A Human Error Approach To Aviation Accident Analysis

Human error is implicated in nearly all aviation accidents, yet most investigation and prevention programs are not designed around any theoretical framework of human error. Appropriate for all levels of expertise, the book provides the knowledge and tools required to conduct a human error analysis of accidents, regardless of operational setting (i.e. military, commercial, or general aviation). The book contains a complete description of the Human Factors Analysis and Classification System (HFACS), which incorporates James Reason's model of latent and active failures as a foundation. Widely disseminated among military and civilian organizations, HFACS encompasses all aspects of human error, including the conditions of operators and elements of supervisory and organizational failure. It attracts a very broad readership. Specifically, the book serves as the main textbook for a course in aviation accident investigation taught by one of the authors at the University of Illinois. This book will also be used in courses designed for military safety officers and flight surgeons in the U.S. Navy, Army and the Canadian Defense Force, who currently utilize the HFACS system during aviation accident investigations. Additionally, the book has been incorporated into the popular workshop on accident analysis and prevention provided by the authors at several professional conferences world-wide. The book is also targeted for students attending Embry-Riddle Aeronautical University which has satellite campuses throughout the world and offers a course in human factors accident investigation for many of its majors. In addition, the book will be incorporated into courses offered by Transportation Safety International and the Southern California Safety Institute. Finally, this book serves as an excellent reference guide for many safety professionals and investigators already in the field.

This comprehensive book provides the knowledge and tools required to conduct a human error analysis of accidents. Serving as an excellent reference guide for many safety professionals and investigators already in the field.

The investigation and modelling of aviation accident causation is dominated by linear models. Aviation is, however, a complex system and as such suffers from being artificially manipulated into non-complex models and methods. This book addresses this issue by developing a new approach to investigating aviation accident causation through information networks. These networks centralise communication and the flow of information as key indicators of a system’s health and risk. This holistic approach focuses on the system environment, the activity that takes place within it, the strategies used to conduct this activity, the way in which the constituent parts of the system (both human and non-human) interact and the behaviour required. Each stage of this book identifies and expands upon the potential of the information network approach, maintaining firm focus on the overall health of a system. The book’s new model offers many potential developments and some key areas are studied in this research. Through the centralisation of barriers and information nodes the method can be applied to almost any situation. The application of Bayesian mathematics to historical data populations provides scope for studying error migration and barrier manipulation. The book also provides application of these predictions to a flight simulator study for the purposes of validation. Beyond this it also discusses the applicability of the approach to industry. Through working with a legacy airline the methods discussed are used as the basis for a new and prospective safety management system.

In this book the author applies contemporary error theory to the needs of investigators and of anyone attempting to understand why someone made a critical error, how that error led to an incident or accident, and how to prevent such errors in the future. Students and investigators of human error will gain an appreciation of the literature on error, with numerous references to both scientific research and investigative reports in a wide variety of applications, from airplane accidents, to bus accidents, to bonfire disasters. Features include: - an easy to follow step by step approach to conducting error investigations that even those new to the field can readily apply. - summaries of recent transportation accidents and human factors literature and relates them to the cause of human error in accidents. - an approach to investigating human error that will be of interest to both human factors psychology and industrial engineering students and instructors, as well as investigators of accidents in aviation, mass transportation, nuclear power, or any industry that is to the adverse effects of error. Based on the author's over 18 years of experience as an accident investigator and instructor of both aircraft accident investigation techniques and human factors psychology, it reviews recent human factors literature, summarizes major transportation accidents, and shows how to investigate the types of errors that typically occur in high risk industries. It presents a model of human error causation influenced largely by James Reason and Neville Moray, and relates it to error investigations with step by step guidelines for data collection and analysis that investigators can readily apply as needed.

Most aviation accidents are attributed to human error, pilot error especially. Human error also greatly effects productivity and profitability. In his overview of this collection of papers, the editor points out that these facts are often misinterpreted as evidence of deficiency on the part of operators involved in accidents. Human factors research reveals a more accurate and useful perspective: The errors made by skilled human operators - such as pilots, controllers, and mechanics - are not root causes but symptoms of the way industry operates. The papers selected for this volume have strongly influenced modern thinking about why skilled experts make errors and how to make aviation error resilient.

This book provides an overview of, and practical guidance on, the range of human factors (HF) methods that can be used for the purposes of accident analysis and investigation in complex sociotechnical systems. Human Factors Methods and Accident Analysis begins with an overview of different accident causation models and an introduction to the concepts of accident analysis and investigation. It then presents a discussion focussing on the importance of, and difficulties associated with, collecting appropriate data for accident analysis purposes. Following this, a range of HF-based accident analysis methods are described, as well as step-by-step guidance on how to apply them. To demonstrate how the different methods are applied, and what the outputs are, the book presents a series of case study applications across a range of safety critical domains. It concludes with a chapter focussing on the data challenges faced when collecting, coding and analysing accident data, along with future directions in the area. Human Factors Methods and Accident Analysis is the first book to offer a practical guide for investigators, practitioners and researchers wishing to apply accident analysis methods. It is also unique in presenting a series of novel applications of accident analysis methods, including HF methods not previously used for these purposes (e.g. EAST, critical path analysis), as well as applications of methods in new domains.

Why would highly skilled, well-trained pilots make errors that lead to accidents when they had safely completed many thousands of previous flights? The majority of all aviation accidents are attributed primarily to human error, but this is often misinterpreted as evidence of lack of skill, vigilance, or conscientiousness of the pilots. The Limits of Expertise is a fresh look at the causes of pilot error and aviation accidents, arguing that accidents can be understood only in the context of how the overall aviation system operates. The authors analyzed in great depth the 19 major U.S. airline accidents from 1991-2000 in which the National Transportation Safety Board (NTSB) found crew error to be a causal factor. Each accident is reviewed in a separate chapter that examines events and crew actions and explores the cognitive processes in play at each step. The approach is guided by extensive evidence from cognitive psychology that human skill and error are opposite sides of the same coin. The book examines the ways in which competing task demands, ambiguity and organizational pressures interact with cognitive processes to make all experts vulnerable to characteristic forms of error. The final chapter identifies themes cutting across the accidents, discusses the role of chance, criticizes simplistic concepts of causality of accidents, and suggests ways to reduce vulnerability to these catastrophes. The authors' complementary experience allowed a unique approach to the study: accident investigation with the NTSB, cognitive psychology research both in the lab and in the field, enormous first-hand experience of piloting, and application of aviation psychology in both civil and military operations. This combination allowed the authors to examine and explain the domain-specific aspects of aviation operations and to extend advances in basic research in cognition to complex issues of human performance in the real world. Although The Limits of Expertise is directed to aviation operations, the implications are clear for understanding the decision processes, skilled performance and errors of professionals in many domains, including medicine.

Human error plays a significant role in many accidents involving safety-critical systems, and it is now a standard requirement in both the US and Europe for Human Factors (HF) to be taken into account in system design and safety assessment. This book will be an essential guide for anyone who uses HF in their everyday work, providing them with consistent and ready-to-use procedures and methods that can be applied to real-life problems. The first part of the book looks at the theoretical framework, methods and techniques that the engineer or safety analyst needs to use when working on a HF-related project. The second part presents four case studies that show the reader how the above framework and guidelines work in practice. The case studies are based on real-life projects carried out by the author for a major European railway system, and in collaboration with international companies such as the International Civil Aviation Organisation, Volvo, Daimler-Chrysler and FIAT.