Why Learning Opportunities From Aviation Incidents Are Lacking
The Impact of Active and Latent Failures and Confidential Reporting
Abstract
Abstract. The rising trend of fatal aircraft accidents since 2018 suggests a limited safety capability of airlines in terms of learning from incidents (LFI). We evaluated 2,208 voluntary incident reports from commercial European pilots using qualitatively driven mixed methods to investigate LFI “bottlenecks.” The results showed that the report frequency depends on the type of pilots’ active failure causing the incident (performance‐based errors, judgment and decision‐making errors and violations). Learning opportunities were lacking, especially for incidents caused by pilots’ inadequate decision-making. Confidential reporting has positive effects on LFI, as these reports contained more information about latent failures. Furthermore, we identified several latent failures that are risk factors for certain unsafe acts. Our results may support airlines in various LFI activities.
References
. (2016). Department of Defense Human Factors Analysis and Classification System (DOD-HFACS), Version 7.0. https://www.safety.af.mil/Divisions/Human-Factors-Division/HFACS/
(1990). Practical statistics for medical research, CRC Press.
. (2020). Mixed methods article reporting standards (MMARS). https://apastyle.apa.org/jars/mixed-table-1.pdf
(2012). Organizational learning: Creating, retaining and transferring knowledge, Springer.
(1996). Organizational learning II. Theory method and practice, Addison-Wesley.
(2016). Multivariate analysemethoden, Springer.
(2017). Mixed Methods – Stand der Debatte und aktuelle Problemlagen
[Mixed Methods – State of the debate and current problems] . KZfSS Kölner Zeitschrift für Soziologie und Sozialpsychologie, 69(S2), 1–37. https://doi.org/10.1007/s11577-017-0450-5(2010).
Logistische Regression [Logistic regression] . In C. WolfH. BestEds., Handbuch der Sozialwissenschaftlichen Datenanalyse (pp. 827–854). Springer. https://doi.org/10.1007/978-3-531-92038-2_31(2020). Multiple approaches to managing workplace safety and health. World Safety Journal, 19(1), 8–10.
(2009). The life cycle of weak signals related to safety. International Journal of Emergency Management, 6(2), 117. https://doi.org/10.1504/ijem.2009.029241
(2001). Confronting failure: Antecedents and consequences of shared beliefs about failure in organizational work groups. Journal of Organizational Behavior, 22(2), 161–177.
. (2018a, August 21). HFACS unsafe acts [Video]. YouTube. https://www.youtube.com/watch?v=lc5iohwZBPc
. (2018b, August 21). HFACS Preconditions for unsafe acts [Video]. YouTube. https://www.youtube.com/watch?v=oYD44TVaYV4
(1988). Statistical power analysis for the behavioral sciences (2nd ed.). Erlbaum Associates.
(2015). Evaluating the reliability of the human factors analysis and classification system. Aerospace Medicine and Human Performance, 86(8), 728–735. https://doi.org/10.3357/amhp.4218.2015
(2013). Transformational leadership, intrinsic motivation, and trust: A moderated-mediated model of workplace safety. Journal of Occupational Health Psychology, 18(2), 198–210. https://doi.org/10.1037/a0031805
(2018). Prosocial and proactive “safety citizenship behaviour” (SCB): The mediating role of affective commitment and psychological ownership. Safety Science, 104, 29–38. https://doi.org/10.1016/j.ssci.2017.12.010
(2017). Automation surprise. Aviation Psychology and Applied Human Factors, 7(1), 28–41. https://doi.org/0.1027/2192-0923/a000113
(2006). The field guide to understanding human error, Ashgate.
(2018). Just culture: Restoring trust and accountability in your organization, CRC Press.
(2014). What is learning? A review of the safety literature to define learning from incidents, accidents and disasters. Journal of Contingencies and Crisis Management, 22(2), 81–96. https://doi.org/10.1111/1468-5973.12039
(2014). Why do organizations not learn from incidents? Bottlenecks, causes and conditions for a failure to effectively learn. Accident Analysis & Prevention, 72, 351–358. https://doi.org/10.1016/j.aap.2014.07.027
(2015). Assessing propensity to learn from safety-related events. Safety Science, 71, 28–38. https://doi.org/10.1016/j.ssci.2014.02.024
(2013). Critical steps in learning from incidents: Using learning potential in the process from reporting an incident to accident prevention. International Journal of Occupational Safety and Ergonomics, 19(1), 63–77. https://doi.org/10.1080/10803548.2013.11076966
(2015). Statistik und Forschungsmethoden, Beltz.
(2016). Assessment of the Human Factors Analysis and Classification System (HFACS): Intra-rater and inter-rater reliability. Safety Science, 82, 393–398. https://doi.org/10.1016/j.ssci.2015.09.028
(1985). Organizational learning. Academy of Management Review, 10(4), 803–813.
(2016). Outcome knowledge and under‐reporting of safety concerns in aviation. Applied Cognitive Psychology, 30(2), 141–151. https://doi.org/10.1002/acp.3179
(2015). Dynamic safety capability. Organizational Psychology Review, 6(3), 248–272. https://doi.org/10.1177/2041386615590679
(2016). Safety climate in organizations. Annual Review of Organizational Psychology and Organizational Behavior, 3, 191–212. https://doi.org/10.1146/annurev-orgpsych-041015-062414
(2000). Perceptions of safety at work: A framework for linking safety climate to safety performance, knowledge, and motivation. Journal of Occupational Health Psychology, 5(3), 347. https://doi.org/10.1037/1076-8998.5.3.347
(2015). Pilots’ willingness to report aviation incidents. Proceedings of the 18th International Symposium on Aviation Psychology, 596–601. https://corescholar.libraries.wright.edu/isap_2015/6
(2015). Knowing stories that matter: Learning for effective safety decision-making. Journal of Risk Research, 18(6), 714–726. https://doi.org/10.1080/13669877.2014.910690
(2017).
System safety and threat and error management: The line operational safety audit (LOSA) . In E. SalasK. A. WilsonE. EdensEds., Critical essays on human factors in aviation. Crew resource management: Critical essays (pp. 1–6). Ashgate.(2006). Resilience engineering. Concepts and precepts, Ashgate Publishing.
. (2013). ECCAIRS aviation data definition standard. https://www.icao.int/safety/airnavigation/AIG/Documents/ADREP%20Taxonomy/ECCAIRS%20Aviation%201.3.0.12%20(VL%20for%20AttrID%20%20431%20-%20Occurrence%20Classes).pdf
. (2018a). Module 3: Safety reporting & investigation. https://www.icao.int/MID/Documents/2018/Aerodrome%20SMS%20Workshop/M3-1-SMS_Aerodrome_Safety Reporting and Investigation.pdf
. (2018b). Safety management system overview. https://www.icao.int/MID/Documents/2018/Aerodrome%20SMS%20Workshop/M0-2-SMS%20Overview.pdf
. 2019 State of global aviation safety. https://www.icao.int/safety/Documents/ICAO_SR_2019_final_web.pdf
(2011). Method for evaluating learning from incidents using the idea of “level of learning”. Journal of Loss Prevention in the Process Industries, 24(4), 333–343. https://doi.org/10.1016/j.jlp.2011.01.011
(2009). A sequential method to identify underlying causes from industrial accidents reported to the MARS database. Journal of Loss Prevention in the Process Industries, 22(2), 197–203. https://doi.org/10.1016/j.jlp.2008.12.009
(2017). A holistic approach to evaluating the effect of safety barriers on the performance of safety reporting systems in aviation organisations. Journal of Air Transport Management, 63, 95–107. https://doi.org/10.1016/j.jairtraman.2017.06.004
(2020). The role(s) of qualitative content analysis in mixed methods research designs. Forum Qualitative Sozialforschung/Forum: Qualitative Social Research, 21(1). https://doi.org/10.17169/fqs-21.1.3412
(2019).
Mixed methods . In N. BaurJ. BlasiusEds., Handbuch Methoden der empirischen Sozialforschung (pp. 159–172). Springer.(2019). Qualitative content analysis: From Kracauer’s beginnings to today’s challenges. Forum Qualitative Sozialforschung/Forum: Qualitative Social Research, 20(3). https://doi.org/10.17169/fqs-20.3.3370
(1977). The Measurement of observer agreement for categorical data. Biometrics, 33(1), 159. https://doi.org/10.2307/2529310
(2016). Improving safety culture with confidential reporting. Proceedings of the Human Factors and Ergonomics Society Annual Meeting, 60(1), 1612–1616. https://doi.org/10.1177/1541931213601372
(2020). Good and bad reasons: The Swiss cheese model and its critics. Safety Science, 126, 1–11. https://doi.org/10.1016/j.ssci.2020.104660
(2017). Training flight accidents: An explorative analysis of influencing factors and accident severity. Aviation Psychology and Applied Human Factors, 7(2), 107–113. https://doi.org/10.1027/2192-0923/a000121
(2015). A systems approach to risk management through leading safety indicators. Reliability Engineering & System Safety, 136, 17–34. https://doi.org/10.1016/j.ress.2014.10.008
(2016). The evaluation of military pilot’s attention distributions on the flight deck. Proceedings of the International Conference on Human-Computer Interaction in Aerospace - HCI-Aero ‘16, 1–6. https://doi.org/10.1145/2950112.2964588
(2006). Pilot error and its relationship with higher organizational levels: HFACS analysis of 523 accidents. Aviation, Space, and Environmental Medicine, 77(10), 1056–1061.
(2014). Comparing safety culture and learning culture. Risk Management, 16(4), 272–293. https://doi.org/10.1057/rm.2015.2
(2017). Learning from Incidents Questionnaire (LFIQ): The validation of an instrument designed to measure the quality of learning from incidents in organisations. Safety Science, 99, 80–93. https://doi.org/10.1016/j.ssci.2017.02.005
(2016). Application of Human Factors Analysis and Classification System (HFACS) to UK rail safety of the line incidents. Accident Analysis & Prevention, 97, 122–131. https://doi.org/10.1016/j.aap.2016.08.023
(2017). Research and development agenda for learning from incidents. Safety Science, 99, 5–13. https://doi.org/10.1016/j.ssci.2016.09.004
(2020). “This is how we debate”: Engineers’ use of stories to reason through disaster causation. Qualitative Sociology, 43, 1–22. https://doi.org/10.1007/s11133-020-09452-1
(2007). Designs in qualitativ orientierter Forschung
[Designs in qualitative oriented research] . Journal für Psychologie, 15(2), 1–10.(2015). Qualitative Inhaltsanalyse. Grundlagen und Techniken
[Qualitative content analysis. Basics and techniques] . Beltz.(2020).
Qualitative Forschungsdesigns [Qualitative research designs] . In G. MeyK. MruckEds., Handbuch Qualitative Forschung in der Psychologie (pp. 1–17). Springer.(2010). Wiederverwendung qualitativer Daten: Archivierung und Sekundärnutzung qualitativer Interviewtranskripte
[Reuse of qualitative data: Archiving and Secondary Use of Qualitative Interview Transcripts] . Springer.(2017). Incident reporting, aviation and anaesthesia. Anaesthesia and Intensive Care, 45(3), 291–294. https://doi.org/10.1177/0310057X1704500304
(2017). Using conditional probabilities to understand “human error” in military aviation mishaps. Proceedings of the Human Factors and Ergonomics Society Annual Meeting, 61(1), 1619–1620. https://doi.org/10.1177/1541931213601889
(2018). Understanding human error in naval aviation mishaps. Human Factors, 60(6), 763–777. https://doi.org/10.1177/0018720818771904
(2016). An application of the HFACS method to aviation accidents in Africa. Aviation Psychology and Applied Human Factors, 6, 33–38. https://doi.org/10.1027/2192-0923/a000093
. (1976). NASA aviation safety reporting system. https://ntrs.nasa.gov/archive/nasa/casi.ntrs.nasa.gov/19760026757.pdf
. (2004). Pilot personality profile using the NEO-PI-R. https://ntrs.nasa.gov/api/citations/20040191539/downloads/20040191539.pdf
(2010). Making things happen: A model of proactive motivation. Journal of Management, 36(4), 827–856. https://doi.org/10.1177/0149206310363732
(2013). Measuring organizational learning from errors: Development and validation of an integrated model and questionnaire. Management Learning, 44(5), 511–536. https://doi.org/10.1177/1350507612444391
(2019). Analyse qualitativer Daten mit MAXQDA
[Analysis of qualitative data with MAXQDA] . Springer.(2016). Die Gestaltung einer konstruktiven Fehlerkultur als Führungsaufgabe in High Reliability Organizations (HRO) am Beispiel der zivilen Luftfahrt
[The design of a constructive error culture as a leadership task in High Reliability Organizations (HRO) using the example of civil aviation] . Struktur und Kultur einer Leadership-Organisation (pp 177–200). Springer. https://doi.org/10.1007/978-3-658-12554-7_10(2013). Can we use near-miss reports for accident prevention? A study in the oil and gas industry in Denmark. Safety Science Monitor, 17(2), 1–12.
(1990). The contribution of latent human failures to the breakdown of complex systems. Philosophical Transactions of the Royal Society of London. B: Biological Sciences, 327(1241), 475–484.
(1998). Achieving a safe culture: Theory and practice. Work & Stress, 12(3), 293–306. https://doi.org/10.1080/02678379808256868
(2016). Managing the risks of organizational accidents, Routledge.
(1992). Human error, Cambridge University Press.
(2020). Das Interview
[The Interview] . Springer.(2012). Systems-based accident analysis methods: A comparison of Accimap, HFACS, and STAMP. Safety Science, 50(4), 1158–1170. https://doi.org/10.1016/j.ssci.2011.11.009
(2017). How to construct a mixed methods research design. KZfSS Kölner Zeitschrift für Soziologie und Sozialpsychologie, 69(2), 107–131. https://doi.org/10.1007/s11577-017-0454-1
(2017). Human error and commercial aviation accidents: An analysis using the human factors analysis and classification system. Human Factors, 49(2), 73–88. https://doi.org/10.1518/001872007X312469
(2017). Influencing factors on error reporting in aviation – a scenario-based approach. Advances in Intelligent Systems and Computing, 3–14. https://doi.org/10.1007/978-3-319-60441-1_1
(2019).
Gütekriterien qualitativer Forschung [Quality criteria of qualitative research] . In U. FlickE. KardorffI. SteinkeEds., Qualitative Forschung – Ein Handbuch (pp 319–331). Rowohlt.(2016). Mixed-fleet flying in commercial aviation: A joint cognitive systems perspective. Cognition, Technology & Work, 18(3), 449–463. https://doi.org/10.1007/s10111-016-0381-3
(2018). Failure to learn from safety incidents: Status, challenges and opportunities. Safety Science, 101, 313–325. https://doi.org/10.1016/j.ssci.2017.09.018
(2017). Crew state monitoring and line-oriented flight training for attention management. 19th International Symposium on Aviation Psychology, 196–201.
(2015). Safety management systems in aviation, Ashgate Publishing.
(2019). Adoption of DoD HFACS for medication error analysis. Exploring resources, process and design for sustainable urban development: Proceedings of the 5th International Conference on Engineering, Technology, and Industrial Application (ICETIA) 2018, AIP Publishing. https://doi.org/10.1063/1.5112414
(2017). Critical incident reporting systems: A necessary multilevel understanding. Safety Science, 96, 198–208. https://doi.org/10.1016/j.ssci.2017.04.004
(2007). Managing the unexpected, Jossey-Bass.
(2019). Operational mishap and incident reports by phase of flight. Journal of Management & Engineering Integration, 12(2), 105–111.
(2017a).
The Human Factors Analysis and Classification System (HFACS) . In D. A. WiegmannS. A. ShappellEds., A human error approach to aviation accident analysis (pp. 45–71). Routledge.(2017b). A human error approach to aviation accident analysis: The human factors analysis and classification system. Routledge.
(2018). Effects of shame and guilt on error reporting among obstetric clinicians. Journal of Obstetric, Gynecologic & Neonatal Nursing, 47(4), 468–478. https://doi.org/10.1016/j.jogn.2018.03.002
(2003). Safety climate: Conceptual and measurement issues. Handbook of Occupational Health Psychology, 123–142. https://doi.org/10.1037/10474-006
(2017). Zero Accident Vision based strategies in organisations: Innovative perspectives. Safety Science, 91, 260–268. https://doi.org/10.1016/j.ssci.2016.08.016
