Papers and Presentations

A partial list of papers and presentations by TACG President Dr. Bob Baron.
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Featured Papers/Presentations

Dying To Save A Life

Pathogens At The State Level: Look Out Below


 


Presentations on YouTube


Approaches to Safety




The Kobe Bryant Helicopter Accident




The Four Pillars of Safety Management




Papers

 

Safety Management Systems & Safety Culture

 

 

 

Human Factors

 

 

 

Flight Operations

 


 

 

Miscellaneous


 

 

 

AeroSafety World Articles

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    Cockpit Discipline

    Cockpit Discipline

     

    The Toxic Captain

    The Toxic Captain

     

    Double Trouble

    Double Trouble

     

    Revisiting Human Factors

    Revisiting Human Factors

     

    Flight Path-ogens

    Flight Path-ogens

     

    Data Delirium

    Data Delirium

     

    Do the Right Thing

    Do The Right Thing

     

    Speaking Of Errors

    Speaking Of Errors

     

    Safety Space
    The Safety Space And Practical Drift

     

     

     

     

     

    Presentations

     

    Safety Management Systems & Safety Culture

     

    Improving Corporate Safety Communication

    Safety communication must have a top-down/bottom-up approach in order to be truly effective. It all starts (or ends) with your safety culture! This presentation addresses the key points of corporate safety communication and how it can be improved.

    The Four Pillars Of Safety In Your Safety Management System (SMS)

    A brief introduction to the Four Pillars of Safety Management. This presentation covers Safety Policy, Safety Risk Management, Safety Assurance, and Safety Promotion. These are the building blocks of a Safety Management System.


    Approaches To Safety

    This presentation addresses the 3 approaches to safety. Reactive, Proactive, and Predictive.

    Safety Performance Monitoring And Measurement

    Safety Performance Monitoring and Measurement provides an organization with the means to determine whether its activities and processes are working effectively to achieve its safety objectives. This presentation addresses the procedures and processes required for effective safety monitoring and measurement. 


    Building A High Reliability Organization (HRO)

    A High-Reliability Organization (HRO) is an organization that has succeeded in avoiding catastrophes in an environment where normal accidents can be expected due to risk factors and complexity. This presentation provides insights to help make your aviation organization an HRO.


    Building A Strong Safety Culture

    As they say, "it all starts at the top." This presentation will help organizations understand the critical importance of having a strong safety culture, which includes a Just culture. If safety doesn't start at the top, then we can't expect line personnel to perform in the safest manner possible. Management must be role models of safety.


    Safety Culture

    Everybody talks about safety culture. Yet, many people have difficulties defining and/or measuring it. This presentation gives a short overview of what safety culture is and how to improve your organizational culture. 

    SMS Or SM Mess? It’s Your Choice!

    A Safety Management System (SMS) needs proper implementation or it can easily wind up becoming an SM Mess! This presentation will help you to have an SMS success!


    Safety Promotion Is Key To An Effective SMS

    Safety promotion is an essential element of your Safety Management System (SMS). However, many aviation organizations come up short on this important "fourth pillar of safety." This presentation will help safety managers ensure that safety promotion is highly effective within their aviation organization.


    The Management Of Change 

    Management of Change (MOC) is a best practice used to ensure that safety, health, and environmental risks are controlled when a company makes changes in its facilities, documentation, personnel, or operations. Changes—both positive and negative—can, and will, introduce new safety risks. These risks, if not mitigated, can lead to significant losses. Learn more about MOC with this presentation.


    How To Get Your CEO Onboard

    Many times, it can be extremely challenging to get the CEO, or any high-level management, to "buy-into safety." A lack of safety knowledge, coupled with an understandable focus on the organization's profitability and success, can make it difficult to get true safety buy-in (meaning demonstrable actions as opposed to lip service). This presentation details what it takes to get your CEO onboard.

    Managing Aviation Safety In The Growing Caribbean Region

    This presentation, made at the Caribbean Aviation Meetup in 2017, focuses on the status of aviation safety in the Caribbean region. Safety statistics for the CAR/SAM region are presented and show that this region has a high rate of accidents and incidents compared to other regions worldwide. Local accident/incident examples are shown, and proactive mitigation strategies are discussed.   

     

     

     

    Human Factors

     

    A Practical Introduction To Human Factors

    A practical introduction to Human Factors, including case studies of Tuninter Airlines Flight 1153, Continental Express Flight 2574, Solitaire Air Flight 6888, and Alaska Airlines Flight 536.

     

    Ramping Up Safety With Human Factors

    According to the Flight Safety Foundation, approximately 27,000 ramp accidents and incidents — one per 1,000 departures — occur worldwide every year. Ramp accidents cost major airlines worldwide at least US$10 billion a year. Realistically, 90-99% of ramp events are attributable to human error and almost all of them are preventable! This presentation addresses some of the contributing factors in ramp incidents and accidents, as well as proactive mitigation strategies to reduce the likelihood of safety events in the airport ramp environment.


    Qantas Flight 32: A Dirty Dozen Perspective

    On November 4, 2010, Qantas Flight 32, an Airbus A-380, on a scheduled passenger service from London to Sydney via Singapore, experienced an uncontained failure in one of its four Trent 900 engines. The failure occurred over Batam Island, Indonesia, four minutes after takeoff from Singapore Changi Airport. This presentation focuses on the maintenance human factors involved in the Qantas Flight 32 incident, specific to the Trent 900 powerplant.


    Human Error As A Learning Tool

    Human error has a bad reputation! However, if errors are used as a learning tool, rather than strictly for punitive purposes, you will actually see fewer accidents, incidents, occurrences, etc., which in turn will save your organization money. Of course, you will need to have a Just Culture in order to make that happen. This presentation will guide you in the process.

    The Human Factors Funnel Model

    Over the last few decades there has been a noticeable shift in the error causation paradigm. Not long ago blame was typically relegated to the person who committed the “active error.” Over the years, however, there has been a shift to the organization itself as being complicit in the active errors that individuals commit. While acknowledging that the propagation of errors can certainly begin with the upper levels of the organization, it appears that the pendulum may now have swung too far in that direction. The author proposes the Human Factors Funnel Model (HFFM) in an effort to balance this disparity.


    A Summary Of Major Industrial Accidents

    A brief Human Factors analysis of some of the most notable industrial accidents in history. We look at the Chernobyl Nuclear Plant, Union Carbide Chemical Plant, NASA Challenger, Exxon Valdez Oil Tanker, Costa Concordia Cruise Ship, Alvia Train Derailment, and the Pan Am/KLM Runway Incursion.

     

     

    Flight Operations


    Procedural Noncompliance: Why Pilots Don’t Always Play By The Book

    In 2015, an Execuflight Hawker HS125-700A, crashed on approach to Akron, Ohio. All onboard perished (2 crew and 7 passengers). The crash illuminated a number of issues related to procedural noncompliance. Latent threats set the precedents, but the pilots were the ones who actually enabled the accident to occur. Instead of being the final safety nets, they instead were the “trigger pullers." But why did the pilots deviate so extensively from procedures? This presentation focuses on the Execuflight accident and highlights many of the issues that can tempt ANY air charter operator to "drift too far from the centerline."


    One-Two-GO Airlines Crash: Case Study

    On September 16, 2007, an MD-82 of One-Two-GO Airlines Company Limited (One-Two-GO), departed from Don Mueang International Airport to Phuket International Airport on a domestic flight with 130 crewmembers and passengers onboard. While conducting a go-around at Phuket International Airport, the airplane veered off and hit an embankment located north of Runway 27, broke up in flames, and was completely destroyed. As a result, 90 crew members and passengers died. This comprehensive case study explores all the human factors that led to this accident.


    Dana Air Crash: Case Study

    On June 3, 2012, Dana Airlines Flight 0992, a Boeing MD-83, crashed into a densely populated area. Engine number 1 lost power seventeen minutes into the flight with a further loss of power on number 2 engine on final approach to runway 18R at Murtala Muhammed Airport, Lagos, Nigeria (LOS). All 153 persons onboard the airplane, including six crew were fatally injured. There were also six ground fatalities. This comprehensive case study explores all the human factors that led to this accident.

     

     

    Miscellaneous


    The International Aviation Safety Assessment Program (IASA)

    Under the International Aviation Safety Assessment (IASA) program, the FAA determines whether another country’s oversight of its air carriers that operate, or seek to operate, into the US, or codeshare with a US air carrier, complies with safety standards established by the International Civil Aviation Organization (ICAO). This presentation goes through the steps of the IASA process.