You don’t want a family to have to meet us
Our safety investigators attend several fatal accidents each year. Many of these accidents occur because of human error. That’s why we want you to understand what human factors are. It really is that important.
One of the hardest parts of a safety investigator’s role is to meet with the bereaved families of pilots and passengers who’ve died in an accident.
Read some personal accounts in our:
Special edition of Vector [PDF 9.6 MB]
But while it might be hard for our investigators to have to do this, it’s not as hard as being those families. So we urge you to take the time to learn all you can about the very ‘human skills’ you need, to operate safely in aviation, because you really don’t want anyone’s family to have to meet us.
Our safety investigators, from left to right: David Oliver, Siobhan Mandich, Peter Stevenson-Wright, Colin Grounsell, Sam Stephenson, Kate Cook, Steve Walker, Lou Child and Dan Foley.
Welcome to the topic of ‘human factors’. We’re very happy you’re here! To get started, take a short, guided tour through the history of aviation safety by watching the video below. This video was created by Australia’s Civil Aviation Safety Authority (CASA). Even though its title suggests it’s just for pilots, its messages are relevant to anyone who participates in aviation.
The short answer is, ‘No!’ Human factors are aspects of being human, such as our ability to process information, make decisions, communicate, and adapt to situations, that either help or hinder people to perform their jobs safely. Understanding human factors is critical to aviation safety.
Unintentional human error plays a part in many incidents and accidents, and this is why it’s so important for us all to take an interest in this subject. It’s not just a theory subject you can pass for your licence and then forget about.
There’s been a big focus on studying human factors in aviation over several decades now, so that we can understand why people do the things they do, why incidents and accidents occur, and what can be done to support people to perform safely. We need to draw on scientific knowledge from disciplines such as psychology, physiology, sociology, biomechanics, and equipment design to understand this very broad subject.
This was a statement made to one of our CAA Safety Investigators while working with an operator to improve their human factors training programme. “No one is going to read this information”, the operator added.
Initially these comments were a major source of frustration for the investigator. Most fatal accidents and serious incidents have a human factors contribution. “Human factors is why people die,” the investigator says. But, on reflection, they realised a subject needs to be presented in an engaging way if we expect people to take an interest in it.
So we decided the onus was on us, the CAA, to create content that participants want to read, that they find useful, and that improves safety as a direct result. Even though human factors research tends to be a bit pilot-centric, the information included in the human factors section of the website aims, where possible, to show how it relates to multiple roles in the aviation industry, not just to pilots.
It’s intended that anyone can use this information to improve their own knowledge or use it to generate organisational training materials. And we provide links to other useful resources so it’s a ‘one stop shop’ for aspiring pilots, trainers, and organisations wanting to know more.
We welcome your feedback at humanfactors@caa.govt.nz. Let us know what you like about these pages and what we could do better so that we can continue to improve our content.
Why do competent people make basic mistakes?
The answer is very simple. Our actions and decisions are influenced by the factors that surround us, whether they’re personal, work-task related, or organisational factors.
James Reason (2003) “You cannot change the human condition, but you can change the conditions in which humans work.”
The essence of human factors is understanding the things that influence our performance. Understanding why we make mistakes is the key to improving human reliability.
A critical skill that all of us - individuals, managers, or organisations - need to develop is the ability to recognise when these external factors are influencing the way we’re performing, and to understand how our behaviours and decisions might be affected by these factors.
How would you cope if an error you made ended in a fatal accident for someone else? We usually only think of the victims of an accident as those who’re injured, or who die. But where that accident was caused by someone else’s error, we have what is known in human factors circles as a ‘second victim’.
A second victim is a person who’s involved in a serious incident or accident and who feels personally responsible for the outcome. Some obvious roles that might find themselves in this position are air traffic controllers and engineers. And that’s why this human factors information is not just for pilots. It’s for anyone who participates in aviation and whose decisions and actions can impact the ‘sharp end’.
As a society, we tend to blame and forget such professionals who may be involved in serious incidents and accidents, assuming that because they weren’t hurt, they’re not a victim. But this is short-sighted and fails to understand the traumatic experience of being the one whose error led to such a consequential outcome.
So while it would be easy to read a lot of the information in this human factors section of our website and think, ‘Oh that only applies to pilots’, think about how those same concepts might apply to your line of work. Your awareness of how your decisions and actions are influenced may just prevent you from ending up a second victim.
We’ve created a section dedicated to air traffic control and maintenance human factors for this very reason - see Human factors - not just for pilots. These professionals are as integral to aviation safety as pilots, and can suffer significantly when safety goes wrong.
It’s equally important to know what influences success, as it is to know what influences failure.
Historically, investigations have been reactive, occurring only once an accident has happened. We, the safety investigators, find out what caused an accident and then implement safety actions to try to prevent it from happening again. But current human factors thinking now incorporates a focus on human performance, recognising that people contribute positively to safety. People are adaptable, innovative and resourceful, and these capabilities can support their performance in a positive way.
To support human performance, we need to understand how people perform their tasks in a real-world environment and what influences them. Learning from this will help people maintain and improve their performance and wellbeing, and also improve the overall safety of the system.
This short podcast excerpt by Todd Conklin, author of Pre-Accident Investigations, talks about the concept of not waiting for failure and of doing safety differently. There will probably always be a need for reactive investigation into the results of human error, but progress lies in thinking differently, in working out what the factors are that help things go right, and in disseminating those lessons as much as we do the lessons from when things have gone wrong.
