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.
Highlights
Modern system complexity emerging from the multiple interactions amongst technology, human agents, and organisational aspects (Martinetti et al, 2018) has driven safety thinking advancements with a focus more on systemic factors rather than components
Based on the analysis framework presented by Karanikas (2015), in this study we employed a broader set of reports to examine the degree to which the nine aspects of new safety thinking and the three categories of safety models stated in the research mentioned above have been visible in safety investigations published between 1999 and 2016
Human error seen as a symptom (HES), Decomposition of folk models (DFM) and Feedback loops examination (FLE) were detected at least in three-quarters of the reports
Summary
Modern system complexity emerging from the multiple interactions amongst technology, human agents, and organisational aspects (Martinetti et al, 2018) has driven safety thinking advancements with a focus more on systemic factors rather than components. Safety perspectives that interpret adverse events merely as results of human errors are linked with tendencies to (in)directly blame underperforming individuals, evaluate system performance levels based on a small number of unfortunate events, and neglect the daily successes of safe practices at the work floor under the reality of conflicting goals or varying conditions. This set of views has been described by Hollnagel (2013) as ‘Safety I’ and by Dekker (2007) as ‘Old View’ and is most frequently linked to safety investigations. Based on the analysis framework presented by Karanikas (2015), in this study we employed a broader set of reports to examine the degree to which the nine aspects of new safety thinking and the three categories of safety models stated in the research mentioned above have been visible in safety investigations published between 1999 and 2016
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