Circular 240. Edition 1
Last modified:1/1/1993
Human Factors Digest No. 7 - Investigation of Human Factors in Accidents and Incidents
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CIRCULAR 240-AN/1441993HUMAN FACTORS DIGESTNo. 7INVESTIGATION OF HUMAN FACTORSIN ACCIDENTS AND INCIDENTSApproved by the Secretary Generaland published under his authorityI C A OCIRCULARINTERNATIONALCIVIL AVIATIONORGANIZATIONMONTREALCANADA
iTABLE OF CONTENTSPage Introduction................................................................1Chapter 1. Need for and Purpose of Human Factors Investigation...................3Background...........................................................3Obstacles and solutions.................................................3The nature of accidents and incidents......................................5Definition of an accident and incident.......................................6Systems approach to the investigation of Human Factors......................6Accident scenario......................................................8Investigation of incidents................................................13Conclusions..........................................................13Chapter 2. Conduct of the Investigation.........................................14General..............................................................14Who should investigate................................................14The single investigator..................................................15The Human Factors investigator..........................................15The Human Factors group...............................................15What information should be collected.....................................16The SHEL model.......................................................16How much information is enough.........................................21Use of checklists.......................................................22Information sources....................................................23Analysis of data........................................................25Chapter 3. Reporting and Preventive Action.....................................29General..............................................................29Structure of the report...................................................30Accident prevention....................................................33Consultation with States.................................................37Data base requirements.................................................37Appendix 1. Human Factors Checklists...........................................39Appendix 2. Witness Interviewing Techniques......................................47Appendix 3. Explanatory Human Factors..........................................53Appendix 4. Aviation Accident/Incident Data Bases.................................55Appendix 5. Human Performance Investigation Training.............................58Appendix 6. Bibliography......................................................59
1INTRODUCTION1.Human Factors are involved in most aviation occurrences. Thus, to advance aviation safety,we must improve our ability to identify the involvement of Human Factors in accidents and incidents. By doingso we can learn more from these experiences and implement new and better measures to prevent repetitiveoccurrences. We cannot prevent humans from making errors, but we can certainly reduce the frequency andminimize the consequences. This is one fundamental reason behind ICAOs accident prevention programme.2.This digest has three purposesto provide investigators and investigation authorities, civil aviation regulatory authorities,company/corporate management, and other aviation personnel with information on theneed for and purpose of the investigation of Human Factorsto outline a methodology for investigating Human Factors in aircraft accidents andincidents andto describe how the information gathered should be reported.3.The digest is intended to complement the ICAO Manual of Aircraft Accident InvestigationDoc 6920. The philosophical approach outlined in this digest should be understood when applying thepractical guidance provided in the investigation and prevention manuals. The field of Human Factors alsoencompasses medical issues however, the thrust of this digest is on the non-medical aspects.4.The primary focus of the digest is on the events which led up to the occurrence and not onpost-accident events, such as search and rescue or survivability issues. It will not include guidance for handlingpost-mortems, toxicological examinations and injury pattern analysis. These special areas are discussed inthe Manual of Aircraft Accident Investigation and the Manual of Civil Aviation Medicine Doc 8984.Nevertheless, the investigator is expected to be familiar with the physiological as well as the psychologicalaspects of human performance.5.Through the international Standards and Recommended Practices SARPs set forth inAnnex 13 to the Chicago Convention and related guidance material, ICAO has assisted States in the accidentinvestigation and prevention field. There is a continued emphasis on objectivity in investigation and prevention.Improvements in the investigation of Human Factors in accidents and incidents will add significantly to thiseffort.6.This digest includes the followingChapter 1 discusses the need for and the purpose of Human Factors investigationaddresses some of the obstacles to Human Factors investigation discusses the natureof human error and accidents and provides a systems approach model by which thescope of the Human Factors investigation can be determined.
2ICAO Circular 240-AN/144Chapter 2 addresses the conduct of the Human Factors investigation discusses theorganization and management of the investigation details who should conduct theinvestigation, what information should be collected, where it can be found, and presentsa discussion on how to analyse the information collected.Chapter 3 discusses the reporting of accidents and incidents with the emphasis on thetreatment of Human Factors information, the identification of hazards and the developmentof safety action to prevent recurrence.Appendix 1 provides examples of Human Factors Checklists.Appendix 2 provides guidance in Witness Interviewing Techniques.Appendix 3 presents a sample listing of Explanatory Factors a proposed expansion ofthe ADREP Manual.Appendix 4 provides a listing of available accident/incident data bases.Appendix 5 presents a list of recommended readings.7.This digest was prepared with the assistance of the ICAO Flight Safety and Human FactorsStudy Group. Particular recognition goes to the Transportation Safety Board of Canada for its support anddiligent work in producing the initial draft.8.Six other Human Factors digests have been published includingDigest No. 1 Fundamental Human Factors Concepts Circular 216Digest No. 2 Flight Crew Training Cockpit Resource Management CRM and Line-Oriented Flight Training LOFT Circular 217Digest No. 3 Training of Operational Personnel in Human Factors Circular 227Digest No. 4 Proceedings of the ICAO Human Factors Seminar Circular 229Digest No. 5 Operational Implications of Automation in Advanced Technology FlightDecks Circular 234 andDigest No. 6 Ergonomics Circular 238.
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Annex 13. Edition 13. Aircraft Accident and Incident InvestigationDoc 8984. Edition 3. Manual of Civil Aviation MedicineCircular 216. Human Factors Digest No. 1 - Fundamental Human Factors ConceptsCircular 217. Human Factors Digest No. 2 - Flight Crew Training: Cockpit Resource Management (CRM) and Line-Oriented Flight Training (LOFT)Circular 227. Human Factors Digest No. 3 - Training of Operational Personnel in Human FactorsCircular 229. Human Factors Digest No. 4 - Proceedings of the ICAO Human Factors SeminarCircular 234. Edition 1. Human Factors Digest No. 5 - Operational Implications of Automation in Advanced Technology Flight DecksCircular 238. Human Factors Digest No. 6 - ErgonomicsDoc 9756. Part 3. Edition 1. Manual of Aircraft Accident and Incident Investigation. Investigation.Doc 9756. Part 1. Edition 2. Manual of Aircraft Accident and Incident Investigation. Organization and Planning.Doc 9756. Part 4. Edition 2. Manual of Aircraft Accident and Incident Investigation. Part IV — Reporting.Doc 9756. Part 4. Edition 3. Manual of Aircraft Accident and Incident Investigation. Part IV. ReportingDoc 9842. Programme Budget of the Organization 2005-2006-2007Circular 241. Edition 1. Human Factors Digest No. 8 - Human Factors in Air Traffic ControlCircular 247. Edition 1. Human Factors Digest No. 10 - Human Factors, Management and OrganizationCircular 249. Edition 1. Human Factors Digest No. 11 - Human Factors in CNS/ATM SystemsCircular 253. Edition 1. Human Factors Digest No. 12 - Human Factors in Aircraft Maintenance and InspectionCircular 300. Edition 1. Human Factors Digest No. 15 - Human Factors in Cabin SafetyВСЕ ДОКУМЕНТЫALL DOCUMENTSICAO CIRCULASЦИРКУЛЯРЫCircular 240Индивидуальный Бандл № 18082022
Table Of Contents
COVER PAGE
TABLE OF CONTENTS
INTRODUCTION
Chapter 1
Chapter 2
Chapter 3
Appendix 1
Appendix 2
Appendix 3
Appendix 4
Appendix 5
Appendix 6