Human Factors in Accident Investigation


Course Description

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.

Who Should Attend

  • Individuals who need to understand the human error issues in aviation accidents and how human error and human limitations can cause accidents.
  • Accident Investigators or those who participate in accident investigation.

How You Will Benefit

  • This course provides the accident investigator with a solid foundation for the recognition of 'Human Error' issues and a process to discover them. It can be taken individually or as part of a series of courses in the SCSI Aircraft Accident Investigation Certificate Program.
  • Practical examples and case studies will enhance your theoretical knowledge.
  • This course is accepted by the Board of Certified Safety Professionals for Continuance of Certification credit.
  • This course is one of the required courses for the Certificate in Aircraft Accident Investigation granted by SCSI.
  • SCSI will award 3.6 CEUs to each participant who successfully completes this course.

Course Topics

  • Human Factors and Human Error from an Investigator's Perspective.
  • Human Performance and Information Processing.
  • A General Model.
  • Illusions.
  • Stress and Fatigue.
  • Pilot Physiology.
  • The Ergonomics of the Cockpit Including Anthropometry, Different Populations and Gender.
  • Crashworthiness and Crew Survivibility.
  • Training and Negative Transfer.
  • Summary of Human Error Causes and Reduction Methods from an Accident Investigator Perspective.
  • Integrated Human Error Investigation Procedures Including Case Studies and Clues.
  • Introduction to Human Factors Analysis and Classification System.
  • The Psychology of Witness Interviewing Including the Interviewing of Key Witnesses Not Normally Associated with Basic Witness Interviewing (e.g., spouses of pilots, survivors, crew members with survivor syndrome, etc.)
  • Pressures on the Accident Investigation Team.
  • Critical Stress Syndrome and Trauma As it Relates to Witnesses and the Investigators.
  • Pathology: Medical Examiner Evidence and its Relationship to other Clues of Human Actions, Failure to Act and Interactions. What the Investigator can ask and obtain from the Aero-medical Examiner?
  • Automation and the Role of the Crew. Autonomy, Authority and Observability.
  • Case studies. Individual and Team Investigation Exercises.

Course Administration

The Human Factors in Accident Investigation Course consists of 5 training days. Students receive  class notes lecture outlines and additional reference material and a Certificate of Completion. The classes are held from 09:00- 17:00 each day.

Student Feedback

  • "Excellent class."
  • "Airline case study provided a great opportunity to discuss all of the issues surrounding automation human factors"
  • "The material was fascinating and presented in an entertaining manner."
  • "The case studies were great. Excellent explanations and  relating to real-world events."