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caused, or had the potential to cause, signifi cant
problems to the function or effectiveness of that
system.
6. A minor incident is defi ned by CAA as an isolated occurrence
or defi ciency not indicative of a signifi cant
system problem.
7. An airspace incident is defi ned by CAA as an incident
involving deviation from, or shortcomings of,
the procedures or rules for (1) avoiding collisions
between aircraft or (2) avoiding collisions between
aircraft and other obstacles when an aircraft is being
provided with an air traffi c service.
8. A defect incident is defi ned by CAA as an incident that
involves failure or malfunction of an aircraft or aircraft
component, whether found in fl ight or on the ground.
Table 3
Six-month Comparison, Defect Incidents, New Zealand, 2003–2004
Aircraft Group
(Maximum Takeoff Weight)
Number of Incidents Change in Incidents
Jan. 1, 2003 to
June 30, 2003
Jan. 1, 2004 to
June 30, 2004 Number Percentage
13,608 kilograms/30,000 pounds or greater 199 283 +84 +42
5,670 kilograms/12,500 pounds to 13,608 kilograms 29 38 +9 +31
Helicopters 38 57 +19 +50
Total 266 378 +112 +42
Note:
A defect incident is defi ned as an incident that involves failure or malfunction of an aircraft or aircraft component,
whether found in fl ight or on the ground.
Source: Civil Aviation Authority of New Zealand
Table 2
Six-month Comparison, Airspace Incidents, New Zealand, 2003–2004
Aircraft Group
(Maximum Takeoff Weight)
Number of Incidents Change in Incidents
Jan. 1, 2003 to
June 30, 2003
Jan. 1, 2004 to
June 30, 2004 Number Percentage
13,608 kilograms/30,000 pounds or greater 39 47 +8 +21
5,670 kilograms/12,500 pounds to 13,608 kilograms 30 25 –5 –17
Helicopters 15 17 +2 +13
Total 84 89 +5 +6
Note:
An airspace incident is defi ned as an incident involving deviation from, or shortcomings of, the procedures or rules for
(1) avoiding collisions between aircraft or (2) avoiding collisions between aircraft and other obstacles when an aircraft
is being provided with an air traffi c service.
Source: Civil Aviation Authority of New Zealand
STATS
4 2 FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • JUNE 2005
PUBLICATIONS
RECEIVED AT FSF JERRY LEDERER
AVIATION SAFETY LIBRARY
Barriers Help Contain
Multiple-failure Accidents
Barriers are critical design elements for safety because they offer double benefits,
the author says. They can prevent a failure or can lessen the consequences if a
failure occurs. Moreover, they offer some protection against multiple failures that
are difficult to anticipate because there are so many potential combinations.
– FSF LIBRARY STAFF
Books
Barriers and Accident Prevention. Hollnagel,
Erik. Aldershot, England: Ashgate Publishing,
2004. 242 pp. Tables, fi gures, bibliography,
indexes.
The book examines many theoretical models
of accident causation, but emphasizes ideas
that the author believes will be useful for readers
who are in a position to change operating
practices.
“A barrier is, generally speaking, an obstacle, an
obstruction or a hindrance that may either (1)
prevent an event from taking place or (2) thwart or
lessen the impact of the consequences if it happens
nonetheless,” says the author. “In the former case,
the purpose of the barrier is to make it impossible
for a specifi c action or event to occur. In the latter
case, the barrier serves, for instance, to slow down
uncontrolled releases of matter and energy, to limit
the reach of the consequences or to weaken them
in other ways.”
Accidents rarely happen today because of a single
failure in advanced technological systems, the
author says; engineers and designers have learned
to guard against the failure of individual devices
or systems.
“This, however, does not rule out accidents that
happen when two or more failures occur together,
as when a simple performance failure combines
with a weakened or dysfunctional barrier,” the author
says. “Such combinations are much harder
to predict than single failures, and therefore also
harder to prevent. Since the number of combinations
of single failures can be exceedingly large, it
is usually futile to prevent multiple-failure accidents
by a strict elimination of individual causes.
A much more effi cient solution is to make use of
barriers, since the effectiveness of a barrier does
not depend on knowing the precise cause of the
event.”
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