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Printed page 47. PDF page 47.
individual hazards in the operational environment but tend to be unsuccessful at identifying multi-dimensional hazards. Identifying operational risk is made more challenging when the various dimensions of a hazard are introduced gradually with small changes over time that do noOpen final report at PDF page 47Loss of control and impact with runway
Printed page 48. PDF page 48.
had been present when Perimeter Aviation began providing service to CDT9, creating a multi-dimensional hazard. However, this multi-dimensional hazard was never identified, which demonstrates a concept known as organizational drift, where incremental changes gradually erOpen final report at PDF page 48Loss of control and impact with runway
Printed page 49. PDF page 49.
TRANSPORTATION SAFETY INVESTIGATION REPORT A23O0122 49 In this occurrence, identifying multi-dimensional hazards was made even more challenging by the incremental nature of the changes to Perimeter Aviation's operations at CDT9, with the different elements of the hazard bOpen final report at PDF page 49Loss of control and impact with runway
Printed page 51. PDF page 51.
its risk not mitigated. 4. If hazard identification processes are unable to recognize multi-dimensional hazards, there is a possibility that these complex hazards will not be identified, resulting in an incomplete understanding of the level of risk in an operation.Open final report at PDF page 51Loss of control and impact with runway