Beyond blame: A systemic accident analysis through a neutralized human factors taxonomy

Abstract

This paper investigates the usage of a systemic neutralized taxonomy for understanding human factors to foster a restorative culture when studying adverse events. The available studies supporting accident analysis from a system-theoretic perspective with human factors-based methods are grounded on error taxonomies and do not reinforce the non-judgemental dimension that is encouraged by modern safety science. We propose a methodology to integrate the system-theoretic accident analysis technique, Causal Analysis based on System Theory, with a neutralized taxonomy of human explanatory factors. The proposed methodology has been applied to an aviation accident involving a military aircraft and a glider. This case revealed various critical interactions among system components, which require dedicated safety recommendations that go beyond the identification of single points of failures and root causes, leading to a deeper understanding of socio-technical orchestrations. Despite the use case in aviation, the proposed methodology remains suitable for various types of safety occurrences in diverse domains and industrial settings. It also represents the basis for supporting future proactive safety-related decision-making processes.