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What went right? An analysis of the protective factors in aviation near misses
Journal article   Open access   Peer reviewed

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

Brian Thoroman, Natassia Goode, Paul M Salmon and Matthew J I Woolley
Ergonomics, Vol.62(2), pp.192-203
2019
pdf
PDF - Author Accepted Version1.06 MBDownloadView
Accepted VersionPDF - Author Accepted Version Open Access
url
https://doi.org/10.1080/00140139.2018.1472804View
Published Version

Abstract

incidents near miss aviation accident causation accident analysis systems thinking accident prevention
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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Engineering, Industrial
Ergonomics
Psychology
Psychology, Applied

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