**4. Results**

Each mandatory occurrence report (MOR) was thoroughly reviewed, and the content of the event and related actions carefully assessed. However, without an intimate knowledge of the operational environment, history of the aircraft reliability and related operational dynamic and contextual influences for example, it was not possible to definitively establish if the recorded causation and related factors were indisputably accurate for each event. Notwithstanding the foregoing, based on the authors experience and judgement the recorded causation factors were harmonised with a taxonomy derived from the elements of the Transport Canada [7] 'dirty dozen' terms associated with common error preconditions. The elements are generally identified as, Lack of communication, Distraction, Lack of resources, Stress, Complacency, Lack of teamwork, Pressure, Lack of awareness, Lack of knowledge, Fatigue, Lack of assertiveness, Norms.

The purpose of aligning the 'potential incident causation factors' with a known taxonomy is to assist with developing clear learning product content and learning objectives. Regulatory code or guidelines for the continuing airworthiness domain do not require a formal approach to learning such as those defined by Bloom [30] and Anderson and Sosniak [31]. Although the reports featured display similar activity profiles, recognition for the need to consider learning taxonomies and the importance of domains of learning (cognitive, affective and psychomotor) when designing continuation training programmes is considered essential. In addition, organisations are not required to have a formal mechanism of assessing efficacy, instead many take comfort in national, European and international holistic safety reports as a means of gauging their performance as part of the collective. Assuming the purpose of learning objectives is to

assist with the delivery and measurement of the effectiveness of learning actions, developing an overview of a harmonised taxonomy is helpful in this regard.

In Table 1 above, potential causation factors for each of the 15 selected incidents were matched with the twelve elements of the 'Dirty Dozen' human factor taxonomy. In order to prevent an over-simplification of each event's contributing factors, the authors were careful not to be seduced into seeking a singular root cause. Therefore, it was decided to include both primary and secondary human factor elements so that causation could be considered in a holistic manner. The following paragraphs (a–h) and Figure 3 give a breakdown of the issues emerging from the assessment of the mandatory occurrence reports (MOR's) as seen through the lens of association with a taxonomy.


**Figure 3.** Representation of primary and secondary causation in the reviewed occurrence reports.
