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factors and fail in balancing the compromise, thus
contributing to safety breakdowns. Successful compromises
far outnumber failed ones; therefore, in order to understand
human performance in context, the industry needs to
systematically capture the mechanisms underlying successful
compromises when operating at the limits of the
system, rather than those that failed. It is suggested that
understanding the human contribution to successes and
failures in aviation can be better achieved by monitoring
normal operations, rather than accidents and incidents. The
Line Operations Safety Audit (LOSA) is the vehicle
endorsed by ICAO to monitor normal operations.
1.2 BACKGROUND
Reactive strategies
Accident investigation
1.2.1 The tool most often used in aviation to document
and understand human performance and define remedial
strategies is the investigation of accidents. However, in terms
of human performance, accidents yield data that are mostly
about actions and decisions that failed to achieve the
successful compromise between production and safety
discussed earlier in this chapter.
1.2.2 There are limitations to the lessons learned from
accidents that might be applied to remedial strategies vis-àvis
human performance. For example, it might be possible
to identify generic accident-inducing scenarios such as
Controlled Flight Into Terrain (CFIT), Rejected Take-Off
(RTO), runway incursions and approach-and-landing accidents.
Also, it might be possible to identify the type and
frequency of external manifestations of errors in these
generic accident-inducing scenarios or discover specific
training deficiencies that are particularly related to identified
errors. This, however, provides only a tip-of-the-iceberg
perspective. Accident investigation, by definition, concentrates
on failures, and in following the rationale advocated
by LOSA, it is necessary to better understand the success
stories to see if they can be incorporated as part of remedial
strategies.
1.2.3 This is not to say that there is no clear role for
accident investigation within the safety process. Accident
investigation remains the vehicle to uncover unanticipated
failures in technology or bizarre events, rare as they may be.
Accident investigation also provides a framework: if only
normal operations were monitored, defining unsafe
behaviours would be a task without a frame of reference.
Therefore, properly focused accident investigation can
reveal how specific behaviours can combine with specific
circumstances to generate unstable and likely catastrophic
scenarios. This requires a contemporary approach to the
investigation: should accident investigation be restricted to
the retrospective analyses discussed earlier, its contribution
in terms of human error would be to increase existing
industry databases, but its usefulness in regard to safety
would be dubious. In addition, the information could
possibly provide the foundations for legal action and the
allocation of blame and punishment.
Combined reactive/proactive strategies
Incident investigation
1.2.4 A tool that the aviation industry has increasingly
used to obtain information on operational human performance
is incident reporting. Incidents tell a more complete
story about system safety than accidents do because they
signal weaknesses within the overall system before the
system breaks down. In addition, it is accepted that incidents
are precursors of accidents and that N-number of incidents
of one kind take place before an accident of the same kind
eventually occurs. The basis for this can be traced back
almost 30 years to research on accidents from different
industries, and there is ample practical evidence that
supports this research. There are, nevertheless, limitations
Chapter 1. Basic error management concepts 1-3
on the value of the information on operational human
performance obtained from incident reporting.
1.2.5 First, reports of incidents are submitted in the
jargon of aviation and, therefore, capture only the external
manifestations of errors (for example, “misunderstood a
frequency”, “busted an altitude”, and “misinterpreted a
clearance”). Furthermore, incidents are reported by the
individuals involved, and because of biases, the reported
processes or mechanisms underlying errors may or may not
reflect reality. This means that incident-reporting systems
take human error at face value, and, therefore, analysts are
left with two tasks. First, they must examine the reported
processes or mechanisms leading up to the errors and
　
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