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need for frequent meetings of the heads of the investigation groups and the need for adequate exchange of
information at such meetings.
Special problems of the particular flight especially concern those aspects of possible impairment of flight
crew fitness and performance that are not demonstrable by autopsy. Errors and deficiency of performance
may occur whether operations are as planned, whether unexpected conditions develop, or whether
emergencies arise. The cause of these errors and performance decrements may be found in:
a) errors of perception. These may be related to auditory, visual, tactile or postural stimuli;
b) errors of judgement and interpretation. Misjudgement of distances, misinterpretation of instruments,
confusion of instructions, sensory illusions, disorientation, lapse of memory, etc., fall into this
category;
c) errors of reaction. These particularly relate to timing and co-ordination of neuromuscular
performance and technique as related to the movement of controls;
Contributing causes of errors and performance deficiency may lie in such areas as:
d) attitude and motivation;
e) emotional affect;
f) perseverance.
All these factors are likely to be exaggerated by fatigue which is an ubiquitous but elusive factor in
aviation operations. It is in the evaluation of these potential factors that the Human Factors Group may be
of invaluable assistance to the Investigator-in-Charge.
The Human Factors Group must distinguish carefully between hypothesis and genuine evidence;
whenever possible, factual evidence must be adduced before an accident can be ascribed to a
psycho-physiological factor. For example, it may be suggested that the pilot was particularly irritable at the
time of the flight. However, a replay of the recordings of his in-flight transmissions may give far better
evidence as to whether this effect was operative at the time of the accident.
The medical contribution in the survived accident
Generally, this is a more straightforward matter than the accident in which all the aircraft occupants were
killed for it largely involves the examination of living and probably co-operative subjects. Essentially the
Human Factors Group will be looking for the same type of evidence as that derived from the pathological
examination of those killed.
A medical examination, preferably by an aviation medical specialist or qualified aviation medical
examiner, should be made on surviving flight crew members to find out whether any physical,
physiological or psychological factors in the operating crew had a bearing on the circumstances of the
accident. Such interrogations are likely to be harrowing to those being questioned. Interviews should be
ICAO Preliminary Unedited Version — October 2008 IV-1-18
properly planned and co-ordinated through the Investigator-in-Charge. A medical assessment might differ
depending upon whether it was carried out soon after the accident before debriefing by other investigators,
or at a later time after interview by others.
It might be desirable for blood and/or urine samples to be taken for analysis both for the presence of
therapeutic substances and to help to determine whether any abnormal state such as hypoglycaemia may
have been present. Before taking such specimens, however, the investigator should ensure that there are no
local legal contraindications. The consent of the subject should be obtained and the purpose of the tests
explained before they are undertaken.
The crew should be interviewed but this should be co-ordinated through the Investigator-in-Charge to
ensure that there is no undue duplication because of the needs of the various Groups.
A detailed record should be made of injuries to all occupants with an assessment of their cause. The
findings must be collated with their seat position, or location in the aircraft, and adjacent environment so
that preventive action such as redesign may be considered.
If the aircraft has been evacuated in the presence of fire or similar hazard (e.g. sinking with a ditching),
a full account of each person’s escape is a valuable contribution to an assessment of factors influencing
success or failure.
As the aim of accident investigation is prevention, attention should also be given to the psychological
effects of the accident upon the flight crew before they are allowed to return to flying duties. The
psychological effects of any accident upon the rescuers should not be forgotten. Adequate, regular
debriefing sessions may help prevent the occurrence of Post Traumatic Stress Disorder.
SUMMARY
The composition of the Human Factors Group must be chosen on the basis of the type of accident and the
evidence likely to be available from human sources. Specialists in aviation medicine will be of greatest
　
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本文鏈接地址：Manual of Civil Aviation Medicine 2(136)