Redefining the incidents to learn from: Safety science insights acquired on the journey from black boxes to Flight Data Monitoring

摘要

The reason Flight Data and Cockpit Voice Recorders (FDRs and CVRs) exist is to learn from incidents. Probably no other single invention has yielded such significant improvements in aviation safety. Indeed, they have been so effective that we now need to redefine what is meant by the term 'incident' and the uses to which data recording technologies are now put. The paradox is that at no previous point in history have we collected so much data, yet safety performance is such that it is rarely used for its original purpose: as a lagging indicator of problems following an accident. In this paper the history of black boxes is briefly surveyed and connected to the underlying safety science knowledge base. Flight Data Monitoring (FDM) is then presented as an exemplar of the paradigm shift from lagging to leading indicators needed in order to continue learning from incidents. In many industries the pre-requisites for comparable Data Monitoring processes are already in place. The benefits to be accrued by following the example set by the aviation industry are considerable. (c) 2017 Elsevier Ltd. All rights reserved.