What went right? An analysis of the protective factors in aviation near misses

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 a 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 16 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 article 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.

Practitioner Statement: The analysis of near misses is an important part of safety management activities. This article demonstrates that Rasmussen?s risk management framework can be used to identify networks of protective factors which prevent accidents. Safety practitioners can use the framework described to discover and support the system-wide networks of protective factors.

Keywords:

• Accident causation
• Accident analysis
• Accident prevention
• Aviation
• Incidents
• Near miss
• Systems thinking

Additional information

Funding

This project was supported by funding from the Australian Research Council [ARC; LP150100287] in partnership with Australian Camps Association, Outdoor Council of Australia, The Outdoor Education Group, Sport and Recreation Victoria, Victorian YMCA Accommodation Services Pty Ltd, Outdoors Victoria, Outdoor Recreation Industry Council (Outdoors NSW), Outdoors WA, Outdoors South Australia, Queensland Outdoor Recreation Federation, Wilderness Escape Outdoor Adventures, Venture Corporate Recharge and Christian Venues Association. Paul Salmon’s contribution was funded through his current Australian Research Council Future Fellowship [FT140100681]. Natassia Goode’s contribution was funded through the University of the Sunshine Coast and the State of Queensland through the Department of Science, Information Technology and Information, Advance Queensland Research Fellowship.