Using Fault Trees and Cognitive Work Analysis to Assess Human Actions in Aviation Accidents

Abstract

One of the functions of the National Transportation Safety Board (NTSB) is to examine and assess accident investigation methods and techniques. In this paper we present an approach being explored to assess human actions in aviation accidents that draws from fault tree analysis and cognitive work analysis. The paper shows how these two different approaches can be used to model human actions in an aviation accident, and then integrate the results of that process into an overall accident investigation process. The paper begins by showing how a fault tree depicts the sources of human interaction failures with aircraft systems, and then proceeds to describe the steps taken to derive the failures using cognitive work analysis. The paper concludes with a discussion of ongoing efforts to test the method and to explore other techniques.

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