HUMAN FACTORS MODELS FOR AVIATION ACCIDENT ANALYSIS AND PREVENTION

摘要

This book argues for the systems-thinking approach to accident and incident investigation. As such it is very much 'on message': bodies like the International Civil Aviation Organization (ICAO), the European Aviation Safety Agency (EASA) and the UK's Civil Aviation Authority (CAA) all recommend the holistic, systems-thinking-informed approach to investigation. Pioneered by The Honourable Mr Justice Virgil P Moshansky in his investigation of the 1989 Dryden accident, where a Fokker F28 crashed due to icing, this approach emphasises the often complex, relational and opaque origins of adverse events. Having surveyed Canada's commercial aviation 'network-space', Moshansky concluded: "This accident was the result of a failure in the air transportation system." Griffin, Young and Stanton's book accepts Prof James Reason's claim that information degradation, non-availability, miscommunication or misinterpretation is frequently the trigger for mishap. Based on original research conducted both in the laboratory and in the field, the authors offer a novel systems-analysis tool based on Bayesian precepts. Specifically, the tool attaches probabilistic risk assessments to pilots' decisions/actions. The tool can be applied retrospectively and prospectively.