Airline ground operations are subject to the conflicting demands of short turn-around times and safety requirements. They involve multiple parties, but are less regulated than airborne processes. Not surprisingly, more than a quarter of all aircraft incidents occur on the ground. These incidents lead to aircraft damage and associated costs, risk of injuries, and can potentially impact in-flight safety. KLM Ground Services has targeted platform safety performance as an area for improvement. However, existing safety awareness programs have had limited effect. A direct link between safety culture surveys and safety performance has not been established, and therefore these are insufficient to give adequate feedback on interventions. Newly developed by the Texas University are the Line Operations Safety Assessments (LOSA), first targeted at cockpit operations. Variants are available since October 2010 for the platform and maintenance environments. The research group for Aviation Engineering at the Amsterdam University of Applied Sciences has used the original platform LOSA material and tailored these to the specific circumstances at KLM. Results to date show that with these modifications, platform LOSA is a useful tool to quantify safety performance and to generate trend data. The effect of safety interventions can now be monitored. Referentie de Boer, R.J., Koncak, B., Habekotté, R., & van Hilten, G.J. (2011), Introduction of ramp-LOSA at KLM Ground Services , Human Factors and Ergonomics Society Annual Meeting, Leeds, United Kingdom
This paper proposes an amendment of the classification of safety events based on their controllability and contemplates the potential of an event to escalate into higher severity classes. It considers (1) whether the end-user had the opportunity to intervene into the course of an event, (2) the level of end-user familiarity with the situation, and (3) the positive or negative effects of end-user intervention against expected outcomes. To examine its potential, we applied the refined classification to 296 aviation safety investigation reports. The results suggested that pilots controlled only three-quarters of the occurrences, more than three-thirds of the controlled cases regarded fairly unfamiliar situations, and the flight crews succeeded to mitigate the possible negative consequences of events in about 71% of the cases. Further statistical tests showed that the controllability-related characteristics of events had not significantly changed over time, and they varied across regions, aircraft, operational and event characteristics, as well as when fatigue had contributed to the occurrences. Overall, the findings demonstrated the value of using the controllability classification before considering the actual outcomes of events as means to support the identification of system resilience and successes. The classification can also be embedded in voluntary reporting systems to allow end-users to express the degree of each of the controllability characteristics so that management can monitor them over time and perform internal and external benchmarking. The mandatory reports concerned, the classification could function as a decision-making parameter for prioritising incident investigations.
BackgroundTo use advanced medical technologies (AMTs) correctly and safely requires both specialist knowledge and skills, and an awareness of risks and how those can be minimized. Reporting safety concerns about AMTs in home care can contribute to an improved quality of care. The extent to which a health care organization has integrated the reporting, evaluation and learning from incidents is a key element of that organization's patient safety culture.ObjectivesTo explore nurses' experiences regarding the education followed in the use of AMTs in the home setting, and their organizations' systems of reporting.DesignDescriptive cross-sectional design.Methods209 home care nurses from across the Netherlands who worked with infusion therapy, parenteral nutrition and/or morphine pumps responded to the online questionnaire between July 2018 and February 2019. The analysis of the data was mainly descriptive.ResultsEducational interventions that are most often used to learn how to use AMTs were, as an average over the three AMTs, instruction by a nurse (71%), practical training in the required skills (71%) and acquiring information to increase theoretical knowledge (69%). Considerable attention is paid to patient safety (88%) and the home setting (89%). However, a substantial proportion of the nurses (up to 29%) use AMTs even though they had not been tested on their skills. 95% of the respondents were well acquainted with the incident reporting protocol of their organization, but only 49% received structural or regular feedback on any actions taken as a result of event reporting.ConclusionsThis study revealed aspects of nurses' education that imply risk factors for patient safety. Practical training is not always given, additional or retraining is often voluntary, and the required skills are not always tested. However, the results show that nurses do have a good awareness of patient safety. Incidents are mainly discussed within the team, but less at the organizational level.
