Аңдатпа
There are many different systems of interaction in practical aviation activities. In particular, in a system consisting of an operator and a machine there are quite often failures due to errors of designers, operators, manufacturers, maintenance, etc. Errors are usually unintentional: a person performs erroneous actions, considering them as correct or most suitable due to insufficient information, neglect of rules and standards and even due to lack of such. The specialists of the American corporation Boeing calculated the share of aviation accidents related to incorrect decision-making. It turned out that of all aviation accidents, such incidents account for 75%. Back in 1990, Professor Reason developed a model describing the causation of an air accident. One of the main elements of this manufacturing system consists of decision-makers, another key element is decision-executors. For top-level decisions and line management actions to be implemented into effective and productive activities carried out directly by pilots and instructors, certain preconditions must be met. The Rison model explains how people contribute to the disruption of complex, interacting and well-protected systems (such as aviation), resulting in an aviation incident. This model reveals to us causal relationships that do not directly lead to an accident, but shows that, although there are lots of protection levels between risks and accidents, there are drawbacks in each layer of protection that, in the case of systemic “flaring-out”, can trigger an accident [3]. The drawbacks of one level of protection do not allow realizing the risk, since there are other protections to prevent a single point of failure, but with systemic accumulation of risks, catastrophic consequences are inevitable. This effect is sometimes called the "aggregate action effect." In our work, we tried to investigate the system of unprotected risks that led to disaster.