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changes to the system that are suggested by human factors. One way of looking at human error is
as human malfunction. The author argues against using this point of view stating that there is no
malfunction on the human’s part because the human is responding appropriately to experience or
the circumstance. A second way of looking at human error is as a system malfunction. A system
that fails has both animate and inanimate components, and humans cause errors with the animate
components. But human performance is not independent of the inanimate components and
environment. A distinction is made between soft deficiencies and hard-system deficiencies. Soft
deficiencies are system characteristics that work against human performance and cause humans
to fail. Hard-system deficiencies are things such as insufficient durability and cause hardware to
fail. A mechanism for system design causing aircraft accidents is presented. It states that soft
deficiencies result from vigilance, which affects effectiveness along with skill and experience.
The effectiveness is compared to flight conditions. If the effectiveness level is too low compared
to flight conditions, the safety margin decreases until an accident occurs. Human factors
specialists, engineers, and others must pursue soft deficiencies jointly. By breaking down the soft
deficiencies, accidents can be understood better and made more preventable.
Besco, R. O. (1988). Modelling system design components of pilot error. Human Error
Avoidance Techniques Conference Proceedings (pp. 53-57). Warrendale, PA: Society of
Automotive Engineers.
A five factored model based on the assumption that errors have a cause and can be prevented by
removing error-inducing elements is developed and reviewed in the context of civilian aircraft
accidents. The five factors are obstacles, knowledge, systems, skill, and attitude. The model
consists of a sequential analysis of inducing elements and the associated reducers. A detailed
step-by-step graphic model is presented in the paper.
7
Besco, R. O. (1998). Analyzing and preventing knowledge deficiencies in flight crew
proficiency and skilled team performance. Dallas, TX: Professional Performance
Improvement.
A five-factor model called the Professional Performance Analysis System (PPAS) is developed
and described which has a main purpose of providing remedies to minimize pilot error and
optimize pilot performance. The model has been successful for use in accident investigation. The
model attempts to deal with knowledge deficiencies and attitudinal problems with a combination
of techniques and methodologies from organizational psychology, flight operations, business
leadership and management sciences. The five interactive factors of the model include
knowledge, skills, attitudes, systems environment, and obstacles. The first step in the analysis is
describing the process, function, task, error, or low performance. At this stage an investigator is
looking to see if the pilot was aware of risks, threats and consequences of their actions and if
there was stimulus that degraded this awareness. The second step is to assess the impact of the
error on this particular accident or incident by determining whether removal would have
prevented the accident. The third step is to assess the visibility of the error to the crewmembers.
The fourth step involves analyzing a detailed flow chart to see if the crew had adequate
knowledge to cope with the errors and anomalies that occurred. There are four levels of learning
that are examined. These include unconsciously incompetent (crew is unaware that they don’t
know something), consciously incompetent (the crew is aware that they don’t know something),
consciously competent (the crew has knowledge and skill but must apply great effort to
accomplish it), and unconsciously competent (the crew has over learned the knowledge or skill
and can apply it without conscious thought). Other questions are explored to determine
deficiencies. Recommendations are given for each of the situations where a problem was
perceived.
(1) Did the crew ever have the knowledge?
(2) Was the knowledge used often?
(3) Was there feedback on the knowledge level?
(4) Was there operationally meaningful curriculum?
(5) Did personal interaction with learning occur?
(6) Is the knowledge compatible with an organization?
(7) Was the individual’s capacity to absorb and apply information lacking?
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Bieder, C., Le-Bot, P., Desmares, E., Bonnet, J. L., & Cara, F. (1998). MERMOS: EDF’s
new advanced HRA method. Probabilistic Safety Assessment and Management: PSAM 4
(pp. 129-134). New York, NY: Springer.
MERMOS is a HRA method that deals with important underlying concepts of HRAs that were
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