ABSTRACT

The role event analysis has in the improvement of safety will be studied from a double perspective potential and uses of event analysis and the event-based learning cycle. The role of event analysis as a learning tool has ample recognition, as much from the technical field as from the philosophical or even the field of clinical psychology. The event analysis is especially useful to highlight parts of a process that do not function adequately, so long as there is sufficient information for its reconstruction. The use of event analysis to establish responsibility can have an antagonistic effect on the investigative process and on the very response capacity to an event. In commercial aviation, the element that initiates the process is the occurrence of an event. Since the beginning of commercial aviation, the identification of the causes of an event has been a basic tool of improvement. A single event can be the origin of important technological or procedural changes.