Military Aviation Incident Reporting from an HTO Perspective

Sammanfattning: The purpose of this study is to find out if the Swedish Air Force and the military aviation industry, Saab Aerosystems, use an HTO perspective in incident investigations. The research objectives are to explore existing organizational and accident models, analyze the reporting system using the models, and suggest possible improvements to the existing incident investigation system. Fishman’s (1999) model for pragmatic studies was used to describe the study’s theoretical approach. Triangulation by literary review, case study and interviews were used to ensure validity and reliability. Three models were chosen: Rollenhagen’s HTO model (1997), Leveson’s STAMP (2002), and Shappell and Wiegmann’s HFACS (2000). The models were further tested in the case study, revealing that their usefulness depends on type of incident, and that they leave a lot up to the investigator. Interviews were conducted with key individuals at Saab Aerosystems as well as at the Swedish Armed Forces’ Headquarters. The interviews showed that the incident reporting system in question is a well functioning one, mainly due to the blame-free culture, multidisciplinary investigative teams, good feedback and a generally good knowledge of the HTO concept. Difficulties within the organizations exist due to organizational boundaries between the manufacturer and the operator, and recurring structural reorganizations within the Swedish Armed Forces. Saab acknowledges the emphasis on technical issues. The Flight Safety department at the headquarters is currently working with implementing HFACS into the Flight Safety Database. Our recommendations for Saab Aerosystems and the Air Force include: For Saab Aerosystems: Evaluate and learn from existing HTO work within the organization, and incorporate the results into existing processes and instructions for incident investigations. Make use of the theoretical models, where applicable, in the processes as well. Focus on HFACS in order to synchronize with the Air Force. Consider employing an HTO specialist. For the Air Force: Consider influences from other HTO models, like Rollenhagen’s or Leveson’s models, while still in the development phase of implementing HFACS. Perform risk analyses regarding the effects on flight safety when doing reorganizations. For both Saab Aerosystems and the Air Force we recommend: Use Leveson’s model STAMP for complex and serious incidents, comprising of organizational, human and technical aspects.