ABSTRACT
It has been widely accepted that the ATM system has achieved a very high safety record mainly through a structured process of incident analysis and a continuous learning process. Aviation industry's commitment to incident and near miss analysis has been exemplified in a set of detailed ICAO documents under the collective term of incident investigation and prevention (i.e., Group 176 of ICAO publications). The aim of incident investigation is to map out the accident trajectory and identify root causes in terms of ‘defenses-in-depth’ that did not work out. The investigation process represents the culmination of an industry wide belief that a thorough examination and a deeper understanding should be achieved about what really happened and what went wrong. There is still a growing effort to develop incident investigation techniques and accident causation models that look deeper into the systemic factors and their dynamics that make a fertile ground for safety critical events. Examples of systemic factors include, the interplay between human and organizational performance, the management of goal trade-offs and the inherent variability of organizational processes.
