Human Factors in Air Accident Investigation: a Training Needs Analysis
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Cranfield University HUMAN FACTORS IN AIR ACCIDENT INVESTIGATION: A TRAINING NEEDS ANALYSIS By Camille Burban School of Aerospace, Transport and Manufacturing Transport systems theme Ph.D 2015-2016 Supervisor: Professor Graham Braithwaite July 2016 This thesis is submitted in partial fulfilment of the requirements for the degree of Doctor of Philosophy of Cranfield University © Cranfield University, 2016. All rights reserved. No part of this publication may be reproduced without the written permission of the copyright holder. HUMAN FACTORS IN AIR ACCIDENT INVESTIGATION: A TRAINING NEEDS ANALYSIS By Camille Burban Supervisor: Professor Graham Braithwaite ii Abstract Human Factors (HF) has long been identified as one of the main causes of incidents and accidents in the transportation industry, and more recently has become increasingly important in air accident investigation and safety improvement. As a result, many National Investigation Agencies (NIAs) are now explicitly acknowledging HF in their final investigation reports. Whereas engineering-and operations-led investigation can highlight what happened and how it occurred, it is increasingly recognised that the integration of HF into an investigation can help understand why a sequence of events led to an incident or accident. However, there are considerable challenges to more thorough integration of HF into air accident investigations. Most notably, there remains a reluctance amongst some NIAs to fully embrace HF and address potentially important HF issues in detail in their investigations. Consequently, there is a risk that some investigations are consistently overlooking potentially critical HF issues, and as a result fail to fully address why an incident or accident occurred. There is a need for research that examines these challenges, including the possible gap that exists between research and industry regarding the development and applicability of accident analysis tools, and that provides practical solutions to enable a better integration of HF in air accident investigations. iii The thesis aims to address this gap in knowledge by examining the training needs of air accident investigators in order to develop more thorough human factors integration in accident investigations. Following the methodological process of a Training Needs Analysis (TNA), it provides recommendations on what NIAs could do to ensure more thorough and credible HF investigations. These recommendations focus on the training provision for investigators and managers, the involvement (or not) of HF specialists, and the adoption of an approved approach or methodology. They are based on the findings from four separate studies conducted as part of the Training Needs Analysis; namely, an analysis of accident investigation reports from five major NIAs, an online questionnaire survey of current air accident investigators, a series of qualitative semi-structured interviews with HF specialists involved in air accident investigations and an associated follow-up questionnaire survey. It was found that the quality of HF integration in accident reports varied between NIAs, with those who systematically involved HF specialists generally producing more detailed and thorough HF investigations. Other key findings include the lack of standardised and adapted HF training for investigators, the lack of HF refresher training, and the need for investigators to understand specialist input. Recommendations from the TNA include the need to involve HF specialists throughout the investigation process in order to provide a thorough and credible HF element to accident investigation report, as well as the necessity to develop adapted and standardised HF training for investigators and managers. iv Acknowledgments First and foremost, I would like to thank my supervisor Professor Graham Braithwaite. This project would have never been achievable without his guidance and support. He trusted me and pushed me when necessary and shared extremely valuable advice when it was very much needed. I am hugely grateful for this amaZing opportunity. I would also like to thank my sponsors, Cranfield University and the Cranfield Safety and Accident Investigation Centre (CSAIC) for the funding throughout those three and a half years. I would not have been able to reach the end of this project without the financial support. The Cranfield Safety and Accident Investigation Centre and the Centre for Air Transport Management have also been a real help and gave me the opportunity to co-supervise, lecture and feel involved. More specifically I would like to thank my co-PhD colleague, Darshi, who is now my friend, and Nicola, Rob and Keith for their encouragement and all those fun ‘lunch-times’. The AAIB and the ATSB also deserve a special thank you. Their openness and availability allowed me to conduct this research and I am very grateful to have had access to so many insightful, experienced and passionate investigators. I would like to thank my very best friends in the UK, France, Switzerland and Australia. Truno, Sophie and Thib, Fox, Soso, Laura ‘ma femme’, Alex, and Gus, ma Cam carrée, Clarisse and Mathilde, Mike, my sis’ Vicki, Mick and finally Charles, Oli and Zoi, the ‘Cranfield crew’, I cannot thank you enough for all the support you provided me with and for believing in me from start to finish. Although my liver might disagree, you have been so important to me during the past three and a half years. Thank you for making every opportunity we had to see each other a distracting and memorable moment. v I would also like to thank one of the most important people in my life, Tom, whose professional and personal support have been essential to this accomplishment, whose sense of humour was vital in moments of doubt and whose patience and understanding were admirable. He has done a tremendous job at keeping me on track and his presence certainly helped me reach the end of this adventure. A big thank you to his family as well for everything they have done. I will always be grateful for their kindness and generosity. Last but not least, I would like to thank my parents and brother without who none of this would have been achievable. Thank you for spending hours listening to my doubts and concerns, always finding the words to make me feel stronger, always making sure I could fly home when needed and thank you for mailing me comforting French pampers. I am extremely lucky to have you in my life. Maman, Pap’ et Max, merci pour votre soutien. vi Table of Contents Abstract ............................................................................................................................... iii Acknowledgments ............................................................................................................. v List of Tables ........................................................................................................................ x List of Figures .................................................................................................................... xi Abbreviations .................................................................................................................. xiii Chapter I – Introduction ................................................................................................. 1 I- 1 Context .................................................................................................................................... 1 I- 1- 1 Aviation Safety and Human Factors ................................................................................... 1 I- 1- 2 Preliminary research ................................................................................................................ 3 I- 2 Aim and objectives .............................................................................................................. 7 I- 3 Structure of the thesis ........................................................................................................ 8 I- 4 Ethics considerations ...................................................................................................... 10 Chapter II – Literature review .................................................................................... 11 II-1 Introduction ...................................................................................................................... 11 II-2 Accident investigation role .......................................................................................... 13 II-2-1 Accident investigation and aviation safety ................................................................... 13 II-2-2 The goal of an accident investigation .............................................................................. 19 II-3 Accident investigation challenges .............................................................................. 22 II- 3- 1 Causation terminology ........................................................................................................ 22 II- 3- 2 Shift in investigation focus: from looking for a single cause to understanding complex systems ................................................................................................................................... 23 II- 3- 3 Investigating incidents ........................................................................................................ 28 II- 3- 4 Independent and blame free investigations .............................................................. 31 II- 3- 5 The accident investigators