Anne van Dalen

38 I Chapter 1 Aviation safety system perspective The safety initiatives of the aviation industry have been compared with those of healthcare. 15,26,27 Following a series of high-profile crashes that threatened the sustainability of the passenger jet industry, the National Aeronautics and Space Administration (NASA) research community and regulatory industries led investigations in the 1970s28. Since then, as part of joint NASA and Federal Aviation Administration (FAA) initiatives, behavioural science researchers have scrutinized tens of thousands of simulator and live flights. These recognized human performance as factors in aviation safety. 29–31 ‘NASA now operates an Aviation Safety Reporting System (ASRS) that offers the incentives of anonymity and immunity to pilots who report an unsafe situation within 10 days of its occurrence. 26 All identifying information in the report is then removed before the incident is investigated and any lessons are publicized.’ Later, if the FAA attempts to take punitive action against those involved, the ASRS reference number provides evidence of a constructive safety attitude, such that penalties are not imposed (provided that the mistakes were inadvertent and did not constitute a criminal offence). 26 Safety management system requirements have also been introduced into European Union (EU) law. The European aviation safety system is based on a comprehensive set of common safety rules, which are overseen by the European Commission, the European Aviation Safety Agency and the National Aviation Authorities. These rules are directly applicable to all EU member states. 17 In addition, the EU has regulated the reporting, analysis and follow-up of aviation safety threats. 32 The current legislation sets out how relevant safety information relating to civil aviation is reported, collected, stored, protected, exchanged, disseminated, analysed and acted upon. 17,33 The aviation industry holds Six Sigma (nearly perfect) safety records, because it uses the system approach, deals with errors non-punitively yet proactively, and reduces the consequences of error before escalation. 28,34–36 This way of reporting and managing error results in a ‘ just culture’, where aviation professionals feel confident to report events (even their own mistakes), by promoting balanced accountability for individuals and organizations responsible. 17 This is a critical ingredient to the creation of a safety