سیستم های گزارش حادثه بحرانی: یک درک چند مرحله ای ضروری است

The nature of critical incident reporting systems and the reality of underreporting of critical incidents in complex socio-technical environments may have skewed our view of causality when it comes to safety management. This study explores the social construction of reporting through case based thematic analysis across three organizational levels and four stakeholder groups in an African Air Navigation Service Provider. The study shows that the reporting system and the act of reporting are not the only drivers. Reporting emerges as a mere actor, while new dimensions of safety drivers emerge from the study: safety also comes from a value contribution focus, a decentralized safety management approach, the centrality of reporting in a safety management system and the dependency on engaged relationships. The study concludes with an illustration of how these dimensions interact and inter-relate, and the necessity of such cognizance in system design and reviews.