This information paper seeks to provide people without an
in-depth knowledge of the practice of 'Human Factors' a general
plain English explanation of what Human Factors is, how it has
evolved, and how it is applied to aircraft accident and incident
safety investigations. The paper also gives a brief explanation of
international agreements and Australian law as they apply to
aircraft accident and incident investigations. Human Factors, which
includes 'Ergonomics' as it is called in some industries, is the
practice of applying scientific knowledge from varied, mostly human
science disciplines such as Psychology, Medicine, Anthropometrics
and Physiology to designing, building, maintaining and managing
systems and products. In general use, the application of human
science knowledge to systems and products is to provide the best
match between the characteristics of people, with the operation of
the systems and products they use. The purpose of applied Human
Factors is to build better and safer products and systems. In
aircraft accident and incident investigation, the specific purpose
of Human Factors is to understand in detail how and why people make
errors (including slips and lapses) or commit violations that lead
to accidents. In the development of aviation, the scope of Human
Factors has evolved from focusing predominantly on the interface
between the pilot and the aircraft to the broader application of
considering all the human activities of the system that is involved
in the placing and supporting the pilot in the operation of the
aircraft. This broader focus considers not only the actions of the
pilot, but also, the cabin crew, the maintenance crews, air traffic
controllers, and the management of the organisation that controls
the activities of the aircraft. The Australian Transport Safety
Bureau (ATSB) must, with as much certainty as possible, be able to
determine not only what happened in any given accidents, but more
importantly, why it happened. This information is critical to the
ATSB role in making safety recommendations aimed at improving
transport safety. The role of the ATSB is clearly defined in the
Australian Transport Safety Investigation Act 2003 (TSI
Act) which reflects Australian agreement to the international
standards and practices for aircraft accident investigation. Both
the TSI Act and international agreements state that the
investigation of aircraft accidents by safety agencies such as the
ATSB is not an activity for apportioning blame or liability, but
rather for the purposes of maintaining or improving safety.