40TH ANNUAL CONFERENCE, Geneva, Switzerland, 19-23 March 2001
WP No. 160
Human Factors in Accident and Incident Investigation
Human Factors issues are involved in most aviation occurrences. ICAO Annex 13 states that the objective of the investigation of aviation accidents and incidents shall be the prevention of future accidents or incidents and that investigations are not in any way designed to apportion blame or liability.
IFATCA has noticed that accident and incident investigation reports usually depict clearly what happened and when, but in too many instances they are not fully explaining how and why the accidents occurred.
IFATCA supports the philosophy expressed in Annex 13, and have established Policy on Accident and Incident Investigation in order that Air traffic Controllers can contribute fully to an investigation. This WP will bring forward HF aspects that should be considered during all such investigations.
Current IFATCA Policy, introduced in 1992, is quite specific in outlining the rights of the individual controller(s) and procedures to be followed with the aim of allowing for an effective accident and incident investigation process which will promote aviation safety and efficiency.
ICAO Annex 13 specifies that:
“The accident investigation authority shall have independence in the conduct of the investigation (into accidents or serious incidents in the territory of a contracting state…) and have unrestricted authority over its conduct. The investigation shall include gathering, recording and analysis of all available relevant information, if possible the determination of the causes, and the completion of the final report followed, if appropriate, by safety recommendations.”
Serious incidents, incidents and safety occurrences, are usually subject of a unit investigation carried out on behalf of, or parallel to, the investigation by an independent investigation authority.
IFATCA have registered several cases where controllers are getting fined, blame are apportioned, and where it appears that management roles, faulty or inadequate equipment and procedures are not considered.
It seems natural that investigations conducted by the states independent investigation authorities generally speaking are more comprehensive and of a higher quality than unit investigations. This because of the differences in resources allocated to the investigation, and the level of expertise available in the investigation teams.
Regardless of who is conducting an investigation, it is of great importance that Human Factor aspects do get their fare share of attention during the investigations.
ICAO released its first edition of Human Factors Training Manual in 1998. In Chapter 4, Human Factors Training for Safety Investigators, ICAO identifies the need for and purpose of Human Factors Investigation, and lists several obstacles for why Human Factors aspects has not been readily accepted.
The IFATCA manual contains several Human Factor policies. However, it requires a very good knowledge of the manual and knowledge in Human Factors, in order to bring these policies forward into useful contributions in an investigation process.
To achieve the main objective of an accident/incident investigation, it is necessary that IFATCA has a clear Policy that is easy to use by both the controllers contributing to investigations, by MA’s during their assistance to individual controllers, and by MA’s as an important expert group in a hearing process when investigation reports are submitted.
The focus on Human Factors issues involved in aviation occurrences is increasing. Existing IFATCA policy on accident and incident investigation does not include the necessary emphasis on Human Factor aspects in order to find out why an accident, serious incident, incident or safety occurrence took place.
Accident investigators, whether working for an appropriate investigation authority or at a unit level, might have limited knowledge in human factor investigation.
It is unacceptable that the purpose of the investigation is not in accordance with the objectives given in Annex 13.
Human factor aspects must be a part of all investigations.
It is necessary to expand existing IFATCA policy. ICAO Human Factors Training Manual contains several human factor checklists aimed at accident and incidents investigators. Attached to this WP is a checklist modified from a controller point of view.
That IFATCA Policy on Accident and Incident Investigation (page 4-4-A-1) para 9 – Right to make Representation, is amended with the addition of:
The controller and his representative should use the Human Factor checklist in the appendix to this policy to make sure that all Human Factor aspects that might have had an impact on the occurrence being investigated are identified and taken into account.
Last Update: September 28, 2020