Major aviation accident investigation methodologies used by ITSA members

The International Civil Aviation Organization (ICAO) Annex 13 framework for aviation investigation is longstanding and well developed but does not require or audit use of methodologies for investigation analysis, including research literature safety/accident models (SAMs). Government Safety Investigation Authority (SIA) websites rarely mention methodologies. Limited published research engages directly with SIAs. A research/practice gap has been suggested. To address ICAO, SIA and research gaps, this qualitative multi-case study examines SIA use and documentation of methodologies for accident analysis. Nine of seventeen SIA members of the International Transportation Safety Association (ITSA) that investigate aviation accidents agreed to participate and provided written answers to our research questions, relevant internal documentation, and exemplar investigation reports. Our key findings are that participant SIAs have augmented ICAO requirements internally by their use of methodologies but that this usage was generally not obvious in published investigation reports and other SIA website material. It also varied significantly among the participants. All participant SIAs reported use of multiple methodologies, sometimes in the same investigation. Explicitly reported SIA methodology usage included: six Reason-based, six Rasmussen-based, three ‘recent systemic’, five ‘BowTie’, five ‘bespoke’, and seven using various other methodologies like ‘SHELL’. The industry impact of this qualitative research is hoped to be significant by being shared with participant SIAs unaware of each other\u27s practice, enabling consideration of different options. It can inform additional aviation SIAs, ICAO, air safety investigators, and other high-risk industry regulators and investigators. Safety researchers may be better placed to develop SAMs with greater practical industry relevance

Barry Turner: The under-acknowledged safety pioneer

Barry Turner’s 1978 Man-made Disasters and Charles Perrow’s 1984 Normal Accidents were seminal books but a detailed comparison has yet to be undertaken. Doing so is important to establish content and priority of key ideas underpinning contemporary safety science. Turner’s research found socio-technical and systemic patterns that meant that major organisational disasters could be foreseen and were preventable. Perrow’s macro-structuralist industry focus was on technologically deterministic but unpredictable and unpreventable “system” accidents, particularly rare catastrophes. Andrew Hopkins and Nick Pidgeon respectively suggested that some prominent writers who wrote after Turner may not have been aware of, or did not properly acknowledge, Turner’s work. Using a methodology involving systematic reading and historical, biographical and thematic theory analysis, a detailed review of Turner’s and Perrow’s backgrounds and publications sheds new light on Turner’s priority and accomplishment, highlighting substantial similarities as well as clear differences. Normal Accidents did not cite Turner in 1984 or when republished with major additions in 1999. Turner became better known after a 1997 second edition of Man-made Disasters but under-acknowledgment issues by Perrow and others continued. Ethical citation and potential reasons for under-acknowledgment are discussed together with lessons applicable more broadly. It is concluded that Turner’s foundational importance for safety science should be better recognised