A Human Error Approach to Aviation Accident Analysis

The Human Factors Analysis and Classification System

Author: Douglas A. Wiegmann,Scott A. Shappell

Publisher: Routledge

ISBN: 1351962353

Category: Technology & Engineering

Page: 184

View: 6144

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.
Posted in Technology & Engineering

Human Factors Models for Aviation Accident Analysis and Prevention

Author: Thomas G.C. Griffin,Mark S. Young,Neville A. Stanton

Publisher: CRC Press

ISBN: 1317120108

Category: Transportation

Page: 226

View: 4253

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.
Posted in Transportation

Investigating Human Error: Incidents, Accidents, and Complex Systems

Author: Barry Strauch

Publisher: Routledge

ISBN: 1351926292

Category: Transportation

Page: 324

View: 7967

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.
Posted in Transportation

Human Factors Methods and Accident Analysis

Practical Guidance and Case Study Applications

Author: Dr Guy H Walker,Dr Daniel P Jenkins,Dr Laura A Rafferty,Dr Michael G Lenné,Professor Neville A Stanton,Professor Paul M Salmon

Publisher: Ashgate Publishing, Ltd.

ISBN: 1409486850

Category: Technology & Engineering

Page: 216

View: 2895

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.
Posted in Technology & Engineering

Managing Maintenance Error

A Practical Guide

Author: James Reason,Alan Hobbs

Publisher: CRC Press

ISBN: 1351920510

Category: Technology & Engineering

Page: 200

View: 4478

Situations and systems are easier to change than the human condition - particularly when people are well-trained and well-motivated, as they usually are in maintenance organisations. This is a down-to-earth practitioner’s guide to managing maintenance error, written in Dr. Reason’s highly readable style. It deals with human risks generally and the special human performance problems arising in maintenance, as well as providing an engineer’s guide for their understanding and the solution. After reviewing the types of error and violation and the conditions that provoke them, the author sets out the broader picture, illustrated by examples of three system failures. Central to the book is a comprehensive review of error management, followed by chapters on:- managing person, the task and the team; - the workplace and the organization; - creating a safe culture; It is then rounded off and brought together, in such a way as to be readily applicable for those who can make it work, to achieve a greater and more consistent level of safety in maintenance activities. The readership will include maintenance engineering staff and safety officers and all those in responsible roles in critical and systems-reliant environments, including transportation, nuclear and conventional power, extractive and other chemical processing and manufacturing industries and medicine.
Posted in Technology & Engineering

Handbook of Aviation Human Factors, Second Edition

Author: John A. Wise,V. David Hopkin,Daniel J. Garland

Publisher: CRC Press

ISBN: 9781420063578

Category: Technology & Engineering

Page: 704

View: 8745

A complete examination of issues and concepts relating to human factors in simulation, this book covers theory and application in space, ships, submarines, naval aviation, and commercial aviation. The authors examine issues of simulation and their effect on the validity and functionality of simulators as a training device. The chapters contain in depth discussions of these particular characteristics and issues. They also incorporate theories pertaining to the motivational aspects of training, simulation of social events, and PC based simulation.
Posted in Technology & Engineering

Basic Guide to System Safety

Author: Jeffrey W. Vincoli

Publisher: John Wiley & Sons

ISBN: 1118904869

Category: Technology & Engineering

Page: 256

View: 3137

This book provides guidance on including prevention through design concepts within an occupational safety and health management system. Through the application of these concepts, decisions pertaining to occupational hazards and risks can be incorporated into the process of design and redesign of work premises, tools, equipment, machinery, substances, and work processes including their construction, manufacture, use, maintenance, and ultimate disposal or reuse. These techniques provide guidance for a life-cycle assessment and design model that balances environmental and occupational safety and health goals over the life span of a facility, process, or product. The new edition is expanded to include primer information on the use of safety assurance techniques in design and construction.
Posted in Technology & Engineering

Beyond Aviation Human Factors

Safety in High Technology Systems

Author: Daniel E. Maurino,James Reason,Neil Johnston,Rob B. Lee

Publisher: Routledge

ISBN: 1351955691

Category: Transportation

Page: 181

View: 6723

The authors believe that a systematic organizational approach to aviation safety must replace the piecemeal approaches largely favoured in the past, but this change needs to be preceded by information to explain why a new approach is necessary. Accident records show a flattening of the safety curve since the early Seventies: instead of new kinds of accident, similar safety deficiencies have become recurrent features in accident reports. This suggests the need to review traditional accident prevention strategies, focused almost exclusively on the action or inaction’s of front-line operational personnel. The organizational model proposed by the authors is one alternative means to pursue safety and prevention strategies in contemporary aviation; it is also applicable to other production systems. The model argues for a broadened approach, which considers the influence of all organizations (the blunt end?) involved in aviation operations, in addition to individual human performance (the sharp end?). If the concepts of systems safety and organizational accidents are to be advanced, aviation management at all levels must be aware of them. This book is intended to provide a bridge from the academic knowledge gained from research, to the needs of practitioners in aviation. It comprises six chapters: the fundamentals, background and justification for an organizational accident causation model to the flight deck, maintenance and air traffic control environments. The last chapter suggest different ways to apply the model as a prevention tool which furthermore enhances organizational effectiveness. The value of the organizational framework pioneered by Professor Reason in analyzing safety in high-technology production systems is felt by his co-authors to have an enduring role to play, both now and in coming decades. Applied now in this book, it has been adopted by ICAO, IFATCA, IMO, the US National Transportation Safety Board, the Transportation Safety B
Posted in Transportation

Human Performance and Limitations in Aviation

Author: R. D. Campbell,Michael Bagshaw

Publisher: John Wiley & Sons

ISBN: 1405147342

Category: Technology & Engineering

Page: 208

View: 5312

Human error is cited as a major cause in over 70% of accidents, and it is widely agreed that a better understanding of human capabilities and limitations - both physical and psychological - would help reduce human error and improve flight safety. This book was first published when the UK Civil Aviation Authority introduced an examination in human performance and limitations for all private and professional pilot licences. Now the Joint Aviation Authorities of Europe have published a new syllabus as part of their Joint Aviation Requirements for Flight Crew Licensing. The book has been completely revised and rewritten to take account of the new syllabus. The coverage of basic aviation psychology has been greatly expanded, and the section on aviation physiology now includes topics on the high altitude environment and on health maintenance. Throughout, the text avoids excessive jargon and technical language. "There is no doubt that this book provides an excellent basic understanding of the human body, its limitations, the psychological processes and how they interact with the aviation environment. I am currently studying for my ATPL Ground Exams and I found this book to be an invaluable aid. It is equally useful for those studying for the PPL and for all pilots who would like to be reminded of their physiological and psychological limitations." –General Aviation, June 2002
Posted in Technology & Engineering

Advances in Aviation Psychology

Author: Michael A. Vidulich,Pamela S. Tsang,John Flach

Publisher: Routledge

ISBN: 1317185234

Category: Psychology

Page: 302

View: 1562

Aviation remains one of the most active and challenging domains for human factors and applied psychology. Since 1981, the biennial International Symposium on Aviation Psychology (ISAP) has been convened for the purposes of (a) presenting the latest research on human performance problems and opportunities within aviation systems, (b) envisioning design solutions that best utilize human capabilities for creating safe and efficient aviation systems, and (c) bringing together scientists, research sponsors, and operators in an effort to bridge the gap between research and application. Though rooted in the presentations of the 17th ISAP, held in 2013 in Dayton, Ohio, Advances in Aviation Psychology is not simply a collection of selected proceeding papers. Based upon the potential impact on emerging trends, current debates or enduring issues present in their work, select authors were invited to expand on their work following the benefit of interactions at the symposium. The invited authors include the featured keynote and plenary speakers who are all leading scientists and prominent researchers that were selected to participate at the symposium. These contributions are supplemented by additional contributors whose work best reflects significant developments in aviation psychology. Consequently the volume includes visions for the next generation of air management and air traffic control, the integration of unmanned (i.e. remotely piloted vehicles) into operational air spaces, and the use of advanced information technologies (e.g. synthetic task environments) for research and training. This book is the first in a series of volumes to be published in conjunction with each subsequent ISAP. The aim of each volume is not only to report the latest findings in aviation psychology but also to suggest new directions for advancing the field.
Posted in Psychology

Human Error in Aviation

Author: R.Key Dismukes

Publisher: Routledge

ISBN: 1351563475

Category: Psychology

Page: 608

View: 6502

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.
Posted in Psychology

Aircraft Accident Investigation

Author: Richard H. Wood,Robert W. Sweginnis

Publisher: N.A

ISBN: 9781892944177

Category: Aeronautics

Page: 516

View: 4123

This book covers all aspects of aircraft accident investigation including inflight fires, electrical circuitry, and composite structure failure. The authors explain basic investigation techniques and procedures required by the National Transportation Safety Board (NTSB) and the International Civil Aviation Organization (ICAO). There are also chapters on accident analysis, investigation management, and report writing. The appendices include the Code of Ethics and Conduct of the International Society of Air Safety Investigators.
Posted in Aeronautics

Safer Complex Industrial Environments

A Human Factors Approach

Author: Erik Hollnagel

Publisher: CRC Press

ISBN: 9781420092493

Category: Technology & Engineering

Page: 264

View: 1751

While a quick response can save you in a time of crisis, avoiding a crisis remains the best defense. When dealing with complex industrial systems, it has become increasingly obvious that preparedness requires a sophisticated understanding of human factors as they relate to the functional characteristics of socio-technology systems. Edited by industrial safety expert Erik Hollnagel and featuring commentary from leaders in the field, Safer Complex Industrial Environments: A Human Factors Approach examines the latest research on the contemporary human factors approach and methods currently in practice. Drawing on examples mainly from the nuclear industry, the book presents a contemporary view on human factors in complex industrial systems. The contributors contrast the traditional view of human factors as a liability with the contemporary view that recognizes human factor as also an asset without which the safe and efficient performance of complex industrial systems would be impossible. It describes how this view has developed in parallel to the increasing complexity and intractability of socio-technical systems and partly as a consequence of that. The book also demonstrates how this duality of the human factor can be reconciled by recognizing that the human and organizational functions that can be the cause of adverse events are also the very foundation for safety. Building on this, the book introduces theories and methods that can be used to describe human and collective performance in a complex socio-technical environment. It explores how contemporary human factors can be used to go beyond failure analysis to actively make complex industrial environments safer.
Posted in Technology & Engineering

Human Performance on the Flight Deck

Author: Don Harris

Publisher: CRC Press

ISBN: 1351929682

Category: Technology & Engineering

Page: 384

View: 1092

Taking an integrated, systems approach to dealing exclusively with the human performance issues encountered on the flight deck of the modern airliner, this book describes the inter-relationships between the various application areas of human factors, recognising that the human contribution to the operation of an airliner does not fall into neat pigeonholes. The relationship between areas such as pilot selection, training, flight deck design and safety management is continually emphasised within the book. It also affirms the upside of human factors in aviation - the positive contribution that it can make to the industry - and avoids placing undue emphasis on when the human component fails. The book is divided into four main parts. Part one describes the underpinning science base, with chapters on human information processing, workload, situation awareness, decision making, error and individual differences. Part two of the book looks at the human in the system, containing chapters on pilot selection, simulation and training, stress, fatigue and alcohol, and environmental stressors. Part three takes a closer look at the machine (the aircraft), beginning with an examination of flight deck display design, followed by chapters on aircraft control, flight deck automation, and HCI on the flight deck. Part four completes the volume with a consideration of safety management issues, both on the flight deck and across the airline; the final chapter in this section looks at human factors for incident and accident investigation. The book is written for professionals within the aviation industry, both on the flight deck and elsewhere, for post-graduate students and for researchers working in the area.
Posted in Technology & Engineering

Safety Management Systems in Aviation

Author: Alan J. Stolzer,John J. Goglia

Publisher: Routledge

ISBN: 1317059832

Category: Transportation

Page: 396

View: 6723

Although aviation is among the safest modes of transportation in the world today, accidents still happen. In order to further reduce accidents and improve safety, proactive approaches must be adopted by the aviation community. The International Civil Aviation Organization (ICAO) has mandated that all of its member states implement Safety Management System (SMS) programs in their aviation industries. While some countries (the United States, Australia, Canada, members of the European Union and New Zealand, for example) have been engaged in SMS for a few years, it is still non-existent in many other countries. This unique and comprehensive book has been designed as a textbook for the student of aviation safety, and as an invaluable reference tool for the SMS practitioner in any segment of aviation. It discusses the quality management underpinnings of SMS, the four components, risk management, reliability engineering, SMS implementation, and the scientific rigor that must be designed into proactive safety. The authors introduce a hypothetical airline-oriented safety scenario at the beginning of the book and conclude it at the end, engaging the reader and adding interest to the text. To enhance the practical application of the material, the book also features numerous SMS in Practice commentaries by some of the most respected names in aviation safety. In this second edition of Safety Management Systems in Aviation, the authors have extensively updated relevant sections to reflect developments since the original book of 2008. New sections include: a brief history of FAA initiatives to establish SMS, data-driven safety studies, developing a system description, SMS in a flight school, and measuring SMS effectiveness.
Posted in Transportation

Behind Human Error

Author: David D. Woods,Sidney Dekker,Richard Cook,Leila Johannesen,Nadine Sarter

Publisher: CRC Press

ISBN: 1317175530

Category: Technology & Engineering

Page: 292

View: 6487

Human error is cited over and over as a cause of incidents and accidents. The result is a widespread perception of a 'human error problem', and solutions are thought to lie in changing the people or their role in the system. For example, we should reduce the human role with more automation, or regiment human behavior by stricter monitoring, rules or procedures. But in practice, things have proved not to be this simple. The label 'human error' is prejudicial and hides much more than it reveals about how a system functions or malfunctions. This book takes you behind the human error label. Divided into five parts, it begins by summarising the most significant research results. Part 2 explores how systems thinking has radically changed our understanding of how accidents occur. Part 3 explains the role of cognitive system factors - bringing knowledge to bear, changing mindset as situations and priorities change, and managing goal conflicts - in operating safely at the sharp end of systems. Part 4 studies how the clumsy use of computer technology can increase the potential for erroneous actions and assessments in many different fields of practice. And Part 5 tells how the hindsight bias always enters into attributions of error, so that what we label human error actually is the result of a social and psychological judgment process by stakeholders in the system in question to focus on only a facet of a set of interacting contributors. If you think you have a human error problem, recognize that the label itself is no explanation and no guide to countermeasures. The potential for constructive change, for progress on safety, lies behind the human error label.
Posted in Technology & Engineering

Aircraft Surveillance Systems

Radar Limitations and the Advent of the Automatic Dependent Surveillance Broadcast

Author: Busyairah Syd Ali

Publisher: Routledge

ISBN: 1317183185

Category: Business & Economics

Page: 150

View: 1084

The Communication, Navigation and Surveillance (CNS) systems provide air traffic controllers with the information necessary to ensure the specified separation between aircraft and efficient management of airspace, as well as assistance to flight crew for safe navigation. However, the radar systems that support air traffic management (ATM), and in particular air traffic control (ATC), are at their operational limit. This is particularly acute in the provision of the ATC services in low altitude, remote and oceanic areas. Limitations in the current surveillance systems include unavailability of services in oceanic and remote areas, limited services during extreme weather conditions, and outdated equipment with limited availability of spare parts to support system operation. These limitations have resulted in fatal accidents. This book addresses the limitations of radar to support ATC in various operational environments, identified and verified by analysing five years of safety data from Avinor, the Air Navigation Service Provider (ANSP) in Norway. It derives a set of taxonomy and from this develops a causal model for incident/accident due to limitations in the surveillance system. The taxonomy provides a new method for ANSPs to categorize incidents while the causal model is useful for incident/accident investigations. The book also provides theoretical justifications for the use of Automatic Dependent Surveillance Broadcast (ADS-B) to overcome the limitations of radar systems and identify areas of improvements to enable seamless ATC services. Written in a style that makes it accessible to non-specialists, Aircraft Surveillance Systems will be of interest to many in the field of aviation, particularly ATM, safety and accident/incident investigation. It will also offer a useful reference on this vital topic for air traffic management courses.
Posted in Business & Economics

Human Factors in Aviation

Author: Earl L. Wiener,David C. Nagel

Publisher: Academic Press

ISBN: 0080570909

Category: Technology & Engineering

Page: 684

View: 8576

Since the 1950s, a number of specialized books dealing with human factors has been published, but very little in aviation. Human Factors in Aviation is the first comprehensive review of contemporary applications of human factors research to aviation. A "must" for aviation professionals, equipment and systems designers, pilots, and managers--with emphasis on definition and solution of specific problems. General areas of human cognition and perception, systems theory, and safety are approached through specific topics in aviation--behavioral analysis of pilot performance, cockpit automation, advancing display and control technology, and training methods.
Posted in Technology & Engineering

The Multitasking Myth

Handling Complexity in Real-World Operations

Author: Dr Immanuel Barshi,Dr Loukia D Loukopoulos,Dr R Key Dismukes

Publisher: Ashgate Publishing, Ltd.

ISBN: 1409485919

Category: Business & Economics

Page: 202

View: 5196

Despite growing concern with the effects of concurrent task demands on human performance, and research demonstrating that these demands are associated with vulnerability to error, so far there has been only limited research into the nature and range of concurrent task demands in real-world settings. This book presents a set of NASA studies that characterize the nature of concurrent task demands confronting airline flight crews in routine operations, as opposed to emergency situations. The authors analyze these demands in light of what is known about cognitive processes, particularly those of attention and memory, with the focus upon inadvertent omissions of intended actions by skilled pilots. The studies reported within the book employed several distinct but complementary methods: ethnographic observations, analysis of incident reports submitted by pilots, and cognitive task analysis. They showed that concurrent task management comprises a set of issues distinct from (though related to) mental workload, an area that has been studied extensively by human factors researchers for more than 30 years. This book will be of direct relevance to aviation psychologists and to those involved in aviation training and operations. It will also interest individuals in any domain that involves concurrent task demands, for example the work of emergency room medical teams. Furthermore, the countermeasures presented in the final chapter to reduce vulnerability to errors associated with concurrent task demands can readily be adapted to work in diverse domains.
Posted in Business & Economics

Managing the Risks of Organizational Accidents

Author: James Reason

Publisher: Routledge

ISBN: 1134855354

Category: Technology & Engineering

Page: 272

View: 4493

Major accidents are rare events due to the many barriers, safeguards and defences developed by modern technologies. But they continue to happen with saddening regularity and their human and financial consequences are all too often unacceptably catastrophic. One of the greatest challenges we face is to develop more effective ways of both understanding and limiting their occurrence. This lucid book presents a set of common principles to further our knowledge of the causes of major accidents in a wide variety of high-technology systems. It also describes tools and techniques for managing the risks of such organizational accidents that go beyond those currently available to system managers and safety professionals. James Reason deals comprehensively with the prevention of major accidents arising from human and organizational causes. He argues that the same general principles and management techniques are appropriate for many different domains. These include banks and insurance companies just as much as nuclear power plants, oil exploration and production companies, chemical process installations and air, sea and rail transport. Its unique combination of principles and practicalities make this seminal book essential reading for all whose daily business is to manage, audit and regulate hazardous technologies of all kinds. It is relevant to those concerned with understanding and controlling human and organizational factors and will also interest academic readers and those working in industrial and government agencies.
Posted in Technology & Engineering