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Background Information Beijing, China, October 15th According to Voices of China's "News Story" report, at noon on October 11th, a thrilling scene occurred at Shanghai Hongqiao Airport. An A320 passenger plane slipped out of the runway and was about to take off. The A330 passenger plane is crossing the runway. After discovering this situation, the A320 passenger plane took off in an emergency and swept past the A330 to avoid a collision accident.
On the afternoon of October 14, the Civil Aviation Administration held an emergency video conference to inform the preliminary conclusions of the 1011 accident investigation. This is a serious human-caused incident caused by a tower controller's forgotten aircraft dynamics and violations of work standards. In the accident, the shortest vertical distance between the two aircraft was only 19 meters and the wingtip was 13 meters away. The 330 units had SOP problems; the 320 units were treated with decisive actions and avoided accidents.
According to the report, this is a man-cause serious incident caused by a tower controller's forgetting the dynamics of the aircraft and violating the work standards. The nature is extremely serious. It belongs to the category A runway incursions and almost crashes. At that time, the distance between the two aircraft was only 19 meters vertically, and the wing tip distance was 13 meters. The 320 units decisively handled and operated correctly and avoided an accident. After the 330 crew accepted the wrong instruction to cross the runway, although they saw the plane taking off, they did not question it.
According to the notification, the controller violated the relevant regulations, blindly directed, and the dual-accounting system was not implemented properly; professional qualifications were of the highest priority; self-control capabilities must be kept up; management tools and work processes were problematic; they must be systematically considered and improved. .
The circular also mentioned that there was a problem with the SOP in Unit 330. It was not observed properly and the answering machine was not closed as required. With the co-pilot, he did not know that Eastern Airlines had crossed the runway. No cross-checks, no mutual confirmation. However, the crew did not mechanically obey the tower and waited for the command in place, accelerated the crossing, avoided the collision between the two planes, and exposed the training problems. 320 crews were in place, making critical decisions and working hard. The co-pilot maneuvered hesitantly, clicking on the brakes, and the captain quickly took over the maneuver to bring the rod to the mechanical stop at a rate of 7.03 degrees per second.
Key points analysis According to CAA's investigation results, the main causes of danger appeared in the tower control crew and the A330 unit that traversed the crew. The problem is caused by problems in multiple links during the implementation process. If only the ATC has forgotten the aircraft dynamics, the A330 will operate strictly according to the SOP. If the observation goes to a dynamic and cross-check, it will not be able to form an invasion on the runway where the aircraft took off. If there is a problem with a single link, other links can effectively make up for it. This is a more mature security system. As we all know, the aviation system’s management system and safety system must be relatively strict. Therefore, the Civil Aviation Administration of China has taken punitive measures against the personnel involved in the accident and has given punishment to the leader of the tower in the main area of ​​responsibility and has also reflected the management of the tower. The fact that loopholes require serious and urgent remedy.
Standard Operation Plan (SOP=SOP=Standard Operation Plan) In this incident, a term that may be unfamiliar to the outdoor industry is reflected in our sight: SOP, which means the standard operating procedure. The so-called standard, here is the concept of optimization, that is not just written out of the operating procedures can be called S P, but must be through the practice of summing up under the current conditions can be achieved in the optimization of the operating program design. To put it more plainly, the so-called standard is to refine, quantify, and optimize relevant operating steps as much as possible. The degree of refinement, quantification, and optimization is understood by everyone under normal conditions without ambiguity.
In traditional enterprises such as manufacturing, SOP is a must-have management tool. However, in the outdoor industry, standardized management is still in its infancy. A few top outdoor institutions have a relatively complete management system and a large number of standardized processes, and the vast majority of clubs may not be faced with the implementation of the problem, but there is no SOP problem, and many aspects of the operation have no rules. Follow the instructions and rely on personal experience to issue instructions and maintain daily operations. However, the instructions are unreliable (in case there is a lack of experience?), instability (for the same link, the last time and this time may issue different instructions) and not easy to obtain (to repeatedly ask who said the instructions, When did you say, he said it?
SOP has several features: people who meet the basic requirements of the job can read it, perform it repeatedly, and easily obtain it. Just can solve the deficiencies of arbitrary instructions. Outdoor activities belong to industries with relatively high risks. As managers, they need to formulate operational procedures for key business steps and provide the basis for the orderly conduct of business operations. In fact, it is not difficult to formulate an SOP. It is to sort out and review the familiar operation steps, and to document, standardize, and share it with related personnel.
How to formulate outdoor activities SOP outdoor activities include a wide range, each project's operation process is not the same. Relatively high risks, such as high altitude mountaineering, rock climbing, ice climbing, canoeing, paragliding, etc., generally have relatively strict technical requirements and operating procedures, as well as more stringent practitioners' requirements, but are not prone to accidents. On the contrary, popular outdoor activities such as trekking, camping, adventure and upstream activities are more prone to problems. The root cause is not the participation of people, but whether the employees and institutions have better management and risk control mechanisms.
We took Yanmengxia, a technical upstream activity, as an example to explain how to turn experience into SOP. An experienced manager or operator familiar with the club’s announcement of the Yanmeng Gorge program simply requires the following steps:
Understand the conditions and characteristics of the route, resource information such as traffic/ground/wizard, analyze the possibility of opening lines, formulate open-line plans to conduct risk assessment on the line, and understand the weather, terrain, distance, environment, rescue, flora and fauna, water conditions, etc. The risk factors determine the leader’s technical requirements, experience requirements, equipment requirements, team members’ entry thresholds, number restrictions, personal equipment requirements for event posting, publicity, interaction with interested players to answer questions, and registration operations urge team members to do equipment and risk. Responses and preparations for pre-trip inspections: public facilities, personal equipment, physical conditions, line weather, ground resources, traffic conditions, etc. Travel, control of formation, management personnel and equipment during activities, and attention to environmental impacts, etc. Organize equipment, collect feedback, settle accounts, return, return equipment
The above steps are only 1-8. The experienced managers or operators may be familiar with the specific time period for each step, and how to do each step is appropriate. However, when writing an SOP, it is necessary to consider that people who read SOPs or who want to do things based on SOPs may not understand some of the details and requirements. Therefore, each step needs to be further refined and standardized so that everyone can read it. Understand, operational SOP.
Take the third step as an example: When determining the technical requirements of the leader, we know that the line needs to drop the rope 2 times, the road rope 2 times, and it must dive 4 times. Therefore, the experienced leader is not suitable to be written in the SOP when the leader is scheduled because it is a vague and subjective concept. The only thing to be written into the SOP is that the team leader must be familiar with the setting of the declining protection station and the drop in the number of people, and have independent practical experience and familiarity with water-based and so on. The staffing ratio cannot be said to be equipped with enough team leaders, but the proportion of team leaders and team members that are clearly required to meet requirements is not less than 1:15, and is supplemented with at least 1-3 support staff/collaborators.
The requirements for team members can not be judged by old donkeys, but can be written as quantifiable standards. For example, they need to have experience in upstream rivers, can swim in water to self-propel, have experience in rope drop, receive pre-training training, and wear life jackets. Protective equipment such as helmets, seat belts, descenders, main locks and gloves.
Based on this idea, the steps in each experience are refined and documented to form a written S P .
5Why approach to analyze the root cause of the problem In the case cited by Wenshou, the Civil Aviation Administration pointed out several reasons for the occurrence of the accident. We have listed the following reasons and classified the cause of the accident in brackets: The controller violated relevant regulations and blindly directed ( Personnel) Double-occupation system responsibilities Responsible for the implementation of incomplete (management) management tools and work processes There are problems, we must consider the reasons systematically, to improve (management) 330 units SOP problems, poor observation (personnel) 330 units do not follow the rules, close The transponder (personnel) 330 crew took the left co-pilot and did not know that Eastern Airlines crossed the runway program, did not cross check, and did not confirm each other (personnel) The 330 crew did not mechanically obey the tower and waited for the command in place, accelerated the crossing and avoided the collision of the two planes. , exposing training problems (personnel)
In the news, only the apparent cause of the accident was given. We have seen that if only a single person fails to operate, it will not be enough to cause such a serious situation. In addition to personnel errors, there are many missing links that reflect the problems of tower management. Therefore, the Civil Aviation Administration has also made a removal from the leadership of the tower. However, if the follow-up accident analysis only stops here, I am afraid we can not find out the underlying causes and prevent them from happening again.
The 5why approach to analyzing an incident allows us to identify the root cause of the incident. That is why the first cause of the accident was caused and asked why. Let us implement this approach for the above reasons and see what results can be obtained. Let's take the first one as an example:
The same method can analyze the deep-seated causes of the other seven surface problems and dig out the dozens of factors that caused the accident. The next step is to improve each factor, so as to effectively improve the management system and greatly reduce the occurrence of The probability of an accident. It should be noted that the 5why 5 is not absolute, and sometimes it may take more than 5 excavations. Sometimes it may be possible to dig the roots two or three times. This is a relative degree and it cannot be dogmatic.
We also use the same methods for outdoor dangers and accidents. For example, sprains happen to players. We should not only identify accidents but ask why. Why sprains? Under what circumstances and road conditions sprain? Is this environment and road condition beyond the ability of the team member? If beyond the ability range, is there any deficiency in the player's assessment process? Is the player physically and mentally ill when sprained? Did you warm up fully? Are you concentrating on walking?
The CAPA=Corrective Action and Preventive Action (CAPA=Corrective Action and Preventive Action) has returned to the aviation case. The CAAC requires the ATC system to check whether the safety production responsibility system is sound; whether the key position personnel training is strictly implemented and whether the qualification ability and work style conform to the position Requirements; whether there is super-capacity operation; whether the control and operation procedures are reasonably optimized; whether there is a violation of the rules and other issues such as the security breach of the red line. It is not too late to make up for the so-called dead sheep. Every accident or dangerous situation should be an opportunity to make up loopholes and improve the system. The CAAC just mentioned all aspects of correction and prevention. To the towers and to China Eastern Airlines, it is necessary to further implement specific action plans in each area and follow up the implementation in order to effectively prevent accidents from happening again.
When formulating corrective and preventive measures, avoid false air and it must be implemented at the operational level. For example, whether there is a super-capacity operation or not, it is necessary to appoint personnel to review the operation status of the airport in accordance with the criteria for super-capacity operation within a specified period of time, and to give clear conclusions.
The corrective and preventive action plan for the outdoor industry may more likely fall on the soundness of the safety system because many aspects rely on experience and operational practices and do not establish a documented SOP. However, if the club has a certain size (more than 3 people), it is recommended that the SOP be established first for the key links as a basic step for corrective and preventive measures. Also using the example given above, the sprained players were not able to simply remind the players to be careful. Systematic corrective and preventive action plans may require: Line classification SOP: Establish line assessment mechanisms with hazardous terrain Route setting risk rating team members assessment SOP: players involved in dangerous routes need to be assessed by the team leader to determine whether it is appropriate to participate in the activities of the team leader led the SOP: warm up before the start of the walk and preach safety precautions, remind players to go hand in hand and concentrate on walking
Corrective Action Plan (CAP=Corrective Action Plan) We will turn the above CAPA into a concrete and actionable action plan. Follow-up only needs to follow up on the matters in the form until you reach the goal of the plan. Remedies for accidents.
When formulating an action plan, you can refer to the SMART principle of performance goals: S=Specific, ie each item is a specific task. The vague description is inoperable and difficult to implement. M=Measurable, that is, the goal of the plan is measurable. The goal of being unable to quantify assessments is difficult to implement and achieve. A=Attainable, that is, the action plan can be achieved. Unrealistic plans are not meaningful or operational. R = Relevant, that is, the action plan is related to the accident or danger. Unrelated work can be reflected in other links. T=Time-bound, that is, the action plan must have a clear completion limit, and the indefinite plan has no plan.
Conclusion
Recalling this article, we start with the apparent causes of accidents or dangers, understand the scientific steps of analyzing problems, identify the 5 why methods of the root cause of the problems, and understand how to formulate standard operating procedures, correct preventive measures, and use SMART principles to formulate action plans. Through the integration, you can analyze the accident cases that are familiar to you, and you can also tap into the difficulties encountered in the day-to-day operations of the club and formulate action plans to solve the problems.
It is true that methodological knowledge and methods are used well. It is a weapon and it is not used well. It may become a shackle. I hope that every outdoor agency practitioner can recognize the importance and value of scientific management tools and make flexible use of them, and strive to improve management methods for the improvement of their own organizations and the industry's professional level, making the outdoor industry as a whole more healthy. Order development.
How to prevent outdoor accidents
How to Prevent Outdoor Activities Incident Date: 2016-10-22 16:00