The causal factor...

Sakuma_at_BDZ.crane.jal.co.jp
Thu, 8 Oct 98 16:29:11 +0900

Dear Graham :
I think you have posed a very important question. I myself have tried to
propose in my presentation at the last AAvPA symposium held in Manly that
"almost 100% of aviation accidents and incidents can be attributed to any human
error by personnel working in the aviation system. This is because humans have
incentives, capabilities and responsibility for safe and effective operation of
the system." All the deficiencies in hardwares, softwares and environments are
the results of any human behaviour involved. Failure to forecast bad weather or
volcano ash is no exception. In my view, there are not a few accident cases
where primary causal factors reside at peripheral areas rather than at front
lines. I personally think that accident investigation for complex systems
should be carefully excuted mainly by well trained aviation human factors
specialists who have wider scope and insight into not only human factors but
many other relevant disciplines like oparation and maintenance engineering.
Hidetake Sakuma

> "Statistics show that approximately 65 percent of all fatal air carrier
> accidents list human error as a probable cause," said Dr. Herman Rediess,
> director of the Office of Aviation Research."
> By probable cause, are we talking about primary cause or causal factors?
> If it is the latter, do we count ATC, Maintenance, design atc. as human error?
> At the risk of sounding pedantic, I believe human error is a contributory
> factor in 100% of aircraft accidents. This does not aim to legitimise human
> error, but to remind us of the importance of work in the area.
> Air traffic controllers, weather forecasters, maintenance engineers,
> designers etc. are all human and therefore prone to human error.
> If we are talking about primary cause then that is a different matter, but
> then let me pose this question:
> If an airliner has a crash in Australia (God forbid), who will determine
> what contribution it has to accident statistics that are based on primary
> cause? The Australian Bureau of Air Safety which investigates accidents in
> Australia stopped using 'primary cause' years ago and now only uses
> 'Findings' and 'Significant Factors'.
> Dr. Graham Braithwaite
> Department of Aviation
> University of New South Wales
> Sydney 2052
> Australia
> Tel: +61 (0) 2 9385 6757
> Fax: +61 (0) 2 9385 6637
> Mobile: 0414 736 467