I would like to reinforce my concerns over ‘box’ type investigation systems. Few if any provide insight as how to gather information prior to allocation, how to asses relevancy, or which box to place it in. Then with the ‘evidence’ in the box, it is easy to allow the conclusion to follow on from the contents.
As an example; the NTSB report into the LEX ‘wrong runway’ accident concluded that there was a crew ‘failure’ which implied ‘blame and train’ action. In this instance a ‘box’ type of investigation was used; this has been critiqued by Hollnagel in a presentation of an alternative process used for evaluating complex systematic issues. I am not suggesting that an operator requires the skills of a FRAM analysis for incidents, but the example (pages 19-24) shows how a different type of investigation (thinking) can identify contributing causes which arise from the different viewpoint. Thus at LEX - the crew’s performance varied as it would in normal operations, but it was the confluence of at least 6 contributing weaknesses which culminated in the accident.
The Changing nature of Risk.
For more on FRAM see
Course materials for FRAM - erikhollnagel2 - ‘FRAM Background’. (The LEX accident is expanded in ‘FRAM AA’)
I suspect that a flight safety officer will not require this type of tool, but the knowledge associated with it could (should) be applied during routine investigations to see what lurks in the complexity of interacting safety weaknesses and human performance found in most incidents.
A benchmark for most of this would be what happens in normal operations, and what differences are there between what is expected and what actually happens in operation – check your SOPs and the general understanding / interpretation of them – in context.
The US DOE publishes a comprehensive reference on human performance, CRM, and SMS aspects which would apply to aviation. There is a guide to investigation in Vol 2 starting on page 85, but beware of asking leading questions.
`Human performance improvement handbook'; `volume 1: Concepts and Principles'.
http://www.hss.doe.gov/nuclearsafety...09_volume1.pdf
`Volume 2: Human performance tools for individuals, work teams, and management'.
http://www.hss.doe.gov/nuclearsafety...09_volume2.pdf