Acknowledgements.
List of Figures and Tables.
Foreword.
Introduction.
Chapter 1 Presence of accident warning signs in all incidents.
1.1 The great losses that result from accidents in large-scale systems.
1.2 The limits of safety measures based on accident investigations.
1.3 The social impact of the Osutaka Mountain JAL plane crash accident.
1.4 Overconfidence in safety measures as a cause of accidents.
1.5 Humility with respect to the facts.
1.6 The unrecovered vertical tailplane fragment of the Japan Airlines aircraft.
1.7 Incidents and the structure of an accident.
1.8 Errors made by a veteran pilot.
1.9 Background to mistakes made by the air traffic controller.
1.10 Improper instructions by the air traffic controller.
1.11 Unbroken chain of events leading to the accident.
1.12 Lessons not applied.
1.13 Differences in understanding between pilot and copilot.
1.14 Matters not clarified by the accident investigation.
1.15 Accident investigations conducted by reverse logic.
1.16 Forward-looking information obtained by IRAS.
1.17 Disasters preventable through conveyance of information.
1.18 Advances in science and technology and new kinds of danger.
1.19 The pitfalls of computer control.
1.20 Where do the relevant danger factors lie?
1.21 The phase that determines the occurrence of an incident.
1.22 Evaluating the degree of danger.
1.23 Breaks in the chain of events leading to an accident.
1.24 An overall picture of the danger factors.
1.25 IRAS and quantification method III.
1.26 Searching for incident patterns.
1.27 Why take up the field of aviation?
1.28 Meaning of Dr Shigeo Okinaka’s document ‘Medical Record’.
Chapter 2 Pre-accident situations experienced by pilots.
2.1 The work of a pilot.
2.2 Take-off and reject take-off procedures.
2.3 New emphasis on high-tech information-processing tasks.
2.4 Landings require extra care.
2.5 Fatigue as a major factor in errors.
2.6 Impatience, fluster, and carelessness after stressful periods.
2.7 Mistakes caused by much or little experience and knowledge.
2.8 Danger arising from interpersonal relationships among crew.
2.9 The dangers of the missed approach.
2.10 Heavy rain causing poor visibility.
2.11 Danger caused by snow.
2.12 Snow and ice build-up on the plane as a factor posing the most
danger.
2.13 Danger of wind at take-off and landing.
2.14 Pitfalls of good weather conditions.
2.15 Latent danger in ever-advancing aviation safety facilities and instruments.
2.16 Airport markings and landmarks as important factors.
2.17 Importance of weather information.
2.18 Close relationship between weather forecasts and fuel on board.
2.19 Point where mechanical problems develop into an accident.
2.20 Pilot training or check flights that increase stress and workload.
2.21 Unexpected changes of instructions as a cause of mistakes.
2.22 Accidents averted by good fortune.
2.23 Improvements and countermeasures uncovered by analysis.
2.24 Degree of danger in ‘hard factors’ and ‘soft factors’.
2.25 Urgently needed response to ‘hard factors’.
2.26 Danger factors increasing in importance and targeted for improvement.
Chapter 3 Imminent danger experienced by air traffic controllers.
3.1 Air traffic control space and various air traffic control services.
3.2 Flight rules: Visual Flight Rule (VFR) and Instrument Flight Rule (IFR) aircraft.
3.3 Air traffic control service work flow and work assignment.
3.4 Peculiarity of air traffic control service.
3.5 Mishearing in communications with pilots.
3.6 Danger created by inappropriate terminology.
3.7 Discrepancies in recognition between air traffic controllers and pilots.
3.8 Problems near the boundaries between air traffic controlled airspaces.
3.9 Oceanic control service via radio station.
3.10 Highly dangerous incidents due to cumulonimbus.
3.11 Danger due to poor visibility within clouds.
3.12 Pitfalls of good weather.
3.13 Wrong expectation by air traffic controllers.
3.14 Slow action by pilots.
3.15 Danger of special flights by small aircraft.
3.16 Incidents that involve consecutive near misses.
3.17 Survey results that overthrow current beliefs.
3.18 Urgently needed improvements.
Chapter 4 Aircraft maintenance personnel and latent danger in aircraft.
4.1 Significance of maintenance work and associated stages.
4.2 Focus on lack of sleep.
4.3 Poor team co-ordination.
4.4 Incidents related to work platforms.
4.5 Work difficult to see under dark conditions.
4.6 Mistakes due to tight spaces.
4.7 Dangerous work within fuel tanks.
4.8 Danger due to inability to make direct observations.
4.9 Shortage and substitution of parts and materials as a cause of accidents.
4.10 Mistakes due to poorly labelled/indicated parts.
4.11 Pitfalls of shift changes and work interruptions.
4.12 Danger caused by insufficient communication between personnel.
4.13 Incidents related to painting and polishing.
4.14 Danger caused by dust.
4.15 Incidents caused by deterioration over time.
4.16 Great difference between ‘occurrence’ and ‘discovery’.
4.17 Actual situation of latent danger factors versus general recognition.
4.18 Limits of ex post facto investigations and the need for the IRAS approach.
Epilogue Towards the establishment of IRAS.
E.1 What have we learned from drug disasters?
E.2 ‘Incidents’ deserve our keen interest.
E.3 IRAS: the key to greater safety 225
E.4 Surveys that cannot be done by overseeing authorities and airline companies.
E.5 Why is the current system of safety reports not working?
E.6 Requirements for establishing IRAS
Appendix A Explanation of quantification method III
Appendix B List of accidents.
Bibliography.
Notes on the text.
Index.
Masako Miyagi is Executive Director of the Japan Research Institute of Air Law. An earlier edition of her book is previously published in the Japanese language under the title Seeking Out the Signs of Major Accidents. She has presented her work at numerous academic meetings for the benefit of mechanical engineers and scientists, reliability engineering associations, aeronautical societies, health and safety organizations, and the chemical, process, and power industries.
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