Strengths and advantages of the CIT

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INTRODUCTION

The above quotation is true for all humans, but society expects and even demands that some industries perform at such an elevated level that they constitute an errorless environment (Bosk, 2000). This is expected especially from the aviation, petrochemicals, nuclear power and health care industries. The industries in which critical incidents such as errors have to be avoided at all costs are those that operate as complex socio-technical systems in high-risk environments.1 The expectation of error-free operation is based on the realisation that a minor human error can have catastrophic consequences. Hence, the safety of each system that drives such industries depends on error-reporting practices which enable learning from errors with the goal of improving overall system performance. Staender (2011) regards learning from critical incidents as experience that leads to expertise, and argues that incident reporting offers this experience in the form of a window onto the system weaknesses that become visible.

Methodological issues

Finally, from a methodological perspective, almost all the prior research on the reporting of critical incidents and reporting systems is quantitative, and does not focus on the intricate deeper social context within which reporting or under-reporting occurs, and the subsequent reciprocal influences. Qualitative approaches have elicited limited content regarding a deeper understanding of the social construct of reporting. In other words, the behaviour of those who report critical incidents in the operational environment, which can produce or inhibit reporting, remains unexplored. The researcher believes that the status of unexplored social construction requires a qualitative approach to determine the range of reporting behaviour. Afterwards, a quantitative approach can be used to understand the depth of the relationships between the various antecedents and consequences that emerge from the qualitative study on reporting behaviour.

Practical issues

Complex problems cannot be fully described in books, but are ‘located in the indeterminate zones of practice’ and are often swamped by a multitude of other problems, and are frequently investigated without any rigour (Klein, 2004). Therefore, this study makes a practical contribution by applying rigour in understanding complex socio-technical system characteristics. One of the aims of a safety management system is to improve the frequency and quality of reporting. As the literature suggests, the reality of under-reporting indicates that this aim is not being reached. Hence, the researcher argues that the design of a critical incident reporting system has to include an understanding of the organisational behaviour that influences the act of reporting and the responses to it.

PURPOSE STATEMENT

The main purpose of this study is to determine the degree to which linear critical incident reporting systems account for the influence of organisational behaviour in the complex socio-technical system of an Air Navigation Service Provider (ANSP) in South Africa. The study also identifies the way in which complexity theory can inform and improve the design of reporting systems from a social-constructionist perspective.

DECLARATION
ACKNOWLEDGEMENTS
ABSTRACT
CHAPTER 1: INTRODUCTION
1.2.1 Defining a critical incident
1.2.2 Theoretical issues
1.2.3 Methodological issues
1.2.4 Practical issues
1.3 PURPOSE STATEMENT
1.4 RESEARCH OBJECTIVES
1.5 RESEARCH PHILOSOPHY
1.6 ACADEMIC VALUE AND CONTRIBUTION OF THE STUDY
1.6.1 Expected theoretical value
1.6.2 Expected methodological value
1.6.3 Expected practical value
1.6.4 Why three articles?
1.7 DELIMITATIONS AND ASSUMPTIONS
1.7.1 Delimitations
1.7.2 Assumptions
1.8 DEFINITION OF KEY TERMS
1.9 OUTLINE OF THE CHAPTERS IN THE STUDY
1.10 SUMMARY
CHAPTER 2: LITERATURE REVIEW
2.1 INTRODUCTION
2.2 ERROR REPORTING
2.2.1 What is reporting?
2.2.2 What qualifies as an error?
2.2.3 What is learning?
2.3 INCIDENT REPORTING LITERATURE
2.3.1 Aviation reporting systems
2.3.2 Purpose of a reporting system
2.4 CATEGORISATION OF INCIDENT REPORTING LITERATURE
2.4.1 Organisational systems and processes of reporting
2.4.2 Reporting system inefficiencies
2.4.3 Enablers and barriers to reporting
2.4.4 Culture, ethics and morals
2.4.5 Reporter perceptions and experiences of reporting
2.4.6 Summary of reporting-related literature
2.5 SYSTEM SAFETY AND SAFETY MANAGEMENT
2.5.1 Progression of safety as a science
2.5.2 Safety management
2.5.3 Safety as an epiphenomenon or non-event
2.5.4 Safety socially constructed
2.5.5 Hollnagel’s Safety-II
2.5.6 Safety as an emergent property?
2.5.7 Complexity of the safety system
CHAPTER 3: THEORIES AND TECHNIQUES
3.1 INTRODUCTION
3.2 CRITICAL INCIDENT TECHNIQUE (CIT)
3.2.1 Strengths and advantages of the CIT
3.2.2 Limitations of the CIT
3.2.3 Components of the CIT
3.2.4 CIT assumptions
3.3 SOCIAL CONSTRUCTION THEORY
3.3.1 Constructivism
3.3.2 Constructionism versus constructivism – what is the difference?
3.3.3 Social construction of reporting
3.3.4 Organisational system
3.3.5 What is constructed?
3.3.6 Ontological and epistemological foundations of the study
3.3.7 Principles of social construction theory
3.4 THEORIES THAT UNDERLIE COMPLEXITY THEORY
3.4.1 General Systems Theory (GST)
3.4.2 Cybernetics
3.4.3 Management cybernetics
3.4.4 GST and cybernetics
3.5 COMPLEXITY THEORY
3.5.1 The development of complexity theory
3.5.2 What is complex?
3.5.3 Complex and complicated
3.5.4 Complexity theory as a field of study
3.5.5 Rule-based and connectionist models
3.5.6 Complex system characteristics
3.5.7 Complex social systems
3.5.8 Limitations of complexity theory
3.6 SUMMARY
CHAPTER 4: RESEARCH DESIGN AND METHODS
4.1 INTRODUCTION
4.2 RESEARCH PARADIGM
4.3 DESCRIPTION OF THE CHOSEN INQUIRY STRATEGY AND BROAD RESEARCH DESIGN
4.3.1 The case for qualitative case-based research
4.3.2 Case study methodology
4.4 SAMPLING
4.4.1 Target population, context and units of analysis
4.4.2 Sampling method
4.4.3 Sample size
4.4.4 The three cases
4.5 DATA COLLECTION
4.5.1 Collection of the secondary data
4.5.2 Collection of primary data
4.6 DATA ANALYSIS
4.7 ASSESSING AND DEMONSTRATING THE QUALITY AND RIGOUR OF THE RESEARCH DESIGN
4.7.1 Credibility
4.7.5 Transferability
4.7.6 Validity and reliability
4.8 RESEARCH ETHICS
4.9 SUMMARY
CHAPTER 5: ARTICLE 1
CHAPTER 6: ARTICLE 2
CHAPTER 7: ARTICLE 3
CHAPTER 8: RESULTS AND DISCUSSION
8.1 INTRODUCTION
8.2 SECONDARY DATA
8.2.1 Safety management manual
8.2.2 Individual performance contracts
8.2.3 Critical incident investigation reports
8.2.4 Statistics on critical incident reports
8.2.5 Corporate communiqués and artefacts
8.2.6 Secondary data conclusion
8.3 UTILITY OF REPORTING
8.4 THE PRAGMATICS OF CRITICAL INCIDENT REPORTING
8.5 ALIGNING THE RESEARCH PROCESS, GOALS AND OUTCOMES WITH THE NEEDS AND VALUES OF THOSE AFFECTED BY THE STUDY.
8.5.1 The operators
8.5.2 Organisational levels of influence
8.5.3 Complexity approach to reporting
8.5.4 The existence of underreporting
8.5.5 Stakeholder conflict
8.6 FROM SOCIAL CONSTRUCTION TO COMPLEXITY
8.6.1 Theoretical exploration
8.6.2 The role of different disciplines, knowledge types and forms of knowledge
8.6.3 The implications of critical complexity for reporting in a socio-technical system
8.6.4 The case for social construction and complexity theory in safety management
8.7 CONCLUSION
CHAPTER 9: CONCLUSIONS, LIMITATIONS AND RECOMMENDATIONS
9.1 INTRODUCTION
9.2 RESEARCH OBJECTIVES
9.3 VALUE OF THE STUDY
9.3.1 Theoretical contribution of the study
9.3.2 Methodological contribution of the study
9.3.3 Practical contribution of the study
9.3.4 Why three articles?
9.4 QUALITY OF THE STUDY
9.4.1 Credibility
9.4.2 Member checking
9.4.3 Discrepant evidence
9.4.4 Triangulation
9.4.5 Transferability
9.4.6 Validity
9.4.7 Reliability
9.5 LIMITATIONS
9.6 RECOMMENDATIONS
9.6.1 Recommendations from a theoretical perspective
9.6.2 Recommendations from a methodological perspective
9.6.3 Recommendations from a practical perspective

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REPORTING FOR SAFETY: TOWARDS A COMPLEXITY FRAMEWORK INFORMING THE SOCIAL CONSTRUCTION OF REPORTING BY MULTI-LEVEL STAKEHOLDER BEHAVIOUR