Incident reduction and risk migration

In 2002 an incident trend in Air Traffic Management in a European Centre was analysed from a Human Factors perspective, and a single solution was developed, which stopped the incidents occurring. Three years later a new incident trend appeared, which upon analysis appeared to be a more complex version of the former pattern. This required a more comprehensive analysis as well as a more co-ordinated and systemic approach to reduction. In the end, nine recommendations were made, of which more than half were implemented. The incidents stopped. This case study is used to highlight the issue of risk migration in the context of incident analysis and reduction.