About the Authors |
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xix | |
Foreword |
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xxi | |
Preface |
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xxix | |
Acknowledgments |
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xxxi | |
Introduction |
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xxxiii | |
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Part I Concepts of Safety |
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1 An Introduction to Commercial Aviation Safety |
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3 | (26) |
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3 | (1) |
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3 | (10) |
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1.1.1 A Story of an Accident |
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3 | (7) |
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1.1.2 The AF447 Accident Report |
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10 | (1) |
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1.1.3 Other Stories of AF447 |
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11 | (1) |
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1.1.4 A Deeper Understanding |
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12 | (1) |
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13 | (6) |
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1.2.1 Four Eras of Commercial Aviation Safety |
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13 | (6) |
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19 | (2) |
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1.3.1 Commercial Aviation Today |
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19 | (1) |
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20 | (1) |
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21 | (3) |
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1.4.1 Suggestions as to Why |
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21 | (1) |
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21 | (1) |
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22 | (1) |
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1.4.4 Constant Innovation |
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23 | (1) |
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23 | (1) |
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1.5 The Impact of COVID-19 |
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24 | (5) |
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24 | (1) |
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24 | (1) |
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1.5.3 The Impact on Technical Safety |
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25 | (1) |
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1.5.4 The Impact on Human Safety |
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26 | (1) |
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1.5.5 The Impact on Organizational and System Safety |
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26 | (1) |
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27 | (1) |
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27 | (1) |
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28 | (1) |
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29 | (28) |
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29 | (1) |
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29 | (4) |
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2.1.1 A Tale of Two Accidents |
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29 | (2) |
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2.1.2 Numbers and Distance |
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31 | (1) |
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2.1.3 Different Rules for Different Flights |
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32 | (1) |
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33 | (4) |
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2.2.1 Why Is Safety Important? |
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33 | (1) |
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34 | (1) |
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34 | (2) |
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36 | (1) |
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37 | (6) |
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37 | (1) |
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2.3.2 Measuring Ultrasafe Systems |
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38 | (1) |
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2.3.3 Reactive, Proactive, and Predictive Safety |
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39 | (1) |
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2.3.4 Safety Reporting Initiatives |
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40 | (1) |
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2.3.5 Safety Monitoring Initiatives |
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41 | (2) |
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43 | (3) |
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2.4.1 Are We Safe Enough Yet? |
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43 | (1) |
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44 | (1) |
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2.4.3 Acceptable Level of Safety |
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44 | (1) |
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2.4.4 Tolerable, Acceptable, and ALARP (As Low As Reasonably Practicable) |
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45 | (1) |
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46 | (11) |
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46 | (2) |
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2.5.2 Commercial Pressure |
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48 | (1) |
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49 | (1) |
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50 | (1) |
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2.5.5 The Cost of Accidents |
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51 | (2) |
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53 | (1) |
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53 | (1) |
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54 | (3) |
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3 Why Do Accidents Happen? |
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57 | (34) |
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57 | (1) |
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57 | (5) |
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57 | (2) |
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3.1.2 The Perception of Accidents |
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59 | (1) |
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3.1.3 Framing the Accident |
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59 | (1) |
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3.1.4 The Mount Erebus Disaster |
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60 | (2) |
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62 | (5) |
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3.2.1 Designing Our Own Accident |
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62 | (2) |
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3.2.2 Accidents and Human Behavior |
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64 | (1) |
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64 | (1) |
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65 | (1) |
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3.2.5 Necessary and Sufficient Conditions |
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66 | (1) |
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3.3 Developing Perspectives |
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67 | (4) |
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3.3.1 Evolving Accident Theories |
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67 | (2) |
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69 | (1) |
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69 | (1) |
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70 | (1) |
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3.4 Linear Causation Models |
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71 | (7) |
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3.4.1 Accident Chains and Dominoes |
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71 | (1) |
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3.4.2 The Accident Triangle |
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71 | (2) |
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3.4.3 Root Cause Analysis |
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73 | (1) |
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3.4.4 Reason's Swiss Cheese Model |
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74 | (2) |
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3.4.5 The Human Factors Analysis Classification System (HFACS) |
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76 | (1) |
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77 | (1) |
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3.5 Complex Causation Models |
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78 | (4) |
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3.5.1 Normal Accident Theory |
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78 | (1) |
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3.5.2 High Reliability Theory (HRT) |
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79 | (1) |
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80 | (1) |
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3.5.4 Functional Resonance Analysis Method (FRAM) |
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81 | (1) |
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3.5.5 Deliberate Myths and Black Swans |
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81 | (1) |
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3.6 Significant Commercial Aviation Accidents |
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82 | (9) |
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88 | (1) |
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88 | (1) |
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89 | (2) |
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4 Investigating Accidents |
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91 | (34) |
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91 | (1) |
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4.1 Why and How to Investigate? |
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92 | (3) |
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4.1.1 Not-for-Blame Investigation |
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93 | (1) |
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4.1.2 Thinking Like an Investigator |
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94 | (1) |
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4.2 Role of Investigators and Regulators |
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95 | (6) |
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4.2.1 Primacy for the Investigation |
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95 | (1) |
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4.2.2 Rights of Participation |
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96 | (1) |
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96 | (1) |
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4.2.4 Powers of an Investigator |
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97 | (1) |
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98 | (1) |
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4.2.6 Approach to Investigation |
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98 | (1) |
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4.2.7 Inclusion of Human Factors |
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98 | (1) |
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4.2.8 Specific Agencies and Their Structures |
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99 | (1) |
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99 | (1) |
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100 | (1) |
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4.3 Notification and Initial Response |
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101 | (1) |
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4.4 Deployment and On-site |
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101 | (2) |
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4.4.1 Inaccessible or Unknown Site |
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102 | (1) |
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102 | (1) |
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103 | (1) |
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103 | (5) |
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104 | (1) |
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4.5.2 Perishable Evidence |
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105 | (1) |
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105 | (1) |
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106 | (1) |
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107 | (1) |
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108 | (1) |
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108 | (3) |
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108 | (3) |
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111 | (2) |
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111 | (1) |
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112 | (1) |
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4.8 Findings, Causes, Recommendations |
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113 | (3) |
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113 | (1) |
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4.8.2 Causes and/or Contributing Factors |
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113 | (1) |
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114 | (1) |
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4.8.4 Most Wanted / Significant Seven |
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115 | (1) |
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4.9 When the System Fails |
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116 | (3) |
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119 | (6) |
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119 | (1) |
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119 | (1) |
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120 | (5) |
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5 An Introduction to Technical Safety |
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125 | (24) |
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125 | (1) |
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5.1 Fundamentals of Flight |
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125 | (2) |
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127 | (6) |
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5.2.1 Airframe Development |
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128 | (1) |
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5.2.2 Jet Engine Development |
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129 | (1) |
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5.2.3 Flight Deck Development |
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130 | (3) |
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5.3 The Importance of Evolution |
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133 | (6) |
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5.3.1 The Comet Accidents |
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133 | (3) |
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5.3.2 The Manchester Fire |
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136 | (3) |
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139 | (1) |
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5.4 The Modern Safety System |
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139 | (3) |
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139 | (1) |
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5.4.2 Government Regulators |
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140 | (1) |
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5.4.3 Design Organizations |
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140 | (1) |
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141 | (1) |
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5.4.5 Maintenance Organization |
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141 | (1) |
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5.4.6 Air Navigation Service Provider |
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141 | (1) |
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5.4.7 Airport or Aerodrome Operator |
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141 | (1) |
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5.4.8 Safety Investigation Agencies |
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142 | (1) |
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142 | (1) |
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5.5 Interactions and Complexity in the Modern Aviation System |
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142 | (7) |
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5.5.1 Incident to an Airbus A340 in 2005 (G-VATL) |
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142 | (1) |
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5.5.2 Qantas Airbus A380 (QF 32) |
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143 | (3) |
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146 | (1) |
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146 | (1) |
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147 | (1) |
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147 | (2) |
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6 Aircraft Safety Systems |
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149 | (32) |
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149 | (1) |
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6.1 Aircraft Design for Safety |
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150 | (10) |
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150 | (1) |
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6.1.2 Organization Designation Authorization and Design / Production Organization |
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151 | (1) |
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151 | (4) |
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6.1.4 Requirements Beyond the Aircraft Design |
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155 | (1) |
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6.1.5 "Grandfather" Rights |
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156 | (1) |
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6.1.6 Certification Pressures and Delegation |
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156 | (1) |
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6.1.7 Modifications and Additions |
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157 | (1) |
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6.1.8 When the Certification and Initial Airworthiness System Fails |
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157 | (3) |
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6.2 Maintaining Aircraft for Safety |
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160 | (5) |
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160 | (1) |
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6.2.2 The Type Certificate Holder |
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160 | (1) |
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161 | (1) |
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6.2.4 FAR and EASA Part-145 Maintenance Repair and Overhaul |
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162 | (1) |
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6.2.5 Maintainer Licensing |
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162 | (1) |
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6.2.6 Aging Aircraft and Changes to Certification |
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162 | (1) |
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6.2.7 Loss of Airworthiness |
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163 | (1) |
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6.2.8 When the Continuing Airworthiness System Fails |
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164 | (1) |
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6.3 Operating an Aircraft Safely |
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165 | (3) |
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6.3.1 Flight Crew Licensing and Training |
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165 | (1) |
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166 | (1) |
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6.3.3 Extended Range Operations |
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166 | (1) |
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6.3.4 Minimum Equipment List |
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167 | (1) |
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167 | (1) |
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167 | (1) |
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168 | (1) |
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6.4 Aircraft Safety Systems |
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168 | (7) |
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168 | (4) |
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6.4.2 Situational Awareness and Crew Alerting |
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172 | (3) |
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175 | (6) |
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175 | (1) |
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176 | (1) |
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176 | (5) |
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181 | (28) |
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181 | (1) |
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7.1 The Passenger Experience |
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181 | (1) |
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7.2 "Turning Round" an Aircraft |
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182 | (1) |
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7.3 Airport Design and Certification |
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182 | (5) |
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7.3.1 ICAO Standards and Recommended Practices |
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182 | (1) |
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7.3.2 Airport Certification |
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183 | (2) |
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7.3.3 Airport Site Selection |
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185 | (2) |
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7.4 Ground Operations Risk |
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187 | (7) |
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7.4.1 Occupational Safety |
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187 | (1) |
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188 | (2) |
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7.4.3 Aviation Fuel Handling |
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190 | (1) |
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7.4.4 Aircraft Rescue and Firefighting |
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190 | (1) |
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7.4.5 De-icing and Anti-icing |
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191 | (1) |
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7.4.6 Hangars and Maintenance Shops |
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192 | (1) |
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7.4.7 Wildlife and Foreign Object Debris (FOD) |
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193 | (1) |
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7.4.8 Airport Terminal Buildings |
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193 | (1) |
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7.5 Flight Operational Risks |
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194 | (10) |
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194 | (1) |
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7.5.2 Classification and Prevention |
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195 | (2) |
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7.5.3 Runway Incursion Case Studies |
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197 | (2) |
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199 | (1) |
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7.5.5 Runway Excursion Case Studies |
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200 | (4) |
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204 | (1) |
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204 | (5) |
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205 | (1) |
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205 | (1) |
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205 | (4) |
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8 Air Traffic Safety Systems |
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209 | (32) |
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209 | (1) |
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8.1 History, Regulation, and Stakeholders |
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210 | (2) |
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8.1.1 History of Air Traffic Control |
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210 | (1) |
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211 | (1) |
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211 | (1) |
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8.2 The ATC System and Its Components |
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212 | (7) |
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212 | (1) |
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213 | (1) |
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8.2.3 Airspace Classification |
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213 | (1) |
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8.2.4 Air Traffic Services |
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213 | (1) |
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8.2.5 Types of ATC Facilities |
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214 | (1) |
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214 | (1) |
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214 | (3) |
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8.2.8 Data Link Communications |
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217 | (2) |
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219 | (2) |
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8.3.1 Traditional Navigation |
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219 | (1) |
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8.3.2 Global Navigation Satellite Systems |
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219 | (1) |
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8.3.3 Satellite-Based Augmentation Systems |
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220 | (1) |
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8.3.4 Advantages of Satellite-Based Navigation |
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220 | (1) |
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8.3.5 Performance-Based Navigation |
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221 | (1) |
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8.4 A Typical Commercial Flight |
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221 | (3) |
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8.4.1 Flight Planning and Aircraft Preparation |
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221 | (1) |
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8.4.2 Start-Up, Pushback, and Taxi |
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222 | (1) |
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8.4.3 Takeoff and Departure |
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222 | (1) |
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222 | (1) |
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8.4.5 Descent, Approach, and Landing |
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223 | (1) |
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8.4.6 Taxi-in and Shutdown |
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223 | (1) |
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8.5 Integration of Other Air Vehicles |
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224 | (2) |
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224 | (1) |
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8.5.2 Small Unmanned Aerial Systems |
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224 | (1) |
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224 | (1) |
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8.5.4 UAS Safety Events and Investigations |
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225 | (1) |
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226 | (4) |
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8.6.1 Aircraft 4D Trajectory Concept |
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226 | (1) |
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8.6.2 FAA NextGen Program |
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226 | (1) |
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8.6.3 Single European Sky ATM Research |
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227 | (1) |
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8.6.4 NextGen--SESAR Harmonization |
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228 | (1) |
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8.6.5 Airport Surface Detection Equipment |
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229 | (1) |
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229 | (1) |
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229 | (1) |
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8.7 ATC Related Case Studies |
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230 | (5) |
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230 | (1) |
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8.7.2 Air France Flight 447 |
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231 | (2) |
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8.7.3 Malaysian Airline Flight MH370 |
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233 | (1) |
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8.7.4 Midair Collision in Brazil |
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233 | (2) |
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235 | (6) |
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235 | (1) |
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236 | (1) |
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236 | (5) |
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9 An Introduction to Human Safety |
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241 | (20) |
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241 | (1) |
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241 | (3) |
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244 | (1) |
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9.3 Fatal Confusion on the Flight Deck |
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245 | (3) |
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9.4 The Birth of Modern Aviation Human Factors |
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248 | (1) |
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9.5 Evolution of Crew Resource Management Principles |
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249 | (4) |
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9.6 CRM Beyond the Flight Deck |
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253 | (1) |
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9.7 The Human within a System |
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253 | (2) |
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9.8 Protecting the Human--Workplace Health and Safety |
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255 | (3) |
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258 | (3) |
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258 | (1) |
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258 | (1) |
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259 | (2) |
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10 Humans as the Challenge |
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261 | (28) |
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261 | (1) |
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10.1 Human-Centered Design |
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261 | (1) |
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10.2 Philosophy of Human Error |
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262 | (2) |
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264 | (1) |
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10.4 Understanding the Human Factor |
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265 | (4) |
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269 | (1) |
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10.6 What about "Pilot Error?" |
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269 | (2) |
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271 | (1) |
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10.8 Situational Awareness (SA) |
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272 | (4) |
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276 | (3) |
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10.10 Tools to Enhance Human Performance |
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279 | (1) |
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279 | (3) |
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10.12 Communication Issues |
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282 | (1) |
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10.13 Humans and Automation |
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283 | (3) |
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10.13.1 The Startle Effect |
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285 | (1) |
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286 | (3) |
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286 | (1) |
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286 | (1) |
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286 | (3) |
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11 Humans as the Solution |
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289 | (18) |
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289 | (1) |
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11.1 Professionalism in Aviation Exemplified |
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289 | (4) |
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11.2 Leadership and Followership for Safety |
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293 | (1) |
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294 | (2) |
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11.4 Enhancing Human Performance |
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296 | (5) |
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11.4.1 Recruitment and Selection |
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296 | (1) |
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11.4.2 Competency-Based Training |
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297 | (2) |
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11.4.3 Practice Makes Perfect |
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299 | (2) |
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301 | (2) |
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11.5.1 Tactical Information Sharing |
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301 | (2) |
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11.5.2 Strategic Information Sharing |
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303 | (1) |
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11.6 Seeing the Big Picture |
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303 | (2) |
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305 | (2) |
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306 | (1) |
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306 | (1) |
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306 | (1) |
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307 | (22) |
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307 | (1) |
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307 | (5) |
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307 | (1) |
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308 | (2) |
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12.1.3 Organizational Culture |
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310 | (1) |
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12.1.4 Defining Safety Culture |
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311 | (1) |
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12.2 Concepts of Safety Culture |
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312 | (5) |
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12.2.1 Describing Safety Culture |
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312 | (1) |
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12.2.2 Modeling Safety Culture |
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313 | (1) |
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12.2.3 Reason's Model of Safety Culture |
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314 | (1) |
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12.2.4 Measuring Safety Culture |
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315 | (2) |
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12.3 The Power of Safety Culture |
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317 | (12) |
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317 | (1) |
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12.3.2 A Culture of Concealment |
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318 | (1) |
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12.3.3 Why Is Safety Culture Important? |
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319 | (1) |
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12.3.4 Does Poor Safety Culture Cause Accidents? |
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320 | (1) |
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12.3.5 Regulating Safety Culture |
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321 | (1) |
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12.3.6 Managing Safety Culture |
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322 | (1) |
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323 | (1) |
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324 | (1) |
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324 | (5) |
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Part IV Organizational and System Safety |
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13 Introduction to System Theory and Practice |
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329 | (22) |
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329 | (1) |
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13.1 The Boeing MAX Accidents |
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329 | (5) |
|
13.2 Systems, Accidents, and Hazards |
|
|
334 | (4) |
|
|
335 | (1) |
|
13.2.2 Reliability Theory |
|
|
335 | (3) |
|
|
338 | (7) |
|
13.3.1 The Third Kind of System |
|
|
339 | (3) |
|
13.3.2 Humans in a System |
|
|
342 | (1) |
|
13.3.3 Control Structures |
|
|
343 | (2) |
|
|
345 | (2) |
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13.4.1 Safety Analysis Using System Theory |
|
|
346 | (1) |
|
13.5 The B-737 MAX Series Aircraft |
|
|
347 | (1) |
|
13.6 Question: Why Was This Not a Problem Before? |
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|
348 | (3) |
|
|
349 | (1) |
|
|
349 | (1) |
|
|
350 | (1) |
|
14 Safety Management Systems and Safety Data |
|
|
351 | (42) |
|
|
351 | (3) |
|
|
354 | (1) |
|
14.2 ICAO Annex 19: Consolidation of SMS Standards |
|
|
355 | (1) |
|
14.3 Structure of SMS: Four Components (Pillars of SMS) |
|
|
355 | (15) |
|
14.3.1 Component 1: Safety Policy |
|
|
356 | (2) |
|
14.3.2 Component 2: Safety Risk Management |
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|
358 | (5) |
|
14.3.3 Component 3: Safety Assurance |
|
|
363 | (4) |
|
14.3.4 Component 4: Safety Promotion |
|
|
367 | (3) |
|
14.4 How to Implement SMS: A Phased Approach |
|
|
370 | (2) |
|
14.5 Future SMS Challenges |
|
|
372 | (1) |
|
|
373 | (12) |
|
14.6.1 Aviation Accident and Safety Statistics |
|
|
375 | (1) |
|
14.6.2 Industry Involvement with Safety Data |
|
|
376 | (9) |
|
14.7 Other Sources of Safety Data |
|
|
385 | (2) |
|
14.8 Caveat Dealing with Safety Statistics |
|
|
387 | (1) |
|
|
388 | (5) |
|
|
390 | (1) |
|
|
391 | (1) |
|
|
392 | (1) |
|
15 Proactive System Safety |
|
|
393 | (26) |
|
|
393 | (1) |
|
15.1 Managing Ultrasafe Systems |
|
|
394 | (8) |
|
15.1.1 High Reliability Organizations (HRO) |
|
|
394 | (1) |
|
|
395 | (1) |
|
15.1.3 Resilience Engineering |
|
|
396 | (2) |
|
|
398 | (3) |
|
15.1.5 Resilience Engineering or HRO? |
|
|
401 | (1) |
|
15.2 Cognitive Systems Engineering |
|
|
402 | (2) |
|
15.2.1 Improving Automation Design |
|
|
402 | (1) |
|
|
403 | (1) |
|
15.3 Certification and Reliability Theory |
|
|
404 | (1) |
|
|
405 | (3) |
|
15.5 Industry and Trade Associations |
|
|
408 | (4) |
|
15.5.1 Nongovernmental Organizations |
|
|
408 | (1) |
|
|
409 | (3) |
|
15.5.3 Industry Trade Associations |
|
|
412 | (1) |
|
15.6 Other Government Oversight |
|
|
412 | (1) |
|
15.7 The Influence of Oversight |
|
|
413 | (1) |
|
15.8 How to Measure Nothing |
|
|
413 | (1) |
|
|
413 | (1) |
|
15.10 Identifying Leading Indicators |
|
|
414 | (5) |
|
|
416 | (1) |
|
|
416 | (1) |
|
|
417 | (2) |
|
16 The Role of Government |
|
|
419 | (38) |
|
|
419 | (1) |
|
16.1 The International Civil Aviation Organization (ICAO) |
|
|
419 | (8) |
|
|
419 | (3) |
|
|
422 | (2) |
|
16.1.3 ICAO Rulemaking and Standards |
|
|
424 | (1) |
|
16.1.4 ICAO Safety Management |
|
|
425 | (1) |
|
16.1.5 ICAO Current Events |
|
|
426 | (1) |
|
16.2 The European Union Aviation Safety Agency (EASA) |
|
|
427 | (5) |
|
|
427 | (1) |
|
|
428 | (1) |
|
|
428 | (3) |
|
16.2.4 EASA Current Events--Response to the War in Ukraine |
|
|
431 | (1) |
|
16.3 The Federal Aviation Administration (FAA) |
|
|
432 | (9) |
|
|
433 | (1) |
|
|
433 | (1) |
|
16.3.3 The FAA and the Boeing 737-MAX Accidents |
|
|
434 | (2) |
|
16.3.4 FAA Rulemaking Process |
|
|
436 | (3) |
|
16.3.5 FAA Airworthiness Directives |
|
|
439 | (1) |
|
16.3.6 The Colgan Air Crash and Its Aftermath |
|
|
439 | (2) |
|
16.4 National Aviation Authorities (NAAs) |
|
|
441 | (4) |
|
16.4.1 Civil Aviation Authority--CAA (UK) |
|
|
441 | (2) |
|
16.4.2 Transport Canada (TC) |
|
|
443 | (1) |
|
16.4.3 Civil Aviation Safety Authority--CASA (Australia) |
|
|
443 | (1) |
|
16.4.4 Agenda Nacional de Aviacao Civil--ANAC (Brasil) |
|
|
444 | (1) |
|
16.4.5 The Civil Aviation Administration of China--CAAC |
|
|
444 | (1) |
|
16.5 The Criminalization of Aviation Accidents |
|
|
445 | (12) |
|
16.5.1 The Growth of Criminalization in Commercial Aviation |
|
|
446 | (1) |
|
16.5.2 Why Does Criminalization Happen? |
|
|
446 | (1) |
|
16.5.3 The Impact on Safety of Criminalization |
|
|
447 | (1) |
|
16.5.4 Mitigating the Effects of Criminalization |
|
|
448 | (1) |
|
16.5.5 Corporate Criminalization |
|
|
448 | (1) |
|
16.5.6 Examples of Criminalization in Commercial Aviation |
|
|
449 | (4) |
|
16.5.7 Resolving Criminalization |
|
|
453 | (1) |
|
|
454 | (1) |
|
|
454 | (1) |
|
|
455 | (1) |
|
|
456 | (1) |
|
17 The Future of Commercial Aviation Safety |
|
|
457 | (28) |
|
|
457 | (1) |
|
|
457 | (7) |
|
17.1.1 The Future by Numbers |
|
|
457 | (1) |
|
|
458 | (2) |
|
17.1.3 Advanced and Integrated Air Traffic Management (ATM) |
|
|
460 | (1) |
|
17.1.4 Challenges on the Near Horizon |
|
|
460 | (2) |
|
17.1.5 Challenges on the Far Horizon |
|
|
462 | (2) |
|
17.2 Digital Transformation |
|
|
464 | (6) |
|
17.2.1 Possibilities and Challenges |
|
|
464 | (1) |
|
17.2.2 Artificial Intelligence |
|
|
465 | (1) |
|
17.2.3 New Technologies Meet Old Rules |
|
|
466 | (1) |
|
17.2.4 Automation--With Humans |
|
|
467 | (1) |
|
17.2.5 Autonomy--Without Humans |
|
|
468 | (2) |
|
17.3 Sustainable Aviation |
|
|
470 | (4) |
|
|
470 | (1) |
|
17.3.2 The Operational Impact of Climate Change |
|
|
471 | (1) |
|
17.3.3 Changing Attitudes and Rules |
|
|
472 | (1) |
|
17.3.4 Technological Solutions |
|
|
473 | (1) |
|
17.4 Managing Future Risks |
|
|
474 | (2) |
|
|
475 | (1) |
|
17.4.2 Insuring the Future |
|
|
475 | (1) |
|
|
476 | (4) |
|
|
476 | (2) |
|
17.5.2 Commercial Spaceflight |
|
|
478 | (2) |
|
|
480 | (5) |
|
|
480 | (1) |
|
|
481 | (1) |
|
|
481 | (4) |
Index |
|
485 | |