Sage Journals: Discover world-class research

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.

Get full access to this article

View all access options for this article.

References

Leveson

(in press). A new accident model for engineering safer systems. Safety Science.

Naikar

Pearce

(2003). Analysing activity for future systems. In the Proceedings of the Human Factors and Ergonomics Society 47th Annual Meeting (Santa Monica, CA: HFES), pp. 1928–1932.

Naikar

Saunders

(in press). Crossing the boundaries of safe operation: An approach for training technical skills in error management. Cognition, Technology and Work.

NASA (2002a). Probabilistic Risk Assessment Procedures Guide for NASA Managers and Practitioners (Washington, DC: NASA Headquarters).

NASA (2002b). Fault Tree Handbook with Aerospace Applications (Washington, DC: NASA Headquarters).

National Transportation Safety Board (NTSB) Aircraft Accident Report NTSB/AAR −04/01 Loss of Pitch Control During Takeoff, Air Midwest Flight 5481, Raytheon (Beechcraft) 1900D, N233YV, Charlotte, North Carolina, January 8, 2003 (Washington, DC: NTSB, 2004).

Rasmussen

Pejtersen

Goodstein

L. P.

(1994). Cognitive Systems Engineering (New York: Wiley).

Sanderson

(in press). Cognitive Work Analysis across the system life-cycle: Achievements, challenges, and prospects in aviation. In Pfister

Edkins

(Eds.), Aviation Resource Management (Vol 3) (Aldershot, UK Ashgate).

Vicente

(1999). Cognitive Work Analysis: Towards Safe, Productive, and Healthy Computer-Based Work (Mahwah, NJ: Lawrence Erlbaum.

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

Abstract

Get full access to this article

References