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The evolution of error and violation descriptions in French Air Force accident reports

Authors : Aslanides, M., Nyssen, A-S., Valot, C., Amalberti, R.
HFAS International Journal, 2007

This paper compares the way human errors and violations were described in two series of accident reports, made before and after the introduction of the 1994 French Air Force Human Factors (HF) Safety Plan (1992-93 versus 1998-2002). The plan aimed at reducing the accident rate by installing a better safety culture with the introduction of multiple incentives, namely a voluntary reporting system and extensive Human Factors education programmes including CRM courses for all pilots, safety officers, and accident investigators. The paper analyses the conclusion sections of 70 accident investigations (35 before and 35 after the introduction of the plan), categorising coding the text from these conclusions to get equivalent semantic categories describing errors, violations and their attributed causes. The main results show a wider systemic consideration of factors in the reports and a more standardised phrasing of errors after the HF plan was introduced. The use of the term 'violation' is absent in both periods, replaced by several related, less emotive words (incorrect procedure, deviance, etc) – but which are also much more underspecified, thereby creating the potential for loopholes in the accurate description of causes contributing to the accidents and in proposing their associated solutions. (...)