WHEN AIRLINES EXPERIENCE ACCIDENTS
, they pull out all the stops to determine what went wrong and why in order to avoid similar accidents in the future. But “near-miss” incidents, where potential accidents have been avoided, don’t receive nearly as much scrutiny.
That means that airlines are missing opportunities to learn, according to research by Peter Madsen, an associate professor of organizational behavior and human resources at Brigham Young University in Provo, Utah; Robin Dillon-Merrill, a professor of operations and information management at Georgetown University’s McDonough School of Business in Washington, D.C.; and Catherine Tinsley, a professor of management, also at the McDonough School. When the researchers examined safety data from 64 U.S. commercial airlines from 1990 to 2007, they found that airlines did examine nearmiss incidents stemming from factors known to have caused accidents in the past, such as fires and ice buildup on wings. But they did not do the same with incidents that have yet to cause accidents, such as the incapacitation of crew members, technical issues with cockpit displays, taxiway congestion, or false alarms.
“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,” says Madsen. However, the researchers argue that just because such seemingly benign incidents haven’t yet caused accidents doesn’t mean they won’t.
For that reason, they recommend that airlines expand their data collection protocols to include all near-misses and work to uncover the root causes of all deviations from the norm—in short, to use them as opportunities to learn.
“It can be hard to learn from near misses because we’re wired to ignore them,” says Madsen. “But the difference between a near miss and a larger failure may only be good fortune.”
“Airline Safety Improvement through Experience with Near-Misses: A Cautionary Tale” was published online ahead of print October 27, 2015, in Risk Analysis.