Human error is implicated in
most, if not all, aviation accidents. Accident investigators,
therefore, need information, tools, and procedures to discover
the role human error has played in an accident/incident being
investigated. This course teaches the required material for investigators
(a) to identify the human error issues involved in an accident
wherever they occurred (e.g., in the cockpit, ATC, management,
maintenance, etc.), and (b) to know when and how to call on the
required Human Factors experts for further analysis.
The course starts with a brief review of the role of human error
in aviation accidents using the SHELL, Reason and Helmreich models
from an investigator perspective as organizing frameworks. A
taxonomy of unsafe acts (organization, supervisor, and operator)
is presented. The course then focuses on what the investigator
needs to know about the individual human and the various factors
which tend to make humans make mistakes including the ability
to process information, deal with a physiologically challenging
environment, and perform within a potentially sub-optimal workplace.
Training and negative transfer, as well as procedures, will also
be presented as additional factors leading to human error.
Although human error has
been implicated in 70 to 80% of all civil and military aviation accidents,
most accident reporting systems are not designed around any theoretical
framework of human error. As a result, most accident databases are not
conducive to a traditional human error analysis, making the identification
of intervention strategies onerous. What is required is a general
human error framework around which new investigative methods can be designed
and existing accident databases restructured. Indeed, a comprehensive
human factors analysis and classification system (HFACS) has recently been
developed to meet those needs. Specifically, the HFACS framework has
been used within the military, commercial, and general aviation sectors to
systematically examine underlying human causal factors and to improve
aviation accident investigations.
Building on the material presented,
the course will then provide an integrated discussion summarizing
from an investigator's perspective current understanding about
causes of human errors and what mechanisms should be in use for
their reduction. The course concludes by providing the accident
investigator with a systematic framework and process to identify
human error issues involved in an accident as well as the factors
which may have led to those errors.
