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What went right? An analysis of the protective factors in aviation near misses.
Ergonomics 2018 May 15
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.
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