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5-M Approach to Accident Investigation
Man
Many questions arise when one considers the “why” of
human failures. Successful accident prevention, therefore,
necessitates probing beyond the human failure to
determine the underlying factors that led to this behavior.
Aircraft Accident Investigation 27
Tenerife 1977 - The two 747s collided on the runway after the
KLM initiated a takeoff without permission while Pan Am had
already announced and begun its takeoff roll. The picture on page
21 shows the aftermath. This is the worst human factors related
disaster in aviation history.
For example:
• Was the individual physically and mentally capable
of responding properly? If not, why not?
• Did the failure derive from a self-induced state,
such as fatigue or alcohol intoxication?
• Had he or she been adequately trained to cope with
the situation?
• If not, who was responsible for the training deficiency
and why?
• Was he or she provided with adequate operational
information on which to base decisions?
• If not, who failed to provide the information and
why?
• Was he or she distracted so that he or she could not
give proper care and attention to duties?
• If so, who or what created the distraction and why?
These are but of few of the many “why” questions that
should be asked during a human-factor investigation.
The answers to these questions are vital for effective
accident prevention.
Machine
Although the machine (aviation technology) has made
substantial advances, there are still occasions when hazards
are found in the design, manufacture, or maintenance
of aircraft. In fact, a number of accidents can be
traced to errors in the conceptual, design, and development
phases of an aircraft. Modern aircraft design,
therefore, attempts to minimize the effect of any one
hazard. For instance, good design should not only seek
to make system failure unlikely, but also ensure that
should it nevertheless occur, a single failure will not
result in an accident.
Medium
The medium (environment) in which aircraft operations
take place, equipment is used, and personnel work directly
affects safety. From the accident prevention
viewpoint, this discussion considers the environment to
comprise two parts--the natural environment and the
artificial environment.
Mission
Notwithstanding the man, machine, medium concept,
some safety experts consider the type of mission, or the
purpose of the operation, to be equally important. Obviously
the risks associated with different types of operation
vary considerably. Each category of operation
has certain intrinsic hazards that have to be accepted.
Management
The responsibility for safety and, thus accident prevention
in any organization ultimately rests with management,
because only management controls the allocation
of resources. For example, airline management selects
the type of aircraft to be purchased, the personnel to fly
and maintain them, the routes over which they operate,
and the training and operating procedures used.
Psychological Factors
Within the broad subject of aviation psychology there
are a number of conditions or situations that could apply
to a particular accident. Here are a few of them
with their definitions as developed jointly by the Life
Sciences Division of the USAF Inspection and Safety
Center and the USAF School of Aviation Medicine.
The purpose of this list is to provide the investigator
with the definition of terms likely to be encountered
when talking with human performance specialists.
Affective States
These are subjective feelings that a person has about his
(her) environment, other people or himself. These are
either EMOTIONS, which are brief, but strong in intensity;
or MOODS, which are low in intensity, but long in
duration.
Attention Anomalies
These can be CHANNELIZED ATTENTION, which is
the focusing upon a limited number of environmental
cues to the exclusion of others; or COGNITIVE SATURATION
in which the amount of information to be
processed exceeds an individual’s span of attention.
Distraction
The interruption and redirection of attention by environmental
cues or mental processes.
Fascination
An attention anomaly in which a person observes environmental
cues, but fails to respond to them.
Habit pattern interference
This is reverting to previously learned response patterns
which are inappropriate to the task at hand.
Inattention
Usually due to a sense of security, self-confidence or
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