human factors

Incident and Accident Investigation 28-7
of the events covered, with attention often being focused on accidents at the expense of the seemingly
less serious, but nevertheless important, incidents. However, if common terminology and taxonomies
can be agreed for the storage of investigation data, this would go some way toward overcoming the disadvantages
of differences in the method. It has already been suggested in this chapter that data can be
viewed as varying in quality depending on the manner in which they are collected and by whom. With
the improved liaison between the investigation bodies, resulting in easier and frequent data transfer
among them, the fact that not all data are regarded as “equal” and that, ideally, the sources of data are
specified when data transfer occurs, will be important.
28.5 Open Reporting
The raison d’etre of any investigation should be the better understanding of causality with a view to
future improvements and the prevention of similar occurrences. Fundamental to this is the existence
of a fair and open reporting culture; i.e., a system in which those involved in aviation can report issues
of concern without the fear or risk of being punished for admitting genuine errors. Such a system is not
easy to achieve, but once in place, is all too easy to destroy. The current trend toward “criminalizing”
the investigative process is guaranteed to destroy any faith that individuals may have that they will be
fairly treated. A recent occurrence in Japan is a case in point (Takeda, 2004). On January 31, 2001 there
was a near mid-air collision in Japanese airspace between a JAL B747 and DC10. The investigation was
conducted by the Aircraft and Railway Accident Investigation Commission who published their report
on July 12, 2002. By May 7, 2003, the Tokyo Metropolitan Police Dept. had opened a criminal case and
the occurrence report was passed to the prosecutors, contrary to ICAO stipulations (Annex 13). Despite
the fact that there were a number of contributory factors in the occurrence, including the pilot of one
of the aircraft failing to follow a TCAS Resolution Advisory (RA), on March 30, 2004 the two controllers
on duty at the time of the incident (one a trainee) were charged with professional negligence.
This is not an isolated occurrence. Similar criminalization has occurred in Italy with respect to the
Linate accident, and also in France and Holland. The aftermath of a serious incident or accident is often
accompanied by a wish to find someone to blame, as clearly demonstrated by the tragic death of the controller
involved in the Ueberlingen mid-air; however, while criminal proceedings may satisfy the desire
of an organization or the public to attribute blame, they do nothing to further the cause of air safety and,
in fact, do a great deal of harm when they threaten or, indeed, eradicate open reporting.
28.6 Investigation Framework
It is important during an investigation that care is taken to ensure that no relevant information is overlooked
in the data-gathering process. For this reason, it is sometimes proposed that investigators adopt
a particular model as an investigative framework. Many of these are not models in the accepted sense of
the term, i.e., they have little or no predictive capability and are, at best, a set of guidelines which can be
used to inform the investigative process. In fact, they tend to represent explicit statements of the good
practice that any investigator worth the name should be utilizing. Models may serve as a structure in
which the nonspecialist can collect data. However, it could be argued that they have only limited utility
in the most important aspects of investigation—namely the evaluation, prioritization, and interpretation
of the data. It is in these areas where the specialist investigator comes into his or her own.
The problem of bias has already been mentioned from the perspective of the reporter. However, investigators
can have biases too and it is essential that he or she is aware of the danger of bringing a biased
approach to a particular investigation or set of circumstances, as well as forming hypotheses before
the relevant data have been sifted and analyzed. The decisions as to what data are relevant in the causal
chain and what can be safely left out of the equation are an exercise of judgment that forms one of the
most important aspects of the investigation process. Any specialist may tend to see things in terms of his
or her own field of specialization and interpret the data accordingly.