A Study on Practical Guidelines for Resilient Flight Operation Behavior Through Case Analysis Based on Integrated Safety Management System

This study focuses on the phenomenon of recurring specific failures in the aviation industry, despite maintaining high safety levels through advanced technology and sophisticated safety management systems. To overcome the limitations of the current Safety-I centered reactive safety management approach, which only addresses surface-level causes and solutions of failures, this study proposes a new integrated approach combining Safety-I and Safety-II. To achieve this, we applied the HEAR (Human Error Analysis and Reduction) framework, which has been validated in the railway sector, to analyze three types of failure cases in aviation - FMS (Flight Management System) operation errors, turbulence-related accidents, and aircraft energy management issues. The analysis revealed that organizational factors (87.1%) were more significant causes of failures than individual/task factors (12.9%). Furthermore, by combining Safety-II methodologies such as AA LIT (American Airlines' Learning and Improvement Team) and FSF LAO (Flight Safety Foundation's Learning from All Operations), we developed specific methods to transform failure cases into resilient success cases. This study emphasizes strengthening safety managers' capabilities and establishing systematic training programs, proposing a paradigm shift in aviation safety management from 'failure prevention' to 'success expansion.' This integrated approach is expected to contribute to improving aviation safety culture and operational performance.