A thoughtful article -
Airlines aren't learning enough from near misses.
The original paper is worth reading, if only the discussion and conclusions -
Madsen - 2015 - Risk Analysis.
- Airlines can learn from all occurrence data (near-misses), theirs and others. So make this data available – EASA?
- It is important to report and investigate deviations from the norm – not the rule. Beware SOP itis; rules and regulation, blame and train.
- Broaden what is reported and make it easier to report (lower costs). Instead of requiring the operator to investigate, report and circulate the facts to the widest audience. – EASA’s communication task, make the data available?
- There will be different interpretations of individual events, but safety can be improved by considering the overall pattern of events (not possible biased conclusions) across the widest operating base. Further, operators might not be best qualified to investigate their own events – outcome bias, availability of specialist resource, and even saving face.
“… a near-miss … offers observers two distinct interpretations - one that provides evidence for hazard threat and one that provides evidence for system resiliency.”
“Too often when events are identified as near-misses, if the effects of the near-miss can be easily corrected, decision makers may assume that by correcting the outward signs of the near-miss they have eliminated the problem, and thus danger does not seem salient.”
Has EASA set themselves up as the only arbiter of these aspects?