An Integrated Framework for Implementing Safety-I and Safety-II Principles in Aviation Safety Management

Despite advanced aviation safety systems, recurring operational failures demonstrate that current safety management system (SMS) implementation practices remain predominantly reactive, with organizations adopting SMS frameworks theoretically embracing Safety-II philosophy while continuing Safety-I-oriented reactive management. This study develops an integrated framework for implementing both Safety-I and Safety-II principles in aviation safety management, addressing the gap between SMS theoretical requirements and actual implementation. Using the HEAR (human error analysis and reduction) framework, we analyzed three representative aviation cases involving FMS operation, turbulence response, and aircraft energy management through a qualitative multiple-case study design. Data collection utilized internal safety reports, official investigation reports, and reconstructed operational scenarios. The analysis employed a four-phase approach integrating predetermined categorization with inductive pattern recognition. Results revealed that 87% of all causes were organizational factors—6.7 times higher than individual/task factors (13%)—yet safety management responses primarily target individual behaviors. We defined “flight crew’s resilient behavior” and developed implementation guidelines by integrating the HEAR framework with the LPAC (learn, plan, adapt, coordinate) model and PAM (pressures, adaptations, and manifestations) framework. Effectiveness evaluation demonstrated a transition from 54 discrete contributing factors to 19 systematically related factors with clearer implementation pathways. Our integrated framework enables organizations to systematically implement both Safety-I analytical capabilities and Safety-II adaptive responses, transforming safety management from reactive “failure prevention” to proactive “success expansion”.