Citation

Thoroman B, Goode N, Salmon P, Wooley M. Ergonomics 2019; 62(2): 192-203.

Affiliation

Centre for Human Factors and Sociotechnical Systems, University of the Sunshine Coast, Faculty of Arts and Business , Locked Bag 4 , Maroochydore , QLD , 4558 , Australia.

Copyright

(Copyright © 2019, Informa - Taylor and Francis Group)

DOI

10.1080/00140139.2018.1472804

PMID

29757710

Abstract

Learning from successful safety outcomes, or what went right, is an important emerging component of maintaining safe systems. Accordingly, there are increasing calls to study normal performance in near misses as part of safety management activities. Despite this, there is limited guidance on how to accomplish this in practice. This article presents a study in which using Rasmussen's risk management framework to analyse sixteen serious incidents from the aviation domain. The findings show that a network of protective factors prevents accidents with factors identified across the sociotechnical system. These protective networks share many properties with those identified in accidents. The paper demonstrates that is possible to identify these networks of protective factors from incident investigation reports. The theoretical implications of these results and future research opportunities are discussed.

Language: en

Keywords

Incidents; accident analysis; accident causation; accident prevention; aviation; near miss; systems thinking