Recognition primed decision making and the organisational response to accidents: Uberlingen and the challenges of safety improvement in European air traffic management

摘要

The pioneering work of Rasmussen, Reason and their colleagues has greatly improved our understanding of the longer term causes of adverse events in safety-critical systems. Far less attention has been paid to the organisational decision making that characterises the response to accidents and incidents. Therefore, this paper examines the interventions by national and international agencies after one of the most serious accidents in European Air Traffic Management. Insights from Naturalistic Decision Making (NDM) and Recognition Primed Decision Making (RPDM) are used to explain the complex ways in which technical, organisational and political constraints shape and support the decisions and actions taken by different agencies. These constraints affect national and international safety organisations in the aftermath of major accidents. In particular, this paper uses NDM and RPDM to assess the interventions made by Swiss Federal agencies and by the Air Navigation Service provider (ANSP) following the Uberlingen mid-air collision in July 1st 2002. Later sections show that there are strong similarities between the technical, organisational and political constraints that informed their decisions and the factors that directed the work of the European Organisation for the Safety of Air Navigation (EUROCONTROL). Some of EURO-CONTROL's safety responsibilities (i.e. the safety regulation elements) will in the future pass to the European Aviation Safety Agency (EASA), an Agency of the European Commission. This transfer of responsibilities has the potential to increase the powers available to ensure the implementation of recommendations following future accidents. At the same time there is a danger that key aspects of existing safety and regulatory activities may be overlooked. It is critical, therefore, that the same level of audit and monitoring be conducted on the European agencies during the transition period as is proposed for service providers and national regulatory agencies. It is important to ensure that these changes do not inadvertently lead to the loss of insights from previous adverse events.