The Regulator's Lot

[...] risk. Quick Review Our typical bow-tie model consists of one or more threats leading to a single top event which results in one or more consequences. The idea is to insert your controls into these [...]

[...] assess one’s exposure to the identified threats. Rethinking Influence On the other side of the top event, let’s look at the criticality of the consequences. In an earlier post, I had used the term [...]

[...] to be things like education and promotion related to the primary line controls. Not all defeating factors, however, are latent conditions. I can think of a few that are events or situations related [...]

[...] there to be three primary things – threats, consequences and controls (including defeating factors and secondary line controls). Therefore, I propose we assess a BT based on: our [...]

[...] is very important to consider this a part of categorising your controls because a bow-tie diagram has the potential to overly constrain your thinking. As I mentioned previously, a [...]

[...] when complex systems appear simple. In the last BT post I wrote, I did highlight that a bow-tie diagram is only ever a model of reality. I think it would be inappropriate to evaluate it using an [...]

[...] The week before last, I finished a 4-year stint with the aviation safety regulator. Even though I’m heading back to industry, I’m not going to stop writing this blog. I [...]

[...] When I joined the aviation safety regulator I was introduced to the concept of systems-based auditing (SBA). Before this I had been [...]

Recently, I sat in on a presentation on a subject I know quite a bit about. I like doing this as it is typically good to get a different perspective o [...]

The week before last, I finished a 4-year stint with the aviation safety regulator. Even though I’m heading back to industry, I’m not going to sto [...]

[...] is still alive. We seem to have slid back into the days of pointing the finger at the front-line operator, stamping the label of “cause” upon them, punting them into touch, dusting our hands and [...]

[...] firing of the heart muscles to use the blood that flows through the system. Much like the front-line operator doesn’t need to understand all the machinations of an SMS to use the processes and [...]

[...] should be extended to try to capture the non-linear, close-coupled nature of  complex socio-technical systems like aviation. The “Post-Reason” world may be upon us but I don’t think it is [...]

[...] view of personal responsibility when we are dealing with accidents in complex socio-technical systems, such as aviation. I’m just going to come out and say it: No one, who [...]

[...]  Rural and Regional Affairs and Transport References Committee’s inquiry into Aviation Accident Investigations. Before I comment, some disclaimers – I’m not going to comment on the [...]

[...] -unwashed ;). To look examine this, I thought I’d look at MSM coverage of aviation accident investigations in Australia. So, I took to Google and searched for pages related to three [...]

[...] and I’ve made a few tweaks to suit the more socio-technical system of which, an aviation organisation is likely to consist. Now, let me introduce you… I’ll go through the components of [...]

[...] to assess risk. They also score risk on maximum foreseeable loss. That scale puts most aviation activities into the highest risk bucket straight away. No complex probability calculations required. [...]