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Found 74 results
  1. Content Article
    These slides provide the outline of a tutorial about the Causal Analysis using System Theory (CAST) and System-Theoretic Accident Model and Processes (STAMP) approaches to accident analysis, delivered at the Second STAMP Conference in 2013. The presentation slides cover: Model and method: Why STAMP and CAST? Why do accident analysis? Goals for an accident analysis technique Overcoming hindsight bias CAST worked example of emergency plane landing
  2. Content Article
    International Standards and Recommended Practices for aircraft accident and incident investigation.
  3. Content Article
    Adam Tasker spent over a decade in the Royal Navy before starting medical training at the University of Warwick. In this article for BMJ Leader, he reflects on a near miss incident that he was involved in while working as a Helicopter Warfare Officer, examining his attitudes and those of his colleagues, and the practices and behaviours of the squadron’s leaders. He compares his experience in the Royal Navy to that of his experience as a medical student, and identifies lessons that are relevant to medical training, professional expectations and the management of clinical incidents. These lessons aim to support the implementation of a Just Culture within the NHS.
  4. Content Article
    Healthcare can be risky. Adverse events carry a high cost – both human and financial – for health systems around the world. So in an effort to improve safety, many health systems have looked to learn from high-risk industries. The aviation and nuclear industries, for example, have excellent safety records despite operating in hazardous conditions. And increasingly, the tools and procedures these industries use to identify hazards are being adopted in healthcare. One prominent example involves the Hierarchy of Risk Controls (HoC) approach, which works by ranking the methods of controlling risks based on their expected effectiveness. According to HoC, the risks at the top are presumed to be more effective than those at the bottom. The ones at the top typically rely less on human behaviour: for example, a new piece of technology is considered to be a stronger risk control than training staff. This article looks more deeply at the (HoC) approach to explore its usefulness and effectiveness in healthcare. To investigate this issue, a team of social scientists examined the risk controls introduced by four hospital teams in England and Scotland after they had identified hazards in their systems. Findings: Most of these risk controls – 35 out of 42 – would be classified as ‘administrative’ by the HoC, and thus considered weak. The risk controls that fell into this ‘administrative’ category included training, standardising processes and procedures, and changing the design and organisation of care. Since other evidence shows these approaches can sometimes be very successful in healthcare, it is probably a mistake to automatically assume they are weak. Completely eliminating reliance on human behaviour is very difficult in the healthcare context and would introduce new risks. A rigid hierarchical approach to classifying risks may not be right for healthcare. Caution is needed before abandoning apparently weak interventions. Learning from other industries may be useful, but it is not always straightforward.
  5. Content Article
    In basic terms, a safety management system (SMS) is a formal arrangement for managing, assuring, and improving safety. An SMS is not a single document, it is a framework for managing all risks that arise from running a transport system. It defines roles and responsibilities, sets arrangements for safety mechanisms, involves workers in the process, and ensures continuous improvement. The Railways and Other Guided Transport Systems (Safety) Regulations 2006 (ROGS) introduced the requirement for and content of an SMS. The regulations require most railway operators to maintain an SMS, and hold a safety certificate or authorisation indicating that the SMS has been accepted by the Office of Rail and Road.
  6. Content Article
    The objective of a Safety Management System is to provide a structured management approach to control safety risks in operations. Effective safety management must take into account the organisation’s specific structures and processes related to safety of operations.
  7. Content Article
    On his last day in office at the Healthcare Safety Investigation Branch (HSIB), outgoing Chief Investigator Keith Conradi wrote to the Secretary of State for Health and Social Care reflecting on his time at HSIB. He outlined concerns about the approach of the Department of Health and Social Care (DHSC) and NHS England to patient safety work carried out by HSIB and the need to introduce a safety management system approach at all levels of healthcare. Patient Safety Learning also shared our thoughts on the issues raised in this letter and we were keen to explore these issues, and Keith’s experience as HSIB’s first Chief Investigator, in greater depth. Here, Patient Safety Learning provides an overview of the recent interview we had with Keith Conradi on this subject. The full transcript of the interview is available to download in the attachment at the end. To begin the interview, we discussed the events leading up to Keith joining HSIB as its first Chief Investigator. He spoke about his background as a pilot and then joining the Air Accidents Investigation Branch, first as an investigator before later becoming its Chief Investigator. There has been much written about the safety lessons that healthcare can learn from the aviation industry. Keith reflected on how his investigation roles in aviation helped to develop his understanding of the importance of creating a safety culture and the role of investigations as part of this. Subsequently he had been invited to a Select Committee inquiry considering the recurrence of avoidable harm in healthcare, where he noted that: “I gave some evidence and it made me aware for the very first time what went on in healthcare. I was quite surprised by how little professional safety investigation went on, and certainly not on a national scale.” One of the outcomes from this inquiry was to explore establishing a new independent, learning-focused safety investigation body in healthcare, the same model that exists in aviation. Keith, who was part of the Expert Advisory Group on this, reflected on the response from DHSC and NHS England at the time: “I think in terms of the specifics, in terms of doing safety investigations, I think there was a lot to learn and there was a curiosity but a lack of understanding of what it really meant. I think there had been such a punitive culture of blame it was hard for some to understand how investigations that avoided blame or liability could be achieved. I had a number of conversations with Jeremy Hunt explaining how it would work. There was some reluctance on whether people would accept it – not the investigation itself but the end results and what would they do with the outputs of a safety investigation and how could this make a difference.” Following this he applied for and was appointed as the Chief Investigator of the newly established HSIB in 2016. Improving investigations in healthcare Considering the significant career shift from aviation to healthcare, we asked Keith about what motivated him to make this move. He reflected on the challenge of this, saying: “I looked at healthcare and thought wow it was almost like the aviation industry 30/40 years ago and I thought it was a huge opportunity to introduce into healthcare some of the culture and safety professionalism that work in the aviation system. And it’s not very often you get the chance to set up something from scratch, which could potentially make a big difference.” He noted that there was a clear recognition at the time that safety investigations in healthcare weren’t being done well, that staff had little time or training to do this, and there was very little system thinking involved. However, before joining HSIB he wasn’t sure how professional safety investigations would fit within existing frameworks in healthcare. On this point, he said: “It opened my eyes to the fact that there was no structure in place at any particular level that was part of a foundation for a safety system. My experience was that some trusts did it well and that other trusts didn’t. It seemed to be down to the people who worked there and their experience or enthusiasm for patient safety that made the difference, rather than a specific organisational structure.” Discussing the quality of safety investigations in the NHS, Keith noted that this had definitely improved during his time at HSIB, with an increase in availability of training, including courses provided by HSIB, and the new Patient Safety Specialist roles. However, he also talked about the importance of having broader support for this, stating: “You can have the best investigation going on at the basic level but how the learning is acted upon is crucial. It has to come from the top to give it the necessary gravitas. Recognition of safety by the Chief Executive will drive its priority throughout the organisation.” One area that differs between healthcare and aviation is the level of engagement affected patients and families have as part of healthcare safety investigations. Keith noted that while there was still some involvement with families regarding airline investigations, such as asking how the pilot had spent their last 24 hours before they flew, this was on a very different scale to healthcare. Keith highlighted how HSIB had recognised the importance of patient and family involvement in investigations at an early stage, saying: “Some of the best information comes from families who may have sat by the bedside of a patient for sometimes days and weeks on end. It’s extraordinary how much insight they can give us about the culture on that ward. It’s a core part of any investigation and I think our family engagement has been one of the big successes to the investigation programme within HSIB.” Turning recommendations into improvement In our Mind the implementation gap report earlier this year, a key issue we highlighted was the need to ensure that there was a system-wide approach to not only sharing the findings and recommendations of HSIB investigations, but also effective transparent performance monitoring to ensure that the accepted recommendations translate into action and improvement. When asked about responses HSIB had first received to their safety recommendations, Keith said: “We were pleasantly surprised that many recommendations were accepted and acted upon – without a system in place and without legislation. But the next bit – have you done it, what difference does that make, what further needs to be done – needs to be addressed.” He spoke about there being some particularly good examples of sharing learning and improvements at a regional level from maternity investigations, but noted difficulties when it came to national bodies, stating: “With bigger organisations, and NHS England received most of our safety recommendations, it was harder to get a quick response and action started. In some organisations there just wasn’t a system in place to clearly identify the process of receiving, signing off and acting on safety recommendations. I understand that HSIB safety recommendations are a relatively new concept and anticipate that organisations will improve their handling of them over time.” In his letter to the Secretary of State, one particular issue he highlighted concerned delayed NHS England participation in HSIB Covid related investigations and how this reduced the safety impact of their output. We asked him about the sense of frustration that came across in how NHS England engaged with these investigations. Commenting on this, he said: “Our philosophy as we went through an investigation was to grab the experts from the national organisation early on, share the evidence we were uncovering and ask them, what do you think? In this way we could jointly start to develop a safety action or recommendation that was smart and pragmatic. This often started fairly quickly but often slowed during the approval process. I accept it is a large organisation with competing pressures and necessary checks and balances, but it felt, from our side, that a higher priority to responding to recommendations would allow valuable learning to be acted on more quickly. In some cases, it felt like everyone quickly agreed about what needed to be done but the final sign off still took an extraordinarily long time.” Transitioning from HSIB to HSSIB HSIB is currently going through an organisational transition to become the Health Services Safety Investigations Body (HSSIB). At the same time, their maternity investigations programme will be formed into a separate body, the Maternity and Newborn Safety Investigations (MNSI) Special Health Authority, with both organisations becoming operational in April 2023. We asked Keith what difference he thought this change would make, with HSSIB established as an independent executive non-departmental public body. While emphasising that for him HSIB had always acted impartially and independently of its parent body, NHS England, that this change was nonetheless a positive move: “It’s really important that NHS staff think of us as an independent body. I think most people did, but there were some people out there who thought, ‘hang on a minute you’re part of NHS England, how can I be really comfortable that what I’m saying won’t make its way back to them’. I think the complete legal independence will give everyone confidence to speak to HSSIB.” He also noted the importance of HSSIB having the legal powers to demand responses from all organisations, commenting: “There were isolated incidences where we didn’t get the information we wanted in a timely enough manner to make our reports even better and this legislation should ensure that this does not happen in the future.” During the passage of legislation to create HSSIB through Parliament there were significant concerns raised around proposals to strengthen ‘safe space’ powers for the new HSSIB. Organisations such as Action against Medical Accidents (AvMA), the Parliamentary and Health Service Ombudsman and the Professional Standards Authority for Health and Social Care have highlighted concerns about the negative impact this may have on patient rights and professional duty of candour. Asking Keith about his reflections on this, he said: “We have legal protection for information that has been given to us and this can only be disclosed through a High Court order, which is exactly how the transport industry operates. I understand the concerns some families may have – that certain witnesses may use this protection to tell us of wrongdoing or criminality, but that’s not the case. If people tell us of something they did that is illegal we are obliged to pass that information on to the appropriate authorities. What some people don’t understand is that information provided under that protected system is used to help us write the report; we just don’t attribute it to a named individual. It enables us to reveal the truth rather than conceal the truth. I do think that’s important. It demonstrably works in other sectors, and I have high confidence this will work in health.” Creating a safety management system One of the key areas where healthcare can potentially learn from the approach of other industries such as aviation, and something that Keith called on for in his letter to the Secretary of State, is the creation of a safety management system. We asked him to comment on what this would look like: “The basics of any safety management system is to have safety objectives, so you set out what you want to achieve. This requires assessment of the hazards and risks and the mitigation to those risks and these need to be transparent. You need an assurance process that constantly monitors the safety performance of the organisation and investigates incidents when they occur. This in turn will drive learning which will further improve safety and crucially embed a safety culture amongst all staff. All of this needs to be recognised at Board level, continually stretching the organisation’s safety objectives." He also emphasised the importance of Board level leadership in supporting this, saying: “A safety management system allows safety to be measured and treated in the same way as performance and other targets, and consequently given the same priority. I do not see this happening at present; it sometimes appears to be an irritation or a frustration, rather than something to build on, learn from and be proud of.” Keith noted that as part of this approach, safety investigations in aviation are an accepted part of the system, understood as being there to improve safety and for the benefit of everyone. Considering what would be needed to move towards this in healthcare, he commented: “There needs to be a willingness to learn from other industries. In fairness, taking a leap by bringing me in was a willingness to learn, but I don’t see this happening more widely. There are examples where people reach out and see how other industries are doing it but this isn’t done structurally. I did make some introductions with my old colleagues in aviation and I took some of the patient safety team to safety meetings I went to at the Department of Transport. I think having people see examples of how things are done elsewhere, accepting that there are huge differences in the way the operation takes place, is incredibly valuable.” Importance of leadership Turning back to Keith’s letter to the Secretary of State, we asked him about his comments on the lack of interest in the activity and potential of HSIB from successive NHS leaders. He acknowledged this, stating: “I was frustrated that some of the most senior people at NHS England did not appear to give patient safety the recognition I believe it requires.” Considering DHSC, he said that initially he had met with Jeremy Hunt regularly and credited him with driving much of the safety agenda, but noted that since his departure that attention had not been replicated. Highlighting the difference with aviation, he commented: “When I was in the Department of Transport, I regularly met with the Secretary of State. Just the fact that others in the organisation see you invited into the top office and having a chat sets a mark of the importance that is being set. Latterly, this didn’t happen in the DHSC and, unsurprisingly, the focus then moves elsewhere. It’s not personal but, as I said in my letter, you cannot delegate safety down the line. There are some key Chief Executives in the airline world and you can see the differences they made even within a safety management system. If you get someone at the highest level absolutely wedded to safety it really does motivate the workforce in that particular direction.” In the UK, the NHS pre-Covid estimate was that there were around 11,000 avoidable deaths annually due to safety concerns, with thousands more patients seriously harmed. This comes at a huge financial cost, with the Organisation for Economic Co-operation and Development (OECD) estimating that the direct cost of treating patients who have been harmed during their care in high-income countries approaches 13% of health spending. Given this context, we asked whether Keith found it surprising that patient safety isn’t treated as a higher priority. Reflecting on this, he said: “A safer hospital is a cheaper one to run. It’s obvious as is the fact that people die in hospitals, that’s the nature of the sector. However, a large number of these deaths are avoidable. However, unlike aviation, these avoidable deaths tend to happen individually and do not grab the headline attention that happens with a major transport disaster. This makes it difficult to galvanise leadership into seeing this as a massive problem. If 11,000 people died in one day in one hospital it would be seen as catastrophic, but it doesn’t happen like this, and this is something we have to contend with. This is why I keep coming back to the need to have a structure in place that continually assesses and mitigates risks.” Finally, we noted that this year a new Chair for the NHS was appointed, Richard Meddings, who like Keith was not from a healthcare background. We asked Keith what key takeaway message he would give him about improving patient safety healthcare and the need to create a safety management system: “People come into the industry and are not really aware of what it is [a safety management system] and what it could look like and the fact it exists. In the airline industry it became a legal requirement for every airline to have a safety management system. I would mandate it within an organisation. All the information is out there across different industries, and it can be started in a very simple form. It’s about opening people’s eyes to it and that it exists and getting the commitment and engagement to make it happen amongst everything else the healthcare system is trying to do. Not just opening their eyes, it also needs lateral thinking. With regard to the International Civil Aviation Organisation, it has published an annex for a safety management system which could serve as a starting point for healthcare. Many entities will have most of the elements already in place, but a safety management system will bring these together in a structured way and allow pragmatic action on the insight the system provides. If its embedded properly if will force you to act.” Download the full interview with Keith here: Keith Conradi interview_full transcript.pdf Further hub resources on Safety Management Systems HSE: Health and safety management systems Skybrary: Safety Management System in aviation What is safety management system? Rail Safety and Standards Board: Introduction to Safety Management System guidance Five Cornerstones to an Effective Safety Management System
  8. Content Article
    Safety in aviation and maritime domains has greatly improved over the years, but there is no room for complacency. This is especially the case as we approach systems with ever more automation and use of remote control in both industries. It is also more complicated because ‘human error’ is often seen as the root cause, when usually it is the system that leads people into mistakes, and seafarers and flight crew alike so often save the day. Accidents, incidents and near misses all offer us valuable lessons from which to improve safety, to do better next time. Yet in the aftermath of adverse events, the wish to blame someone, which makes sense of something that was never intended to happen, might make us lose sight of the real causes of accidents, leading to more tragedy and loss. The key to learning is using the right tool with which to understand what happened and why. This means going beyond the surface ‘facts’ and suppositions, seeing beneath the ‘usual suspects’ of factors that yield little in terms of how to prevent the next one. The SHIELD (Safety Human Incident & Error Learning Database) taxonomy has been developed by reviewing a number of existing taxonomies - in this case, a set of related terms for describing human performance and error - to derive a means of objectively classifying events in a way that helps us develop safety countermeasures afterwards. Whilst it can analyse single events it is particularly insightful when looking - and learning - across related events
  9. Content Article
    Eurocontrol’s HindSight magazine is a magazine on human and organisational factors in operations, in air traffic management and beyond. This issue is on the theme of Handling Surprises: Tales of the Unexpected. You will find a diverse selection of articles from frontline staff, senior managers, and specialists in operations, human factors, safety, and resilience engineering in the context of aviation, healthcare, maritime and web operations. The articles reflect surprise handling by individuals, teams and organisations from the perspectives of personal experience, theory, research and training. 
  10. Content Article
    Alarms are signals intended to capture and direct human attention to a potential issue that may require monitoring, assessment or intervention. They play a critical safety role in high-risk industries such as healthcare, which relies heavily on auditory and visual alarms. While there are some guidelines to inform alarm design and use, alarm fatigue and other alarm issues are challenges in the healthcare setting. The automotive, aviation, and nuclear industries have used the science of human factors to develop alarm design and use guidelines. This study in the journal Patient Safety aimed to assess whether these guidelines may provide insights for advancing patient safety in healthcare.
  11. Content Article
    A ‘Just Culture’ aims to improve patient safety by looking at the organisational and individual factors that contribute to incidents. It encourages people to speak up about their errors and mistakes so that action can be taken to prevent those errors from being repeated.  Adam Tasker and Julia Jones are graduate medical students at Warwick Medical School. They wanted to explore doctors’ perceptions of culture and identify ways to foster a Just Culture, so they conducted a qualitative research study at one of the hospitals where they were doing their medical training. We asked them about why Just Culture is important in the health and care system, and what they discovered from their research.
  12. Content Article
    Sometimes after an incident, a system-wide change is implemented that makes work more difficult and creates new problems. This story from aviation is one such example, which contains useful lessons for responding to rare events. Steven Shorrock recounts the tale. 
  13. Content Article
    Eurocontrol’s HindSight magazine is a magazine on human and organisational factors in operations, in air traffic management and beyond. This issue has articles from front-line staff and specialists in safety, human factors, and human and organisational performance, in aviation and elsewhere. The articles cover all aspects of everyday work, including routine work, unwanted events, and excellence. The authors discuss a variety of ways to learn from everyday work, including observation, discussion, surveys, reflection, and data analysis. There are articles on specific topics to help learn from others’ experience, including from other sectors in ‘views from elsewhere’
  14. Content Article
    Patient Safety Learning recently interviewed Keith Conradi, former HSIB chief executive, on why healthcare needs to operate as a safety management system. In this interview, we speak to Jono Broad, part of the South West Integrated Personalised Care team at NHS England, to hear his response to this, how patients, families and relatives can get involved, and why we need to really embed patient safety in a management culture and a healthcare management system.
  15. Event
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    This free webinar will uncover the intricacies of accident investigation from a human factors perspective. It will feature examples from rail, air and maritime from our speakers who are all specialist human factors investigators. Hear first hand how they tackle investigations and get insights into this vital work that lead to improvements in safety across all travel sectors. Will Tutton will briefly mention the Herald of Free Enterprise, but will mainly talk about the cargo vessel Kaami, which ran aground in Scotland in March 2020. The investigation focused on front line operators. Lisa Fitzsimons will talk about common themes relating to human performance and organisational factors which emerge when investigating the technical aspects of an air accident, drawing upon several recent examples. Becky Charles will discuss track worker safety and specifically about an incident which occurred at Margam, UK in July 2019 where two trackworkers were struck and fatally injured. Register
  16. Event
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    This free webinar will explore near misses in three different sectors and how controls can, or cannot, be developed to prevent future events. It will start with an introduction to the concept of near misses in healthcare and the challenges faced in learning from these near misses to improve safety. You will then hear how near misses are approached in rail and nuclear and how controls are developed in their processes. At this event, you’ll: Gain valuable insights from all three sectors: healthcare, rail and nuclear. Hear discussion about defining near misses with respect to controls. Learn how to build barriers in systems. Who will this be of interest to? This webinar will be of interest to anyone involved in the management of safety events in their industry/ organisation, and especially human factors practitioners, safety investigators, policy leads and regulators. Register
  17. Content Article
    This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Laura and Suzy talk to us about the importance of embedding human factors in the design of healthcare systems and tools, the importance of equipping staff to think about system safety, and their work to establish a nationwide conversation about the impact of fatigue.
  18. Content Article
    This report contains the findings and recommendations of the Organization Designation Authorization (ODA) Expert Review Panel formed under Section 103 of the 2020 Aircraft Certification, Safety, and Accountability Act (ACSAA). Reporting to the US Federal Aviation Administration (FAA) and Congressional committees of jurisdiction, the Expert Panel reviewed the safety management processes and their effectiveness for each holder of an ODA for the design and production of transport aeroplanes. Key findings of the Expert Panel There is a disconnect between Boeing’s senior management and other members of the organisation on safety culture. Interviewees, including ODA Unit Members (UM), also questioned whether Boeing’s safety reporting systems would function in a way that ensures open communication and non-retaliation. The Expert Panel also observed inadequate and confusing implementation of the five components of a positive safety culture (Reporting Culture, Just Culture, Flexible Culture, Learning Culture, and Informed Culture). Boeing’s Safety Management System (SMS) procedures reflect the International Civil Aviation Organization (ICAO) and the FAA SMS frameworks. However, the Boeing SMS procedures are not structured in a way that ensures all employees understand their role in the company’s SMS. The procedures and training are complex and in a constant state of change, creating employee confusion especially among different work sites and employee groups. There is a lack of awareness of safety-related metrics at all levels of the organisation; employees had difficulty distinguishing the differences among various measuring methods, their purpose, and outcomes. Boeing’s restructuring of the management of the ODA unit decreased opportunities for interference and retaliation against UMs, and provides effective organisational messaging regarding independence of UMs. However, the restructuring, while better, still allows opportunities for retaliation to occur, particularly with regards to salary and furlough ranking. This influences the ability of UMs to execute their delegated functions effectively. The Expert Panel also found additional issues at Boeing that affect aviation safety, which include inadequate human factors consideration commensurate to its importance to aviation safety and lack of pilot input in aircraft design and operation.
  19. Content Article
    The International Civil Aviation Organization (ICAO) High-level Safety Conference (HLSC) held in 2010 provided the impetus for the development of a new Annex dedicated to Safety Management.  An Annex dedicated to safety management will re-enforce the role played by the State in managing safety at the State level, stressing the concept of overall safety performance in all domains, in coordination with service providers. 
  20. Content Article
    This podcast by the National Patient Safety Board asks how healthcare can address the systemic challenges that have prevented progress on patient safety for decades. Hosted by Karen Wolk Feinstein, this episode looks at lessons that can be taken from other industries that have made safety a top priority. Karen talks to guests Professor Nancy Leveson, engineer and systems safety expert, and Dr. Michael Shabot, former healthcare executive and expert in high-reliability healthcare safety and quality.
  21. Event
    Join the Airport Training Experts Miroslav SPAK and Frederic Rooseleer for a 90 minutes live training session. Enhanced operational efficiency and sustainability can be achieved by optimising the current operations through implementation of advanced solutions maximizing utilisation of the airport capacity. These solutions have been initially developed and validated under SESAR, and recently packaged by EUROCONTROL to cover Runway Performance, Surface Management and Total Airport Management. This webinar will provide information on the total airport management building blocks and also a review of the key runway performance solutions available for deployment as well as their benefits, supporting implementation needs and reference material. Register
  22. Content Article
    Safety voice is theorised as an important factor for mitigating accidents, but behavioural research during actual hazards has been scant. Research indicates power distance and poor listening to safety concerns (safety listening) suppresses safety voice. Yet, despite fruitful hypotheses and training programmes, data is based on imagined and simulated scenarios and it remains unclear to what extent speaking-up poses a genuine problem for safety management, how negative responses shape the behaviour, or how this can be explained by power distance. Moreover, this means it remains unclear how the concept of safety voice is relevant for understanding accidents. To address this, 172 Cockpit Voice Recorder transcripts of historic aviation accidents were identified, integrated into a novel dataset , coded in terms of safety voice and safety listening and triangulated with Hofstede’s power distance. Results revealed that flight crew spoke-up in all but two accidents, provided the first direct evidence that power distance and safety listening explain variation in safety voice during accidents, and indicated partial effectiveness of CRM training programmes because safety voice and safety listening changed over the course of history, but only for low power distance environments. Thus, findings imply that accidents cannot be assumed to emerge from a lack of safety voice, or that the behaviour is sufficient for avoiding harm, and indicate a need for improving interventions across environments. Findings underscore that the literature should be grounded in real accidents and make safety voice more effective through improving ‘safety listening’.
  23. Content Article
    'The Theatre: Surgical Learning & Innovation Podcast' is a podcast by the Royal College of Surgeons of England. This episode features a panel discussion on the nature of “human factors” in surgery, presented by Peter Brennan, consultant oral and maxillofacial surgeon, Louise Cousins, trainee general surgeon, Neil Tayler, British Airways pilot and trainer, and Graham Shaw, also a British Airways pilot and Director of Critical Factors, a consulting and training service for professionals operating in safety-critical environments.
  24. Content Article
    This is the final report of the accident on 1 June 2009 to the Airbus A330-203 registered F-GZCP operated by Air France flight AF 447 Rio de Janeiro - Paris. The investigation was carried out by the BEA, the French Civil Aviation Safety Investigation Authority.
  25. Content Article
    Over the few years, the Royal Air Force (RAF) has been going through a cultural evolution. In this episode of the Human Factors podcast, Ian James and Avril Webb give an insight into how the implementation of Human Factors and attitudes to safety have evolved in the RAF, and the positive impact this has had on the organisation.
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