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behavioural patterns which compromise safe operations.
d) Literature search. Whether the safety issues under examination have to do with particular
equipment, technology, maintenance, human performance, environmental factors, or organizational
and management issues, undoubtedly a great deal has already been written on the subject. Prior to
commencing a safety study, it may be appropriate to carry out a literature search on the issue under
consideration. Careful use of the Internet can provide a wealth of information.
e) Experts’ testimony. Direct contact with recognized subject matter experts may be warranted.
Experts may be contacted informally or be invited to provide more formal input through submissions
to a hearing or public inquiry.
f) Public inquiries. For major safety issues that must be considered from many perspectives, State
authorities may convene some form of public inquiry. This provides an opportunity for all
stakeholders (individually or as representatives of particular interest groups) to present their views
through an open, impartial process.
g) Hearings. Less formal meetings than public inquiries may be convened with a view to hearing the
different (and often divergent) views of the major aviation stakeholders. As opposed to a public
inquiry, the stakeholders are heard in camera (or private); in this way, they may be more candid in
stating their positions.
9.4 SIGNIFICANT SAFETY ISSUES LISTS (SILs)
9.4.1 Some State regulatory authorities, investigative agencies and large operators have found that
maintaining a list of high priority safety issues is an effective means for highlighting areas warranting further
study and analysis. These lists are known as significant safety issues lists (SILs); however, they are
sometimes referred to as the “Top Ten” or the “Most Wanted” lists. Such lists prioritize those safety issues
that put the aviation system (or the organization) at risk. As a result, they may be useful in identifying issues
for safety assessment, safety survey or safety study. If SILs are to be of value in guiding the work of those
involved in safety management, they must not chronicle every perceived hazard. They should be limited to
ten issues.
Chapter 9. Safety Analysis and Safety Studies 9-5
9.4.2 Typical issues that may warrant inclusion on a SIL are listed below:
a) frequency of ground proximity warning system (GPWS) warnings;
b) frequency of TCAS advisories;
c) runway incursions;
d) altitude deviations (busts);
e) call sign confusion;
f) unstabilized approaches; and
g) air proximities (near misses) at selected aerodromes.
9.4.3 SILs should be reviewed and updated annually, adding new high-risk issues and deleting lesserrisk
issues.
— — — — — — — —
9-APP 1-1
Appendix 1 to Chapter 9
UNDERSTANDING BIAS1
Everyone’s judgement is shaped by personal experience. Notwithstanding the quest for objectivity, time
does not always permit the collection and careful evaluation of sufficient data to ensure objectivity. Based on
a lifetime of personal experiences, we all develop mental models that generally serve us well in evaluating
everyday situations “intuitively”, without having all the facts. Unfortunately, many of these mental models
reflect personal bias. Bias is the tendency to apply a particular response regardless of the situation. The
following are some of the basic biases that can affect the validity of safety analyses:
a) Frequency bias. We tend to over- or underestimate the probability of occurrence of a particular
event because our evaluation is based solely on our personal experience. We assume that our
limited experience is representative of the global situation.
b) Selectivity bias. Our personal preferences cause a tendency to select items based on a restricted
core of facts. We have a tendency to ignore those facts which do not quite fit the pattern we expect.
We may focus our attention on physically important characteristics, or obvious evidence (e.g. loud,
bright and recent) and ignore cues that might provide more relevant information about the nature of
the situation.
c) Familiarity bias. In any given situation, we tend to choose the most familiar solutions and patterns.
Those facts and processes which match our own mental models (or preconceived notions) are more
easily assimilated. We tend to do things in accordance with the patterns of our previous experience,
even if they are not the optimum solutions for the current situation, e.g. the route we pick to go
somewhere may not always be the most efficient under changing circumstances.
d) Conformity bias. We have a tendency to look for results that support our decision rather than
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