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evaluating any particular unsafe condition, the views of others, including peers and specialists,
should be sought. A multidisciplinary team formed to evaluate evidence of an unsafe condition can
also assist in identifying and evaluating the best course for corrective action.
f) Cost-benefit analysis. The acceptance of recommended risk control measures may be dependent
on credible cost-benefit analyses. The costs of implementing the proposed measures are weighed
against the expected benefits over time. Sometimes, cost-benefit analysis may suggest that
accepting the risk is preferable to the time, effort and cost necessary to implement corrective action.
9.3 SAFETY STUDIES
9.3.1 Some complex or pervasive safety issues can best be understood through an examination in the
broadest possible context. Safety concerns of a global nature may be addressed on an industry- or Statewide
scale. For example, the industry has been concerned with the frequency and severity of approach and
landing accidents and has undertaken major studies, made many safety recommendations and implemented
global measures to reduce the risks of accidents during the critical approach and landing phases of flight.
The convincing argument necessary to achieve large-scale or global changes requires significant data,
appropriate analysis and effective communication. Safety arguments based on isolated occurrences and
anecdotal information will not succeed.
9.3.2 In this manual, these larger, more complex safety analyses are referred to as “safety studies”.
The term includes many types of studies and analyses conducted by State authorities, airlines,
manufacturers, and professional and industry associations. ICAO recognizes that safety recommendations
may arise not only from the investigation of accidents and serious incidents but also from safety studies.2
Safety studies have application to hazard identification and analysis in flight operations, maintenance, cabin
safety, air traffic control, airport operations, etc.
9.3.3 Safety studies of industry-wide concerns generally require a major sponsor. The Flight Safety
Foundation, in collaboration with major aircraft manufacturers, ICAO, NASA and other key industry
stakeholders, has taken a leading role in many such studies. Civil aviation authorities of specific States have
also conducted major safety studies, thereby identifying safety risks of global interest. In addition, several
State authorities have used safety studies to identify and resolve hazards in their national aviation systems.
Although it is unlikely that small or medium-sized operators would undertake a major safety study, large
operators and regulatory officials may be involved in identifying systemic safety issues.
Selecting study issues
9.3.4 Large operators, manufacturers, safety organizations and regulatory authorities may maintain
significant safety issues lists (SILs). (The topic of maintaining SILs can be found in 9.4.) These lists may be
based on the accident and incident record in such areas as runway incursions, ground proximity warnings,
and traffic alert and collision avoidance system (TCAS) advisories. The safety issues may be prioritized in
terms of the risks to the organization or the industry.
9.3.5 Given the degree of collaboration and sharing of information necessary to conduct an effective
safety study, issues selected for study must have a broad base of support among participants and
contributors.
2. See Annex 13, Chapter 8.
9-4 Safety Management Manual (SMM)
Information gathering
9.3.6 The methods outlined below are available for acquiring the information to support a safety study:
a) Review of occurrence records. Investigated occurrences may be reviewed by selecting those
occurrences which meet some pre-defined characteristics, such as runway incursions or crew
fatigue. By reviewing all available material on file, specific elements may be identified that are
suitable for further analysis.
b) Structured interviews. Useful information can be acquired through structured interviews. While
they can be time-consuming, interviews offer the potential for acquiring quality information, even if
there is not a statistically representative sample. Success will depend on the ability of the analyst to
reduce large amounts of anecdotal information to useful data.
c) Directed field investigations. Investigations of relatively insignificant occurrences (which might
normally not be investigated) may uncover sufficient additional information to permit a more in-depth
analysis. Although not many of these investigations when considered individually contribute much to
the collective knowledge of the factors contributing to such occurrences, collectively they may reveal
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