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Investigating human error

Chief Commissioner Martin Dolan

By Martin Dolan, Chief Commissioner


I recently attended the Australian Aviation Psychology Association (AAvPA) conference in Sydney. This biennial conference gives human factors experts the opportunity to discuss human performance and limitations with the aim of improving transport safety. 

The ATSB has been a leader in integrating human factors approaches into safety investigation methodologies. A number of our investigators have strong professional backgrounds in the various human factors disciplines and are essential to our safety improvement task.


The field of human factors is—and always will be—an essential part of the ATSB’s investigation process.

At the conference, I acknowledged the continued importance of developing and improving safety systems so as to minimise the incidence of human error. One of the main aims of the ATSB is to understand why errors have happened and reduce the risk of them happening again. This can involve better identification and management of risk, improved procedures, better training, enhanced oversight of safety-critical activities and so on.

At the same time, we know that it can’t stop there.

We’re all human, which means among other more positive things that we’re fallible and prone to error. This remains true whatever our level of professionalism, however good our training, whatever procedures are in place to help us. As a result, good safety systems also need to detect and manage errors when they do occur — and before they lead to significant safety consequences.

For the ATSB, this requires us to understand what sorts of errors will occur, despite everyone’s best efforts, and investigate them when they happen. Sometimes we’ll find that the error was detected and managed – that the system worked as intended. Sometimes we’ll find that the detection and handling of error could have been better and we’ll point out where improvements could be made.

In either case, we accept that error can be reduced, but can’t be eliminated.

Just as important, we know that generally people don’t mean to harm themselves or others. Nor do they intend to make mistakes. Nevertheless, mistakes happen. This is why the ATSB doesn’t investigate to lay blame or to find fault. We investigate to see what changes need to be made to the overall system of safety, whether in preventing error or dealing with its consequences.

The field of human factors is—and always will be—an essential part of the ATSB’s investigation process. I congratulate AAvPA on its efforts to improve transport safety by advancing the understanding of human factors across the transport community.

Written by Martin Dolan, Chief Commissioner at 3:00 PM
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