Field Investigations: Human Factors Overview and Objectives

Human Factors is the science of human performance, capabilities, and limitations, from the perspectives of cognition, psychology, and physiology, especially when considering the human interface with all other aspects of a system (environment, hardware, software, other humans).

Human error continues to be implicated in the vast majority of transportation and industry accidents, and air transportation is certainly no exception. For decades, we read that approximately 75 – 80% of aircraft accidents were associated with human error, but analyzing accident data from a systems perspective, we see that percentage is much closer to 100%, when we consider the role of crew, aircraft and aircraft component manufacturers, Air Traffic Controllers, maintainers, schedulers, airline management, regulatory oversight, airport management, and so forth. Gone are the days of citing “pilot error” as causal. Modern taxonomy seeks to identify the root causes of the human error such as organizational deficiencies, design problems, automation, and lack of effective oversight. 

As a member of the team at a major aviation accident, the human performance investigator has specific areas of responsibility during the on-site investigation and afterward. As with other aspects of the on-site investigation, the human performance investigator focuses first on collecting any perishable evidence, such as arranging for toxicological testing and witness statements (perishable in that memory tends to become less accurate and less detailed over time and witnesses can become to track down over time). A critical part of the human performance investigation is to reconstruct the prior 72-hour period leading up to the accident, of the pilots, controllers, and any other individuals pertinent to the accident, such as family members having background knowledge of the pilots. These timeline reconstructions provide pertinent detail about sleeping and eating history/habits, fitness routines, medical backgrounds, moods, financial or family stresses, major life events, preparation for the accident trip, and other information that could prove critical to understanding the accident. Background records such as airman, training, and medical records are also pertinent.

One of the NTSB’s most pressing safety concerns and one they often advocate for via their Most Wanted List, is reducing fatigue-related accidents. Findings collected from the 72-hour reconstruction can be instrumental in the Human Performance investigators quantifying fatigue and determining if fatigue played a role in the accident. This is accomplished through the collection of critical evidence from family, layover hotels, colleagues, phone records, restaurant receipts, etc., to determine normal baseline sleep for that individual, any sleep disorders or variances in sleep patterns, estimates of sleep attained for the past 72 hours, work hours, continuous hours awake, arrival at the layover hotel, times meals were ordered, phone call logs, critical operations during circadian lows, and work hours opposed to normal circadian rhythms. These variables can be used to create an accurate snapshot of acute and cumulative fatigue, which has been attributed to human error and accidents in all modes of transportation.


Assignment :

In this discussion activity, discuss the type of artifact(s) you feel will best demonstrate the achievement of the Human Factors field investigations objectives. In addition to your discussion points, feel free to post a sample, outline, diagram, video clip, etc., of your artifact. 

  1. Given the established role of the NTSB Human Performance Group, discriminate the effectiveness of this role in finalized accident investigation findings and recommendations.
  2. Analyze human factors issues associated with human error in aircraft accidents, specifically situational awareness, decision-making, risk perception, and automation.
  3. Demonstrate the association between human performance investigation and aviation safety initiatives. 

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