Integrating Threat and Error Management With Safety II Principles

This research develops a qualitative framework integrating Threat and Error Management (TEM) with Safety II principles, demonstrating how transitioning from “what went wrong” to “how work usually goes right” enhances accident investigation practice. Current accident investigation approaches identify failures but overlook how crews using similar decision‐making procedures achieve successful outcomes under comparable conditions. Traditional TEM analysis and Safety II principles have been applied separately, with limited research exploring their retrospective integration. The research employs a qualitative two‐stage methodology integrating traditional TEM analysis with Safety II principles through interpretive analysis of operational behaviours. Stage one employs conventional TEM analysis to identify threats, errors, and undesired aircraft states. Stage two integrates Safety II principles through Work‐as‐Imagined versus Work‐as‐Done analysis, Performance Variability Assessment, and Critical Decision Point Analysis. The Air India Express VT‐AYA runway excursion (2019) serves as the case study. Out of 18 identified TEM categories, 55% were managed effectively, and of the nine crew adaptation patterns, 67% represented beneficial or neutral performance variability, enhancing safety outcomes. Systematic breakdown occurred only when organisational goal conflicts exceeded the boundary where approximate adjustments could bridge procedural assumptions and operational reality, validating the Safety II principle that success and failure conditions are fundamentally similar. Integrated TEM and Safety II analysis reveals additional dimensions, goal conflicts, efficiency‐thoroughness trade‐offs, and adaptive capacity boundaries that conventional methods systematically overlook. While traditional TEM identifies what went wrong (threats, errors, undesired states), Safety‐II integration explains why the same adaptive processes that routinely ensure safety encountered systemic boundaries in this instance. The integrated methodology provides investigators a practical tool to operationalise Safety II principles. This approach contributes to the understanding of accident investigation from failure analysis to normal adaptive processes across high‐risk industries

Aviation · Crew · Crew resource management · Human error · Safety case · Safety culture · Air Traffic Management and Optimization · Human-Automation Interaction and Safety · Occupational Health and Safety Research

• Human Error

  Open Access•James Reason•Human Error•1990

  Add to list

• Safety–I and Safety–II

  Erik Hollnagel•Safety-I and Safety-II•2018

  Add to list