# Safety Voice and Safety Listening During Aviation Accidents: Cockpit Voice Recordings Reveal That Speaking-Up to Power Is Not Enough *Noort, Reader & Gillespie · Voice & Silence, Safety & Error, Power & Equity, Culture & Context · Safety Science · 2021 · Paywalled* Speaking up is necessary and not sufficient, and this is the paper that demonstrates the second half at scale. Noort, Reader and Gillespie coded 14,128 conversational turns from 172 cockpit voice recorder transcripts of aviation accidents between 1962 and 2018, asking whether accidents happen because nobody raised the hazard. Overwhelmingly they do not: safety voice occurred in all but two of the 172 accidents. What varied was what happened next, and the construct the paper contributes is safety listening, coded from the response in the three turns following each act of voice, from disaffirmed through ignored to affirmed and acted upon. Poor listening reduced the amount of subsequent voice in a transcript, did so specifically for junior crew, who were listened to less than senior crew throughout, and went with more damage to the aircraft. The finding is easily misread as a demotion of voice, and it is not one. A concern raised and ignored is a failure with a remedy, because the information reached the flight deck and something could still have been done with it. A concern never raised leaves nothing to act on at all, and no amount of good listening recovers it. The asymmetry matters for practice: this is evidence that speak-up training has been working on the more tractable half of the problem, not evidence that the half it worked on was the wrong one. The authors set it out as a threat mitigation chain running from hazard to concern to voice to listening to mitigation, and argue the field should move from making safety voice more likely to making it more effective. The power distance results are more tangled than the abstract suggests, and two of the three hypotheses about it failed. Junior crew spoke up less where power distance was high while senior crew spoke up more, an interaction with seniority rather than a main effect; but power distance did not predict poor listening to juniors, and listening did not mediate what it was predicted to mediate. The paper therefore supplies the first behavioural support for the claim that power distance suppresses junior voice while removing the mechanism usually offered for it. Safety listening improved across the period only in low power distance countries, which is the sharpest practical claim here: CRM as delivered has not transferred to the environments the power distance argument says need it most. Read the design honestly, because the authors do. The sample is accidents and only accidents, with no normal flights and no near misses, so nothing here compares crews who crashed with crews who did not, and the authors state plainly that attributing blame from this data is invalid rather than merely undesirable. An absence of coded voice is not silence, since someone may say nothing because they have nothing to say. The effects are directional rather than large, the voice models accounting for around 4% of variance, interrater reliability was 0.62 computed on two transcripts, a handful of reported test statistics sit oddly with their stated p values, and power distance is Hofstede's national index attached to the airline's country of registration rather than to anyone actually on the flight deck. - **This page:** https://explore.psychsafety.com/n/noort-reader-gillespie-2021/ - **View the source paper:** https://doi.org/10.1016/j.ssci.2021.105260 - **Interactive map:** https://explore.psychsafety.com/?mode=papers&node=noort-reader-gillespie-2021 ## Neighbours (20) - [Psychological Safety and Learning Behavior in Work Teams](https://explore.psychsafety.com/n/edmondson-1999.md) (paper) - [Employee Voice and Silence](https://explore.psychsafety.com/n/morrison-2014.md) (paper) - [Crew Resource Mgmt](https://explore.psychsafety.com/n/crew-resource-management-and-psychological-safety.md) - [Human Error: Models and Management](https://explore.psychsafety.com/n/reason-2000.md) (paper) - [Independent Review on the Care Given to Mrs Elaine Bromiley](https://explore.psychsafety.com/n/harmer-bromiley-2005.md) (paper) - [Leadership Behavior and Employee Voice: Is the Door Really Open?](https://explore.psychsafety.com/n/detert-burris-2007.md) (paper) - [The Evolution of Crew Resource Management Training in Commercial Aviation](https://explore.psychsafety.com/n/helmreich-merritt-wilhelm-1999.md) (paper) - [Crisis-Ready Teams: Data-Driven Lessons from Aviation, Nuclear Power, Emergency Medicine, and Mine Rescue](https://explore.psychsafety.com/n/waller-kaplan-2024.md) (paper) - [Making it Safe: The Effects of Leader Inclusiveness and Professional Status on Psychological Safety and Improvement Efforts in Health Care Teams](https://explore.psychsafety.com/n/nembhard-edmondson-2006.md) (paper) - [Reducing Power Gradients](https://explore.psychsafety.com/n/reducing-power-gradients.md) - [Silence That May Kill: When Aircrew Members Don't Speak Up and Why](https://explore.psychsafety.com/n/bienefeld-grote-2012.md) (paper) - [The Deepwater Horizon Explosion: Non-Technical Skills, Safety Culture, and System Complexity](https://explore.psychsafety.com/n/reader-oconnor-2014.md) (paper) - [Amplifying Weak Signals](https://explore.psychsafety.com/n/amplifying-weak-signals.md) - [CAP 737: Flight-crew Human Factors Handbook](https://explore.psychsafety.com/n/caa-2023-cap737.md) (paper) - [PS in Aviation](https://explore.psychsafety.com/n/psychological-safety-aviation.md) - [Safety in High-Reliability Organizations: The Role of Upward Voice, Team Learning, and Safety Climate](https://explore.psychsafety.com/n/silla-gajudo-gracia-2025.md) (paper) - [Speaking Up at Work](https://explore.psychsafety.com/n/speaking-up-at-work.md) - [The Persistence of Safety Silence: How Flight Deck Microcultures Influence the Efficacy of Crew Resource Management](https://explore.psychsafety.com/n/perkins-et-al-2022.md) (paper) - [Exploring the Core of Crew Resource Management Course: Speak Up or Stay Silent](https://explore.psychsafety.com/n/espevik-saus-olsen-2017.md) (paper) - [Present but Useless: Why Power and Culture Create Structural Silence in the Cockpit](https://explore.psychsafety.com/n/guo-yang-2026.md) (paper)