飞机管理指导方针 Aircraft management guidelines(73)

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There is no specific time limit for when accidents occurred. The guiding rule is to count all acci-dents that have occurred using current barriers or controls; i.e., current technology and processes. Accidents that occurred before a significant change in technology or process may be ignored, if the current technology and process would likely have prevented them.
Risk management
The industry consensus is that risks assessed as ‘High’ on this matrix demand actions to reduce the risk. Many companies use a structured approach to ensure that the actions taken to reduce risks to a tolerable level are indeed adequate. The use of a ‘bow-tie’ in such a structured approach is an industry best practice. The figure below gives a graphic depiction of the ‘bow-tie’ concept.

Bow ties should be developed for all High Risk hazards. In aviation, two generic hazardous events that should normally be addressed with a bow tie are release of an unairworthy aircraft and devia-tion from intended safe flight path. A bow tie should concisely document the barriers and controls in place to prevent the release of a hazard, and the recovery measures in place to minimize the con-sequences should the hazard be released. Cross references should be provided to link the reader to any other documents that define processes and procedures used to ensure the effectiveness of these barriers, controls, and recovery measures. The figure below suggests how many independent and effective measures should be in place for High, Medium, and Low Risk hazards.
Risk acceptance criteria
Control/Barrier
 High Risk
(Intolerable)
 Medium Risk
(Incorporate Risk Reduction Measures)
 Low Risk
(Manage for Continuous Improvement)
 
Threat
 Minimum of 3 independent, effective controls/barriers to be in place for each threat
 Minimum of 2 independent effective controls/barriers for each threat
 Minimum of 1 effective control/barrier for each threat
 
Consequence Recovery
 Minimum of 3 independent, effective recovery measures for each consequence
 Minimum of 2 independent, effective recovery measures for each consequence
 Minimum of 1 effective recovery measure for each consequence
 
Escalation
 Minimum of 2 independent effective controls/barriers for each escalation factor
 Minimum of 1 effective control/barrier for each escalation factor
 Minimum of 1 effective control/barrier for each escalation factor
 

The most important word in the above risk acceptance criteria is ‘effective.’ Effectiveness should be based on demonstrated performance. Where barriers and controls depend on human actions, they should be complemented by training and competence assurance processes.
Bow ties not only assist in proactively establishing the barriers, controls, and recovery measures nec-essary to manage risks, they offer a frame of reference for understanding how hazardous events (inci-dents and accidents) occur and for refining the barriers, controls, and recovery measures to prevent recurrence. Used in this way, bow ties can be continuously improved with experience.
　
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