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built into the aviation system to protect against inappropriate performance or poor decisions at all levels of
the system (i.e. the front-line workplace, the supervisory levels and senior management). This model shows
that while organizational factors, including management decisions, can create latent conditions that could
lead to an accident, they also contribute to the system’s defences.
4.4.10 Errors and violations having an immediate adverse effect can be viewed as unsafe acts; these
are generally associated with front-line personnel (pilots, ATCOs, AMEs, etc.). These unsafe acts may
penetrate the various defences put in place to protect the aviation system by company management, the
regulatory authorities, etc., resulting in an accident. These unsafe acts may be the result of normal errors, or
they may result from deliberate violations of prescribed procedures and practices. The model recognizes
that there are many error- or violation-producing conditions in the work environment that may affect
individual or team behaviour.
4.4.11 These unsafe acts are committed in an operational context which includes latent unsafe
conditions. A latent condition is the result of an action or decision made well before an accident. Its
consequences may remain dormant for a long time. Individually, these latent conditions are usually not
harmful since they are not perceived as being failures in the first place.
4.4.12 Latent unsafe conditions may only become evident once the system’s defences have been
breached. They may have been present in the system well before an accident and are generally created by
decision-makers, regulators and other people far removed in time and space from the accident. Front-line
Chapter 4. Understanding Safety 4-5
Figure 4-2. Accident causation model
(Adapted from Prof. James Reason)
operational personnel can inherit defects in the system, such as those created by poor equipment or task
design; conflicting goals (e.g. service that is on time versus safety); defective organizations (e.g. poor
internal communications); or bad management decisions (e.g. deferral of a maintenance item). Effective
safety management efforts aim to identify and mitigate these latent unsafe conditions on a system-wide
basis, rather than by localized efforts to minimize unsafe acts by individuals. Such unsafe acts may only be
symptoms of safety problems, not causes.
4.4.13 Even in the best-run organizations, most latent unsafe conditions start with the decisionmakers.
These decision-makers are subject to normal human biases and limitations, as well as to very real
constraints of time, budget, politics, etc. Since some of the unsafe decisions cannot be prevented, steps
must be taken to detect them and to reduce their adverse consequences.
4.4.14 Fallible decisions by line management may take the form of inadequate procedures, poor
scheduling or neglect of recognizable hazards. They may lead to inadequate knowledge and skills or
inappropriate operating procedures. How well line management and the organization as a whole perform
their functions sets the scene for error- or violation-producing conditions. For example, how effective is
management with respect to setting attainable work goals, organizing tasks and resources, managing dayto-
day affairs, and communicating internally and externally? The fallible decisions made by company
management and regulatory authorities are too often the consequence of inadequate resources. However,
avoiding the costs of strengthening the safety of the system can facilitate accidents that are so expensive as
to bankrupt the operator.
Incidents: precursors of accidents
4.4.15 Regardless of the accident causation model used, typically there would have been precursors
evident before the accident. All too often, these precursors only become evident with hindsight. Latent
Accident
Crew/Team Defences Outcome
Errors
and
violations
Error- and
violationproducing
conditions
Workplace
Organization
and
management
decisions
Organization
Defences put in place by aviation system
Unsafe acts
4-6 Safety Management Manual (SMM)
unsafe conditions may have existed at the time of the occurrence. Identifying and validating these latent
unsafe conditions require an objective, in-depth risk analysis. Although it is important to fully investigate
accidents with high numbers of fatalities, it may not be the most fruitful means for identifying safety
deficiencies. Care must be taken to ensure that the “blood priority” (often prevalent in the media after
significant loss of life) does not detract from a rational risk analysis of latent unsafe conditions in aviation.
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Safety Management Manual (SMM) 安全管理手册(26)
