Abstract
In recent years, the U.S. commercial airline industry has achieved unprecedented levels of safety, with the statistical risk associated with U.S. commercial aviation falling to 0.003 fatalities per 100 million passengers. But decades of research on organizational learning show that success often breeds complacency and failure inspires improvement. With accidents as rare events, can the airline industry continue safety advancements? This question is complicated by the complex system in which the industry operates where chance combinations of multiple factors contribute to what are largely probabilistic (rather than deterministic) outcomes.
Thus, some apparent successes are realized because of good fortune rather than good processes, and this research intends to bring attention to these events, the near-misses. The processes that create these near-misses could pose a threat if multiple contributing factors combine in adverse ways without the intervention of good fortune. Yet, near-misses (if recognized as such) can, theoretically, offer a mechanism for continuing safety improvements, above and beyond learning gleaned from observable failure. We test whether or not this learning is apparent in the airline industry.
Using data from 1990 to 2007, fixed effects Poisson regressions show that airlines learn from accidents (their own and others), and from one category of near-misses—those where the possible dangers are salient.
Unfortunately, airlines do not improve following near-miss incidents when the focal event has no clear warnings of significant danger. Therefore, while airlines need to and can learn from certain near-misses, we conclude with recommendations for improving airline learning from all near-misses.
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Some points from the full-text paper:
- A problem with learning from near-misses is that they do not always evoke images of danger or vulnerability and thus are open to interpretation. Is a near-miss evidence of systemic vulnerability or resilience?
- It is stated that “Near-misses may masquerade as success, and apparent success tends to breed complacency because decision-makers institutionalize established organizational practices and routines and reduce organizational search activities aimed at identifying further system improvements.” (pg. 2)
- Such near-misses without apparent negative consequence can reinforce dangerous behaviours and conditions, with a perception that this behaviour neutralises the hazard
- Research from the authors show that when near-misses are coupled with cues of obvious danger then people experience feelings of caution and thoughts of system vulnerability; thereby countering the outcome bias effect.
- This study found that while airlines learn to improve safety performance in response accidents, it was found that airlines only learned from certain types of near-misses. Airlines learned from near-misses that could be associated with clear signs of danger, but not from near-misses that did not have this association.
- The authors discuss methods to improve the learning capability. This includes 1) expanding their successful data-collecting efforts but broadening the scope of what is considered a near-miss and, through priming, using training and communications that help to associate negative consequences with events; and 2) Remaining vigilant towards any deviations from normal performance and uncover the sources of the deviations. On this, it is stated that often when the effects of near-misses can be easily corrected, it may be assumed that by correcting the outward signs of the near-miss then the problem will be eliminated and it is not salient anymore.
Authors: Madsen, P., Dillon, R. L. and Tinsley, C. H. (2015), Risk Analysis
Study link: https://doi.org/10.1111/risa.12503
Link to the LinkedIn article: https://www.linkedin.com/pulse/airline-safety-improvement-through-experience-tale-ben-hutchinson
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