Back to the future, Bills and Reason!
Kharon post # 42 from ATSB reports thread:
I wonder if he ever looks back at what he built, probably not. Come home Kym – all is forgiven;your Mum's worried, the dog won't eat, the cat's out of the bag and there's hell to pay with the Senate.
On the subject of the Kym Bills era…came across a 2006 ATSB endorsed paper labelled.. ‘A Layman’s Introduction to Human Factors in Aircraft Accident and Incident Investigation’(ATSB SAFETY INFORMATION PAPER B2006/0094 ), which IMO has particular relevance to the AAI Senate inquiry and the Beaker era (beyond all sensible reason) vs the Bills era (back to the future).
After reading this paper you will again be left scratching your head over the PelAir Final Report debacle 
and how a supposedly independent, highly respected, well principled transport safety investigative agency (as the ATSB was) could so comprehensively lose their way in the space of three short years.
Okay so here are some quotes of relevance from the paper:
From Executive summary...
“This paper is concerned primarily with the relationship of Human Factors to aircraft accident and incident investigations. The purpose of applying Human Factors knowledge to such investigations is to not only understand what happened in a given accident, but more importantly, why it happened. Without understanding why an accident occurred, safety investigation agencies such as the Australian Transport
Safety Bureau (ATSB) are limited in their ability to draw meaningful conclusions and propose effective safety action and recommendations for change.”
“Since it was known very early on in aviation history that the pilot ‘failed’
significantly more often than the plane did, most aircraft accidents were classified as ‘pilot error’ and often the explanation went little further than that. The use of the term ‘pilot error’ provides a simple, but often misleading explanation of a complex accident sequence.
Sections of the community and some high-risk industries seem to desire a simple explanation for complex events. That is, of what ‘caused’ the event and who is to ‘blame’. Some also tend to see Human Factors as a process of helping individuals avoid their responsibility for accidents.”
“With the evolution of human factors, human sciences knowledge is now not only applied against a systems engineering background, but also against a psychosocial and more recently a business management framework. These evolutionary developments break away from the idea that a pilot operates in a vacuum and that accidents are events isolated from the system which nurtured them.”
Excerpt from Introduction:
1.1 Background to this paper
The term, Human Factors, is a relatively new term that is not well understood by
some sectors of the community.
Apart from a lack of knowledge about the subject, the misunderstanding seems to
be partly due to the fact that some people seem to believe that investigations into
accidents explicitly for the purposes of improving transport safety should be
concerned with identifying and punishing the people guilty of causing those
accidents.
Given this view, and the fact that in many cases Human Factors investigations tend
to confirm that people who have accidents are victims of their own human frailties,
some members of the community seem to believe modern Human Factors
investigations simply help guilty parties avoid taking responsibility for their actions. {That certainly sounds familiar???
)
These notions are completely at odds with the purpose of a safety investigation
which, first and foremost, must be concerned with understanding why an accident
occurred and, on that basis, making effective recommendations to prevent
recurrence and improve transport safety for both the Australian and international travelling public.
In an effort to increase the level of general understanding within the community, the
Executive Director (top stuff KB
) of the ATSB commissioned this layman’s information report.
1.2 Objective of this paper
Human Factors is a large and complex subject and a full or detailed coverage of the topic is beyond the scope of this paper. The objective of this paper is to give a
layman’s general explanation of the history, development and application of Human
Factors, particularly as it relates to safety investigations of aircraft accidents and
incidents.
The ATSB would welcome constructive suggestions for improvement of this paper
for a future edition. Any suggestions should be mindful of the introductory focus of
the paper. The ATSB runs a five-day course on introductory human factors which
includes much more depth and employs a number of specialist human factors
investigators. Any suggestions should be sent by email to [email protected] by 31 August 2006.
The whole paper is well worth the time to read and IMO if Kym Bills (and his former lieutenant Alan Stray) had still been at the helm at the time of the Norfolk Ditching investigation, there would have been a much more different outcome and a final report that the Senators and industry would have been proud of. 
Note: The ‘beyond pilot error’ (Airbus A300, American Airlines flight 587 in New York City on 12 November 2001) example on page 12-13 focuses on the progress, largely initiated by the ATSB, in Human Factors research and its relevance to AAI.