Jon Holbrook

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Focusing on undesired operator behaviors is pervasive in system design and safety management cultures in aviation. This focus limits the data that are collected, the questions that are asked during data analysis, and therefore our understanding of what operators do in everyday work. Human performance represents a significant source of aviation safety data that includes both desired and undesired actions. When safety is characterized only in terms of errors and failures, the vast majority of human impacts on system safety and performance are ignored. The outcomes of safety data analyses dictate what is learned from those data, which in turn informs safety policies and safety-related decision making. When learning opportunities are systematically restricted by focusing only on rare failure events, not only do we learn less (and less often), but we can draw misleading conclusions by relying on a non-representative sample of human performance data. Changes in how we define and think about safety can highlight new opportunities for collection and analysis of safety-relevant data. Developing an integrated safety picture to better inform safety-related decision making and policies depends upon identifying, collecting, and interpreting safety-producing behaviors in addition to safety-reducing behaviors. Opportunities and challenges in collecting and analyzing the largely unexploited data on desired, safety-producing operator behaviors are discussed.