The Review is a valuable tool as a public / political safety overview - governance and money; the point is enhanced by good graphic depiction.
However, within the industry it’s use requires deeper knowledge of the ‘tool’ and processes, data provenance, assumptions, and thus limitations in application.
The data sources are repositories of ‘findings’ from accidents, and occurrence reports from organisations and individuals across the industry - thence categorised - by whom, where. The value of each is bounded; accident reports by what is written, key findings, national / cultural viewpoints, focus and strength of recommendations. Also by the limits of investigation - perhaps only factual data, excluding speculative issues particularly relating to human activity.
MORs and individual input similarly at risk of bias, inward looking, self analysis, error admission leading to superficial solutions opposed to reasoned understanding. This is not to discount everything, but how to differentiate the value of the data; count errors or gain understanding of influencing factors.
Many ‘safety issues’ are collection ‘buckets’ for a wide range of events; i.e. grouping an approach to stall / autothrotle event with an upset due to wake turbulence, icing or storms, all categorised ‘LoC’. Similarly there are no indications of how contributing factors interact, the overall context, or relative importance.
Continuing with existing ‘linear’ thinking looking for explanation is increasingly frustrated by inability to define problems or identify clear ‘solutions’, together with bureaucracy and lengthy time scales.
An alternative is to consider a systems approach to thinking (1&2), not as a replacement, but as a different starting point for thoughts and managing ‘wicked issues’ - no agreed definition of the problem or solution. This requires acknowledging that there may be no solution, only containment where understanding the processes is vitally important; ‘
better to travel safely than arrive’.
An alternative starting point need not change established methods for the ‘easier’ problems - according to definition; alternatively a change might help avoid interventions that could backfire due to unforeseen reactions.
Further concerns arise from projected ‘big data’ analysis; what value if we start with poor or corrupted data. Also, many current safety initiatives now quote the Review as definite data, justifying the need for action; solutions to address specific problems which might be artefacts of data collection in the first instance - ‘boot strapping’.
1
http://www.demos.co.uk/files/Connect...ts_-_web-2.pdf Sections 1 and 5
2
http://scpsystem.weebly.com/uploads/...s_thinking.pdf
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The point is not to change what we think, but to change the way we think about these issues.”