Tracing New Safety Thinking Practices in Safety Investigation Reports

Abstract

Modern safety thinking and models focus more on systemic factors rather than simple cause-effect attributions of unfavourable events on the behaviour of individual system actors. This study concludes previous research during which we had traced practices of new safety thinking practices (NSTPs) in aviation investigation reports by using an analysis framework that includes nine relevant approaches and three safety model types mentioned in the literature. In this paper, we present the application of the framework to 277 aviation reports which were published between 1999 and 2016 and were randomly selected from the online repositories of five aviation authorities. The results suggested that all NSTPs were traceable across the sample, thus followed by investigators, but at different extents. We also observed a very low degree of using systemic accident models. Statistical tests revealed differences amongst the five investigation authorities in half of the analysis framework items and no significant variation of frequencies over time apart from the Safety-II aspect. Although the findings of this study cannot be generalised due to the non-representative sample used, it can be assumed that the so-called new safety thinking has been already attempted since decades and that recent efforts to communicate and foster the corresponding aspects through research and educational means have not yet yielded the expected impact. The framework used in this study can be applied to any industry sector by using larger samples as a means to investigate attitudes of investigators towards safety thinking practices and respective reasons regardless of any labelling of the former as “old” and “new”. Although NSTPs are in the direction of enabling fairer and more in-depth analyses, when considering the inevitable constraints of investigations, it is more important to understand the perceived strengths and weaknesses of each approach from the viewpoint of practitioners rather than demonstrating a judgmental approach in favour or not of any investigation practice.

Silence in Aviation: Development and Validation of a Tool to Measure Reasons for Aircraft Maintenance Staff not Reporting

“…The performance-based approach sees and evaluates the world as it is, which is contrary to the traditional safety management approach that views the world as it should be (Reason, 2008). It places people in the center of the system by acknowledging that people and organizations can make errors and violate rules, and that risks cannot be totally eliminated (Karanikas & Chionis, 2019). As stressed by Reason (2008), human errors are inevitable and it is necessary to have systems to counter and capture them by 'voluntary reporting' in a 'just culture' environment.…”