Handbook of Aviation Human Factors

By Daniel J. Garland; John A. Wise et al. | Go to book overview

26
Aviation Incident and Accident Investigation

Sue Baker Civil Aviation Authority, Gatwick, UK

Any discussion of aviation-related incident and accident investigation invariably prompts a number of questions, many of which raise fairly fundamental issues about the nature and purpose of the investigation process. For example, should time and resources be expended on the investigations of incidents rather than focusing all the effort on the major aviation accidents? What is the underlying purpose of investigations and who should conduct them and, if a full-scale field investigation is conducted, what benefits can be gained from this as against a more limited and less resource-intensive "desk-top" enquiry? One of the aims of this chapter is to attempt to answer these questions and to consider, in some detail, the practice and process of investigation in the aviation sphere. The information on which this chapter is based is drawn from firsthand experience of the investigation of air traffic control (ATC) related incidents and accidents in the United Kingdom, but it seems reasonable to assume that the points raised have a general application extending beyond the ATC area or any one state.

In order to convey an insight into what incident investigation is and what it does, it may be helpful to consider what incident investigation is not. First and foremost, it should not be an exercise in the apportioning of blame. The individual does not work in a vacuum. Mistakes are made in the context of the system, and unless the system itself is considered during an investigation, the whole process is likely to be of dubious value. Blaming and/or punishing an individual serves no valuable function for the person concerned. All this would do is to maintain the status quo and therefore the circumstances under which further errors may occur, doing little or nothing to rectify shortcomings or prevent future occurrences. A report published by the UK Air Accident Investigation Branch in 1990 illustrates the point. In the accident in question, a BAC 1-11 had been inadvertently fitted with the wrong sized windscreen retaining bolts during maintenance. At around 17,000 ft the affected windscreen separated from the aircraft, and in the ensuing depressurization the pilot was partially sucked through the gap. The accident gave rise to a number of human factors concerns regarding the maintenance procedures, which are outside the scope of this chapter. However, what

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Handbook of Aviation Human Factors
Table of contents

Table of contents

  • Human Factors in Transportation ii
  • Title Page iii
  • Contents vii
  • Series Foreword xi
  • Preface xiii
  • I Introduction 1
  • 1: A Historical Overview of Human Factors in Aviation 3
  • References 13
  • 2: Aviation Research and Development: A Framework for the Effective Practice of Human Factors, or "What Your Mentor Never Told You About a Career in Human Factors . . ." 15
  • 3: Measurement in Aviation Systems 33
  • Summary Appraisal 46
  • References 47
  • 4: Underpinnings of System Evaluation 51
  • References 66
  • 5: Organizational Factors Associated With Safety and Mission Success in Aviation Environments 67
  • Conclusion 100
  • Acknowledgments 101
  • References 101
  • II Human Capabilities and Performance 105
  • 6: Processes Underlying Human Performance 107
  • Conclusion 166
  • References 168
  • 7: Automation in Aviation: A Human Factors Perspective 173
  • Conclusion 189
  • Acknowledgments 190
  • References 190
  • 8: Team Processes and Their Training in Aviation 193
  • References 211
  • 9: Crew Resource Management: A Time for Reflection 215
  • Conclusions 230
  • Acknowledgments 232
  • References 232
  • 10: Fatigue and Biological Rhythms 235
  • References 250
  • 11: Situation Awareness in Aviation Systems 257
  • References 274
  • 12: Aviation Personnel Selection and Training 277
  • References 305
  • III Aircraft 309
  • 13: Pilot Performance 311
  • References 323
  • 14: Controls, Displays, and Workplace Design 327
  • Conclusions 352
  • References 353
  • 15: Flight Simulation 355
  • Conclusion 384
  • Acknowledgments 384
  • References 384
  • 16: Human Factors Considerations in Aircraft Cabin Design 389
  • Conclusion 403
  • References 403
  • 17: Helicopter Human Factors 405
  • Summary 423
  • References 428
  • IV Air Traffic Control 429
  • 18: Air Traffic Control 431
  • Suggested Reading 454
  • 19: Air Traffic Controller Memory: Capabilities, Limitations, and Volatility 455
  • References 488
  • 20: Air Traffic Control Automation 497
  • References 515
  • 21: Human Factors in Air Traffic Control/Flight Deck Integration: Implications of Data-Link Simulation Research 519
  • References 544
  • V Aviation Operations And Design 547
  • 22: Human Factors of Functionality and Intelligent Avionics 549
  • Conclusion 563
  • References 564
  • 23: Weather Information Presentation 567
  • References 588
  • 24: Human Factors in Aviation Maintenance 591
  • References 603
  • 25: Human Factors in U.S. Civil Aviation Security 607
  • Epilogue 630
  • References 630
  • 26: Aviation Incident and Accident Investigation 631
  • Conclusion 640
  • References 641
  • 27: Forensic Aviation Human Factors [Accident/Incident Analyses for Legal Proceedings] 643
  • Introduction 644
  • References 668
  • Author Index 669
  • Subject Index 685
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