BYU study: Airlines don't learn enough from near-miss incidents
A new study led by a Brigham Young University professor indicates that airlines are flying past an opportunity to increase safety by ignoring too many near-misses.
A new study led by a Brigham Young University professor indicates that airlines are flying past an opportunity to increase safety by ignoring too many near-misses.
Organizational behavior professor Peter Madsen and researchers from Georgetown University’s McDonough School of Business studied safety data of 64 commercial airlines from 1990-2007 to determine where less-obvious near-miss incidents were being ignored.
As expected, their study, published in Risk Analysis, found that airlines improve their safety performance in response to their own accidents and accidents experienced by other airlines. However, airlines learn from near-misses only when there are obvious signs of risk.
“Studies show pilots or crew members make at least one potentially hazardous error on 68 percent of commercial airline flights, but very few of these errors lead to an accident,” Madsen said. “Airlines need to institute policies that encourage learning from these seemingly innocuous near-misses.”
Specifically, airlines pay attention to near-misses that have led to accidents in the past, such as fire on the plane and ice build-up on wings. But they don’t look closely at near-misses that have yet to cause an accident, including an airplane rolling on the runway when it should be stopped.
“We’re not saying airlines aren’t doing a good job. They are paying attention to near-misses more than any other industry in the world,” Madsen said. “That said, near-misses that are considered benign might be slipping through the cracks.”
Examples of “benign” near-misses identified by researchers include incapacitation of a flight crew member, software or mechanical problems with cockpit displays, poor handling of aircraft while decelerating on the runway after touchdown, traffic congestion on the taxiway during aircraft taxiing and nuisance warnings and false alarms.
The researchers suggest airlines can improve in two ways. One is to continue successful data-collection efforts, but expand which near-misses are reported. The other is to remain vigilant toward deviations from normal and uncover root causes of the deviations.
Madsen said one way airline personnel can improve on the second point is by focusing on events the industry once considered unacceptable but now occur so often that they’ve come to be accepted as normal.
“It can be hard to learn from near-misses because we’re wired to ignore them,” Madsen said. “But the difference between a near-miss and a larger failure may only be good fortune.”
Funding for the study came in part from the U.S. Department of Homeland Security’s National Center for Risk and Economic Analysis of Terrorism Events.