Not another air crash investigation: Reading the black boxes of aviation safety cultures

David Falco Passenier

Research output: PhD ThesisPhD-Thesis - Research and graduation internal

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Abstract

This dissertation encompasses a set of studies that address persistent yet problematic assumptions about the way complex and hazardous technologies are operated by the members of aviation safety cultures. Aviation safety culture is often described as humble in terms of its acceptance of human errors and technical failures, underscored by the many redundancies, meticulous planning, and adherence to standard operating procedures. However, because of the extensive standardisation and conformity presumed necessary to stay in control, it is hard to grasp how deviations from standards belong to such a culture. Deviations from standards however are implied in the more varied, fragile, and messy processes by which operational experts are known to apply procedures and planning in practice. As I demonstrate in the introduction, essential knowledge about these deviating processes is easily ‘black-boxed’ in formal-legal narratives and theories applied to accident investigations. The central research question of my dissertation therefore is: What role do deviations from standards play in committed safety cultures? Reading this theoretical black box in the context of the Dutch commercial aviation industry, I find that deviations from standards reflect widespread ingenuity and dexterity of operational experts dealing with contradictions in complex sociotechnical systems. My studies find certain social and organisational processes responsible for dealing with contradictions when problems come to the surface. The overall response can be characterised as innovative deviance, driven by operational experts and relying on ‘accomplices’ amongst the authorities tasked with management, oversight, prosecution, and governance. The contextualising study in chapter 2 indicates that there is a social risk in deviating for aviation professionals, which creates some tensions. I observed how the tensions surface in flight crews’ work in the cockpit in the form of humour, emotions, and stress normally seen during the interactions of a routine working day. The study of airline pilots’ cockpit work practices in chapter 3 uncovers expert-drivers of the emergence and normalisation of organisational deviance, or routine nonconformity with procedures. I note that while seminal accident studies of NASA focuses on the negative consequences of deviance, I focus on positive consequences. Expertise development means developing intuition and using deviations from standards as opportunities to communicate about different intuitions between professionals with varying experience. There is an argument that ‘opening’ a theoretical black box can turn into an empty exercise if one ignores the moral and practical problems associated with them. In chapters 4 and 5 I therefore engage with the engineering disciplines. Their safety culture models are often a-political, while qualitative studies show that safety cultures develop through power and (office-) politics. By formalising these insights in a multi-agent model, chapter 4 translates the idea that safety commitment in organisational cultures does not always follow predictable paths. Instead, by modelling a maintenance company’s power relations and work process, and conducting simulations with this model, we demonstrate how commitment to safety emerges in non-linear ways from (mostly routine) work and social interactions. In chapter 5 I report how this methodology offered a useful alternative for safety management to existing theories in the case of a ground services organisation. The methodology may allow companies to achieve a fuller social understanding of safety commitment and help to apply control in more effective ways. These findings contribute to our understanding of safety cultures and also have wider implications. Innovative deviance represents practical innovations, such as workarounds and shortcuts, that enable people to realise cultural values. In other societal contexts and domains, innovative deviance may proceed differently than in the Netherlands. Further research should explore the social and organisational responses elsewhere, since it seems likely that innovative deviance is a phenomenon that is globally present.
Original languageEnglish
QualificationPhD
Awarding Institution
  • Vrije Universiteit Amsterdam
Supervisors/Advisors
  • Groenewegen, Peter, Supervisor
  • de Bakker, F.G.A., Supervisor
  • Wolbers, Jeroen Jan, Co-supervisor
Award date25 Mar 2021
Place of Publications.l.
Publisher
Print ISBNs9789464164589
Electronic ISBNs9789464164589
Publication statusPublished - 25 Mar 2021

Keywords

  • Safety culture
  • Organizational deviance
  • Risk management
  • Aviation
  • Improvisation
  • Ethnography
  • Agent modelling.

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