“ … not to say that accident investigations and LOSA are of no value because they record outcomes rather than underlying reasons”.
I agree, but accident reports must be used with care as these are critically dependent on the interpretation of the instructor/reader – the inference.
Many accident reports adhere strictly to the ICAO guidance in only presenting ‘factual’ evidence, thus many of the NTS aspects, being supposition, are avoided, or glibly labeled ‘pilot error’ or CRM. This is an opportunity for poor association and reduced training value. As stated previously there are few ‘facts’ in aviation and where given, often involve hindsight or other biases – in this instance, originating at the point of use.
However, recently some accident investigations have attempted to address the human issues. In some reports, ASTB in Australia have presented human factors in a speculative manner, with arguments for and against, and concluding on the balance of probabilities. This enables a reader to consider all of the possible contributions in the context of the accident, and although not ‘provable’ as fact, are of more value than just stating the outcome.
Other investigators have also attempted to grasp the human factors issues, most very successfully, and usually with informed or speculative discussion of the cognitive issues. These approaches will benefit NTS training and provide assessors with a wider baseline of context based behaviors – the real world.
There are fewer similarities with LOSA; the value of the report depends on the observer (incident report), but to date, the reporting method does not address the ‘factors’ or even speculate on NTS. Thus, I remain skeptical about use of LOSA in this area.
However, consider if we encouraged pilots to conduct their own (personal) LOSA during normal operations (threat and error management), this might identify some unseen threats, and, with honest self reflective assessment, pilots could improve their NTS – greater opportunity for practice.
For interest:-
What Can You Learn from Accident Reports? Page 7.
Also:
TRIS Online: The Effect of Accident Report Formats on Invulnerability and Hindsight Bias
Human Factors in the Investigation of Accidents and Incidents.
Why System Safety Professionals Should Read Accident Reports.