Written by Source: Hogrefe Open Access Paper
Sieberichs, S., & Kluge, A. (2021). Why learning opportunities from aviation incidents are lacking. Aviation Psychology and Applied Human Factors.
This award-winning paper examined details from over 2000 incident reports from commercial airlines. The premise of the paper is that we could be doing more to learn from the incidents we are (and aren’t) reporting on!
Some important lessons from the paper are as follows:
The cause of an incident impacts whether it is reported or not.
- How frequently incidents get reported depends upon the cause. It found some types of incidents are less reported depending on the type of active failure causing the incident (pilots’ unsafe acts) – particularly with regard to judgment and decision-making errors.
Performance based errors are highly reported…
There are a disproportionately high number of reports on performance-based errors. This creates a circular effect which that biases people’s concept of what should be reported limiting people’s ‘safety imagination’ further towards skill based reporting . More than half of all incidents recorded in the database were caused by incorrectly applied procedures.
Lack of attention is the second strongest risk factor for performance-based errors and also the most frequently mentioned risk factor in all evaluated reports.
Decision-making errors are under-reported…
- Pilots stated that they are rather unlikely to report incidents caused by operational decision errors.
- Reports of incidents caused by judgment and decision-making errors account for less than 10% of all reports evaluated.
- This relatively small number of reports limits learning opportunities in this area. The number of reports does not correspond to the number of actual incidents.
Pilots are not as assertive as they would like to think…
- In a NASA (2004) survey three quarters of the commercial pilots interviewed stated that they had a high degree of assertiveness.
- However, this research showed that a lack of assertiveness is the strongest risk factor for judgment and decision-making errors.
- Lack of assertiveness was also the second strongest risk factor for violations.
The value of CRM training in sharing stories
This paper notes that sharing stories can be an effective tool against complacency and reduces the probability of incidents caused by violations.
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For those interested in the details, check out the abstract below. The full paper is available via open open access here: Sieberichs, S., & Kluge, A. (2021). Why learning opportunities from aviation incidents are lacking. Aviation Psychology and Applied Human Factors.
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.
The latest safety report of the International Civil Aviation Organization (ICAO) shows an increasing accident rate since 2018, after a steady decline in the previous years (ICAO, 2019). In 2018, 11 fatal accidents occurred in scheduled commercial operations – the highest number in 5 years (ICAO, 2019). These disturbing statistics show that, despite substantial safety management and organizational learning processes, (preventable) accidents continue to occur, claiming lives, causing financial losses, and impairing the competitiveness of airlines (Stemn et al., 2018). One explanation for this trend may be that in the past, airlines have failed to learn their necessary lessons from accidents, as well as from minor incidents (Drupsteen et al., 2013; Stemn et al., 2018).