Human error is implicated in nearly all aviation accidents, yet most investigation and prevention programmes are not designed around any theoretical framework of human error. Appropriate for all levels of expertise, this book provides the knowledge and tools required to conduct a human error analysis of accidents, regardless of operational category (military, commercial or general aviation). The book contains a complete description and domestication 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 organizational failure.
Author(s): Douglas A. Wiegmann, Scott A. Shappell
Year: 2003
Language: English
Pages: 350
Contents......Page 6
List of Figures......Page 8
List of Tables......Page 11
Acknowledgements......Page 12
Preface......Page 13
1 Errare Humanum Est — To Err is Human......Page 18
Aviation Safety Trends......Page 20
Some Reasons for Concern......Page 25
Human Error and Aviation Accidents......Page 27
Engineering Aspects of an Investigation......Page 29
Human Factors Aspects of an Investigation......Page 32
Conclusion......Page 35
2 Human Error Perspectives......Page 37
The Cognitive Perspective......Page 38
The Ergonomic Perspective......Page 43
The Behavioral Perspective......Page 47
The Aeromedical Perspective......Page 49
The Psychosocial Perspective......Page 51
The Organizational Perspective......Page 54
Conclusion......Page 61
Elements of a Productive System......Page 62
Breakdown of a Productive System......Page 64
Strengths and Limitations of Reason's Model......Page 66
Unsafe Acts of Operators......Page 67
Errors......Page 68
Violations......Page 72
Preconditions for Unsafe Acts......Page 73
Condition of Operators......Page 74
Personnel Factors......Page 77
Environmental Factors......Page 78
Unsafe Supervision......Page 80
Organizational influences......Page 83
Conclusion......Page 87
4 Aviation Case Studies using HFACS......Page 89
Sometimes Experience does Count......Page 90
Human Factors Analysis using HFACS......Page 92
Summary......Page 99
A World Cup Soccer Game They would Never See......Page 100
Human factors Analysis using HFACS......Page 103
Summary......Page 107
The Volcano Special......Page 108
Human Factors Analysis using HFACS......Page 111
Summary......Page 114
Conclusion......Page 115
5 Exposing the Face of Human Error......Page 116
Quantifying Proficiency within the Fleet......Page 123
Crew Resource Management Training: Success or Failure......Page 128
The Redheaded Stepchild of Aviation......Page 133
Conclusion......Page 138
6 Beyond Gut Feelings.........Page 139
Validity of a Framework......Page 140
Reliability......Page 141
Comprehensiveness......Page 149
Diagnosticity......Page 155
Usability......Page 162
Conclusion......Page 164
7 But What About...?......Page 166
References......Page 174
F......Page 180
P......Page 181
Z......Page 182
