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(e.g. engineering, operations and management) that make up the aviation community; and
d) the ease with which humans can adapt to different situations, further complicating the determination
of what constitutes a breakdown in human performance.
8.6.3 The logic necessary to convincingly analyse some of the less tangible human performance
phenomena is different from that required for other aspects of an investigation. Deductive methods are
relatively easy to present and lead to convincing conclusions. For example, a measured wind shear
produced a calculated aircraft performance loss, and a conclusion could be reached that the wind shear
exceeded the aircraft’s performance capability. Such straight cause/effect relationships cannot be so easily
established with some human performance issues such as complacency, fatigue, distraction or judgement.
For example, if an investigation revealed that a crew member made an error leading to an occurrence under
particular conditions (such as complacency, fatigue or distraction), it does not necessarily follow that the
error was made because of these preconditions. There will inevitably be some degree of speculation
involved in such a conclusion. The viability of such speculative conclusions is only as good as the reasoning
process used and the weight of evidence available.
8.6.4 Inductive reasoning involves probabilities. Inferences can be drawn from the most probable or
most likely explanations of behavioural events. Inductive conclusions can always be challenged, and their
credibility depends on the weight of evidence supporting them. Accordingly, they must be based upon a
consistent and accepted reasoning method.
8.6.5 Analysis of human performance issues needs to take into account the objective of the
investigation (i.e. understanding why something happened). Occurrences are seldom the result of a single
cause. Although individual factors when viewed in isolation may seem insignificant, in combination they can
result in a sequence of events and conditions that culminate in an accident. The SHEL model provides a
systematic approach to examining the constituent elements of the system, as well as the interfaces between
them.
8.6.6 Understanding the context in which humans err is fundamental to understanding the unsafe
conditions that may have affected their behaviour and decision-making. These unsafe conditions may be
indicative of systemic risks posing significant accident potential.
8.7 SAFETY RECOMMENDATIONS
8.7.1 When an investigation identifies hazards or unmitigated risks, safety action is required. The need
for action must be communicated by means of safety recommendations to those with the authority to expend
the necessary resources. Failure to make appropriate safety recommendations may leave the risk
unattended. For those formulating safety recommendations, the following considerations may apply:
a) Action agency. Who can best take the necessary corrective action? Who has the necessary
authority and resources to intervene? Ideally, problems should be addressed at the lowest possible
level of authority, such as the departmental or company level as opposed to the national or
regulatory level. However, if several organizations are exposed to the same unsafe conditions,
extending the recommended action may be warranted. State and international authorities, or
multinational manufacturers may best be able to initiate the necessary safety action.
b) What versus how. Safety recommendations should clearly articulate what should be done, not how
to do it. The focus is on communicating the nature of the risks requiring control measures. Detailed
8-8 Safety Management Manual (SMM)
safety recommendations which spell out exactly how the problem should be fixed, should be
avoided. The responsible manager should be in a better position to judge the specifics of the most
appropriate action for the current operating conditions. The effectiveness of any recommendation
will be measured in terms of the extent to which the risks have been reduced, rather than strict
adherence to the wording in the recommendation.
c) General versus specific wording. Since the purpose of the safety recommendation is to convince
others of an unsafe condition putting some or all of the system at risk, specific language should be
used in summarizing the scope and consequences of the identified risks. On the other hand, since
the recommendation should specify what is to be done (not how to do it), concise wording is
preferable.
d) Recipient’s perspective. In recommending safety action, the following considerations pertain to the
recipient’s perspective:
1) The safety recommendation is addressed to the most appropriate action authority (i.e. the one
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