The motivation for conducting investigations extends beyond discovering the cause of any one incident or accident. The main focus has to be on lessons learned with a view to the prevention of similar incidents or accidents in the future. The greater the volume of information that can be gathered, the more complete is the picture that can be gained and the firmer is the basis for any recommendations for future improvements. The additional knowledge gained from investigating incidents, in addition to less frequent accidents, is invaluable in compiling the overall picture.
The collation and analysis of data, together with the compilation of reports and recommendations arising from a specific incident or accident, is not the end of the story. An incident or accident from which no lessons are learned is a wasted event. There has to be practicable and accurate feedback and that feedback has to be acted on. It is therefore essential that efficient mechanisms exist, not only to disseminate information to those individuals and/or organizations where it can do most good in terms of prevention, but also to monitor that the feedback has been utilized.
A successful investigation demands a balanced approach to the problem. Each of the team of experts involved in the investigation will have his or her own area of expertise, none of which should be allowed to assume undue priority and importance in the investigative process. The underlying causal factors in incident and accident occurrence will vary, however. Accidents involving engine failure as the root causal factor, for example, will give rise to different findings with different emphases than those in which training or ground equipment are primarily implicated.
The inclusion of human factors as a potential issue in incident and accident occurrence has come fairly late on the investigative scene. However, to ignore the human factors aspects of these events will, almost inevitably, lead to an unbalanced and incomplete picture in attempting to determine not only what happened, but why.
Air Accidents Investigation Branch. ( 1990). Report on the accident to BAC One-Eleven, G-BJRT over Didcot, Oxfordshire on 10 June 1990. Department of Transport, HMSO, London.
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Baker S., & Marshall E. ( 1988). Evaluating the man-machine interface--The search for data. In J. Patrick & K. D. Duncan (Eds.), Training, human decision making and control (p. 83). Amsterdam: North-Holland.
International Civil Aviation Organization. ( 1993). Human factors, management and organization ( ICAO Circular 247-AN/148, Human Factors Digest No. 10). Montreal, Canada: Author.
International Civil Aviation Organization. ( 1993). Investigation of human factors incidents and accidents ( ICAO Circular 240-AN/144, Human Factors Digest No. 7). Montreal, Canada: Author.