Outcome-Based Risk Pathways: Utilizing Safety Reports to Understand Risks in Air Traffic Control

摘要

Many accident investigation taxonomies have been developed over the years to assist in identifying and classifying causal factors and errors involved in near misses events and accidents. While these taxonomies are often used to better understand individual events, they also offer the potential for quantifying the relationships between causal factors and errors to better understand emerging systemic issues. In an effort to extend beyond traditional frequency-based accident analysis, this work details the relationships among causal factors by examining any differences among outcome types. An analysis of 417 Aviation Safety Reporting System (ASRS) reports yielded five key risk pathways present in air traffic control safety events involving actual or near losses of standard separation minima. These risk pathways allow mitigation strategies to be targeted directly at the key causal factors in order to produce the greatest positive impact on the system as a whole.