2003/42 International and national Regulatory frame in Civil Aviation (7 hours) ICAO SARPs and NAA Regulations aimed at Accident Investigation/Prevention. The accident prevention loop and Safety Management System. Cases study. Course Languages Italian and English During the whole Course, a simultaneous translation service Italian-English / English-Italian will be available. Course Director Prof. Franco Persiani – Dean of the II Faculty of Engineering - University of Bologna Teaching Programme Coordinator Capt. Franco Lodi (cell. 335-1806262) Certificate Participants will receive a certificate on successful completion of the course and earn 6 university credits.
Application Course fee: € 1.000,00. The notice for admission to the Course and the application forms can be downloaded from: www.unibo.it (look at the course "Gestione dei rischi: il ruolo del management nelle organizzazioni aeronautiche") Click here to read the English translation of the notice for admission >> The deadline for the admission application is the 21st of September 2005 (documentation must be sent by registered mail with return receipt, or by first-class post (“posta celere”) with return receipt and shall have to arrive no later than 21st September 2005). Italian or EU citizens with a diploma or degree attained abroad shall have to present a copy of the High School Diploma or University Degree certified by the diplomatic Representation, translated, accompanied by a statement of validity issued by the Italian diplomatic Representation or Consulate in the Country where the qualification was obtained. International applicants (citizens of non-Community countries living abroad) shall have to comply with the same provisions, but the documents must be sent directly by the Italian diplomatic Representation or Consulate in the country to: Università di Bologna Ufficio Master Via Zamboni 33 40126 BOLOGNA ITALY Click here to read the English translation of the application forms (1)(2)(3) Please, notice that the translated forms are not official documents; all foreign applicants must fill in the official forms in Italian. For any problem, please contact: chiara.mattarelli@isaers.com Course Location The Course will be held in the Aula Magna of the II Faculty of Engineering in Forlì, Via Fontanelle 40 (nearby Forlì Airport). how to reach the Faculty >> Hotel Accommodation click to see information >>
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