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While using accident investigations to identify hazards is important, it is a reactive and costly method to
improve safety.
1:600 Rule
4.4.16 Research into industrial safety in 1969 indicated that for every 600 reported occurrences with
no injury or damage, there were some:
• 30 incidents involving property damage;
• 10 accidents involving serious injuries; and
• 1 major or fatal injury.
4.4.17 The 1-10-30-600 ratio shown in Figure 4-3 is indicative of a wasted opportunity if investigative
efforts are focused only on those rare occurrences where there is serious injury or significant damage. The
Figure 4-3. 1:600 Rule
1
10
30
600
Fatal accident
Serious
accidents
Accidents
Incidents
Chapter 4. Understanding Safety 4-7
factors contributing to such accidents may be present in hundreds of incidents and could be identified —
before serious injury or damage ensues. Effective safety management requires that staff and management
identify and analyse hazards before they result in accidents.
4.4.18 In aviation incidents, injury and damage are generally less significant than in accidents.
Accordingly, there is less publicity associated with these occurrences. In principle, more information
regarding such occurrences should be available (e.g. live witnesses and undamaged flight recorders).
Without the threat of substantial damage suits, there also tends to be less of an adversarial atmosphere
during the investigation. Thus, there should be a better opportunity to identify why the incidents occurred
and, equally, how the defences in place prevented them from becoming accidents. In an ideal world, the
underlying safety deficiencies could all be identified and preventive measures to ameliorate these unsafe
conditions could be initiated before an accident occurs.
4.5 CONTEXT FOR ACCIDENTS AND INCIDENTS
4.5.1 Accidents and incidents occur within a defined set of circumstances and conditions. These
include the aircraft and other equipment, the weather, the airport and flight services, as well as the
regulatory, industry and corporate operating climate. They also include the permutations and combinations
of human behaviour. At any given time, some of these factors may converge in such a way as to create
conditions that are ripe for an accident. Understanding the context in which accidents occur is fundamental
to safety management. Some of the principal factors shaping the context for accidents and incidents include
equipment design, supporting infrastructure, human and cultural factors, corporate safety culture and cost
factors. All of these factors are discussed in this section except for the cost factors which are covered in 4.8.
Equipment design
4.5.2 Equipment (and job) design is fundamental to safe aviation operations. Simplistically, the
designer is concerned with such questions as:
a) Does the equipment do what it is supposed to do?
b) Does the equipment interface well with the operator? Is it “user-friendly”?
c) Does the equipment fit in the allocated space?
4.5.3 From the equipment operator’s perspective, the equipment must “work as advertised”. The
ergonomic design must minimize the risk (and consequences) of errors. Are the switches accessible? Is
the controlling action intuitive? Are the dials and displays adequate under all operating conditions? Is the
equipment resistant to mistakes? (For example, “Are you sure you want to delete this file?”)
4.5.4 The designer also needs to consider the equipment maintainer’s perspective. There must be
sufficient space available to permit access for required maintenance under typical working conditions and
with normal human strength and reach limitations. The design must also incorporate adequate feedback to
warn of an incorrect assembly.
4.5.5 With advances in automation, design considerations become even more apparent. Whether it is
the pilot in the cockpit, ATCOs at their consoles, or an AME using automated diagnostic equipment, the
scope for new types of human errors has expanded significantly. Although increased automation has
reduced the potential for many types of accidents, safety managers now face new challenges induced by
that automation, such as the lack of situational awareness and boredom.
4-8 Safety Management Manual (SMM)
Supporting infrastructure
4.5.6 From the perspective of an operator or a service provider, the availability of adequate supporting
infrastructure is essential to the safe operation of aircraft. This includes the adequacy of the State’s
performance with respect to such matters as:
a) personnel licensing;
b) certification of aircraft, operators, service providers and aerodromes;
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Safety Management Manual (SMM) 安全管理手册(27)
