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TRANSCRIPT
“Human Factors, understanding mistakes to
prevent technological accidents, an application of
the HFACS model at the Tuninter 1153 disaster
(August 6th, 2005)”
Roberto Carella1, Gianluca De Donno2
1University of Basilicata
2University of Rome “La Sapienza”
Abstract. The term Human Factors refers to a multidisciplinary approach
that takes care of the interaction between man and his working environment
and the ways in which man acts within it. The Human Factors approach,
starting from how people perceive the outside world and behave
accordingly, deals with the design of tools, products and systems with which
humans interact. The principles of Human Factors are applicable to the
design of small objects such as a simple pen or a computer mouse, up to
very complex systems such as an aircraft or a Space Shuttle. In summary,
the study of Human Factors is, therefore, an approach that was born in a
working organizational context, and key elements are analysis and the inter-
human relations, with the main aim to minimize the danger and the perverse
combinations of risk and error that often generate unknowingly incident.
Human Factors is now a multi-disciplinary approach, which collects and
applies different knowledge from different sciences, medicine, engineering,
psychology, sociology, theory of organizations, with the aim of improving
safety conditions at different levels of the organization involved which will
prevent unexpected events of a certain hazard . In aviation, the International
Civil Aviation Organization (ICAO), through Circular 227 defines "Human
Factors as the object of studying people while performing their duties, their
inclusion in the workplace in a physical sense and interpersonal relating
with their working tools and procedures to follow. The objective of this
approach is the pursuit of safety and efficiency; it is therefore an approach to
security that considers the whole organization fully involved and responsible
for an accident.
Keywords: Human Factors, Organization, Technology, Knowledge
Management.
1 Human Factors in Aviation
In the history of Aviation there are a series of successes and failures with the
result of improving and continue to realize the dream. Aviation accidents
have been and continue to be numerous, and a large percentage of them
cause many deaths and economic and social damage for organizations
involved. Before the Second World War the majority of aircraft accidents
were caused by structural failure of the aircraft, due to bad weather
conditions, and pilots had to manage often alone in complex situations.
Human Factors, was understood as a certain individual inability to manage
complicated situations, poor knowledge of the flight, fatigue, were elements
that contributed to the occurrence of air disasters. It was after the Second
World War that the structure of the aircraft was made more reliable thanks to
technological interventions, and there was better flight assistance with the
intensification of communications between the control tower and the crews
and the analysis of the Flight Data Recorder, the famous black box. In
aviation, studying the causes of technological and organizational accidents,
there is a substantial difference between incident and accident. Incidents are
less serious events, occurring on a frequent basis and are to be considered,
reported or investigated in order to avoid their recurrence. Accidents are less
frequent and are events that have disastrous consequences, victims and
affected individual, social and economic issues. During the first IATA
Conference in Istanbul (1975) was consolidated the knowledge that men,
pilots and crew members, have a strong responsibility in the dynamics of a
plane crash, and since then, training programs were made especially to
improve certain skills and competencies related to group dynamics and
situations which can present during a mission. In this context arises “Crew
Resource Management” that tries to prepare the “Non-technical Skills” of
the crew. In fact accidents are not only the result of technical or human
error, but are the result of several concomitant and concatenated, causes
which involve the whole organization. This approach aims to highlight the
unavoidable human error and study as well the shortcomings in a technical
and a practical level and those at the front line, due to inefficiencies in
procedures and faulty communication both vertically and horizontally across
organizations. On 28 April 1988, something happened that changed the way
to manage all the activities pre-flight, culminating in implementation at the
organizational level, a series of practices and procedures geared towards
total security. On this date, in fact, a Boeing 737-297 of Aloha Airlines,
took off from Hili airport in Hawaii, but only a few minutes from take-off
was forced to make an emergency landing in Kahului Airport. There had
been a phenomenon which never happened before: the top part of the
fuselage had separated causing an explosive decompression that forced the
pilot to abort his mission, which killed a victim and injured many others.
The National Transportation Safety Board (NTSB) concluded its report,
identifying a cause-related to corrosion due to a phenomena of careless
maintenance of the aircraft. It was understood then, that bad maintenance
programs, resulting from poor management of these activities, could have a
devastating impact on aviation safety and it was for this reason that in 1993,
the second conference of IATA in Montreal, it was decided to launch new
programs training that took the name of “Maintenance Resource
Management”, and pointed to a safety management level of maintenance. It
was recognized that human error was ”unavoidable“, and deficiencies were
studied at a technical and practical level in procedures and in faulty
communication both vertically and horizontally across organizations. All the
systems are based on the consideration that not only man fails, but the whole
system, in line with the considerations of a distinguished psychologist and
professor at the University of Manchester, James Reason. He, through the
analysis of several disasters, in his book Human Error (1990) introduces the
”Theory of Latent Factors”, saying that accidents are the result of a series of
active factors (active failure), and latent factors (latent failure) in the system.
The former are generally committed by the operators in the first line, the
second are real organizational deficiencies, sometimes voluntary, decided by
the company management. Therefore in aviation the Human Factors
approach primarily desires to increase levels of security, trying to mitigate
and avoid errors, not only through the study of behaviour and situations, but
also trying to introduce and correct certain internal processes and procedures
in organization involved in aviation activities. And above all people are the
main element , which are built around the framework of this approach and
agents that interacts each other and that have to deal with a multitude of
factors. The key issue is, therefore, to continuously implement and
disseminate a ”culture of safety“ at all levels of an organization, in order to
keep ever high attention which is the basis of complex systems such
airports, aircraft, companies involved in aviation. James Reason considers
and defines the error as a deviation from something that should follow a
linear path, a path that points to the achievement of a goal. The psychologist
follows the theories formulated by Rasmussen providing a classification of
the errors according to the intentions, actions, context and outcome. With
regard to the intention, we can identify the kinds of errors closely related to
the desired objective. When the goal is not reached due to deviations from
the predetermined initial path, there are errors due to distractions, or failures
in the performance that Reason defines as ”slip and lapse”. The slips are
easily recognizable, because we know our intentions and we quickly realize
the error, the lapses are promptly identified too, but they could be
discovered later on. If the action plan is well executed but it did not reach
the goal, we are faced with a mistake, that is a failure due to bad planning
processes. Mistakes however, are difficult to recognize because sometimes
we do not know the right path to follow to achieve a goal, and it all depends
on the result. The end result can be positive or negative and is often linked
to randomness; we realize only at the end of a path if we made a mistake or
not. The errors classified in the category of actions, refer to the nature of the
actions themselves. These omissions are not required when an action is
performed; there are intrusions when certain actions are performed in a
context, but refer to other activities; there are repetitions at a time when
various actions are repeated unnecessarily; when certain actions are correct,
but they are referring to other contexts; disorders when right actions are
performed in the wrong sequence; are uncoordinated when correct actions
are not performed when appropriate; fusion when several actions are fused
together, leading to not pursuing the objective.
Reason also identifies another category of errors, voluntary and related to
procedural situations. These are acts that are committed voluntarily during
procedures, because it may seem unsuitable, or routinely violated, because
we know that will lead to the achievement of a goal. They are actions that
the psychologist calls “violations”, and that despite being wrong, always do
not have a different result from that intended in the sense that they are not
always wrong actions with negative results. All the different types of unsafe
acts are those that in the theory of latent factors, are identified as active and
latent failures. But if on the one hand the above theory provides a clear way
to interpret accidents in organized systems, on the other hand says nothing
about relating the opportunity to identify the real causes of these, or to
identify the active and latent factors. To overcome, the U.S. Army Safety
Center, the U.S. Air Force Safety Center, the NTBS, and the Federal
Aviation Administration, on the basis of the analysis of three hundred
aircraft accidents in the U.S. Navy, built a model of investigation, able to
find the various errors that are configured at the organizational level, in a
plane crash. The model is called “Human Factors Analysis and
Classification System” (HFACS; Douglas A. Wiegmann; Scott A. Shappell), and
is a framework for easy application and understanding divided into four sub-
frameworks, and analyzing four levels of deficiencies from the one closest
to accident, namely ”dangerous acts” and then analyze the “preconditions
for dangerous acts”, the “dangerous supervision” and finally the
”organizational influences.” The dangerous acts are those that Reason
defines active failure and are divided into ”errors“ and ”violations“. These
in the HFACS model, errors are to be identified, respectively, as skill,
judgment and perception, and routine and exceptional violations. Once
having discovered the active factors that have caused the accident, the
model goes on to analyze the causes that have caused it, trying to understand
at a higher level what has happened or what has influenced their creation.
The assumptions look to environmental factors including also the technical
and technological shortcomings of the system; inadequate practices of the
operators, with reference to the conduct of the crew, and the preparation of
the staff involved. It also investigates the psychological and physiological
conditions of the operators and their physical or mental limitations. The
dangerous supervision tries to bring out misconduct or inappropriate
decisions by those who are supposed to ensure compliance with certain
procedures or activities, schedules, inadequate, failures on the correction of
errors, and violations of these figures that are supervisors . At the last level
of the first investigation but the first in the scale of the model, there are
”organizational influences“, related to the processes, the management of
human and economic resources and materials, and related to organizational
climate, some habits, practices, ways of incorrectly seeing and doing, far
from contributing to the actual birth of a probable accident. The HFACS
model, is an investigative tool that greatly helps to understand why and how
an accident happened and provides several elements which go to seek to
highlight active and latent failures, and shows, in line with the theory of
Reason, that the presence of both factors is crucial. However this model
only investigates what has already happened, and so provides guidelines,
suggestions, and adjustments to the level of processes or activities that are
part of an organizational structure complex.
2 Methodology
Given the relative paucity of research on Human Factors, we proposed an
approach for this study based on an exploratory case study (Yin, 1994) with
a qualitative research design that allows a detailed exploration of the topic
(Eisenhardt, 1989). Data collection involved: access to newspapers,
organizational documents collected on the Internet, information bulletins,
public domain lists, relations and released by institutions.
3 Case Study: the accident of Tuninter 1153 (August
6th, 2005)
Aviation accidents have been and continue to be numerous, and a large
percentage of these cause many deaths, economic damage, despite
increasingly sophisticated technologies, and practices of flight always in
continuous improvement. The Human Factors Analysis and Classification
System, built on analysis of three hundred aircraft accidents of the Navy of
the United States, (in which participated civil and military organizations
such as the U.S. Army Safety Centre , the U.S. Air Force Safety Centre, the
NTBS , and the FAA) , based on the concepts of active and latent factor
error of Reason, HFACS identifies four levels of shortcomings: dangerous
acts, conditions of dangerous acts , dangerous supervision, and
organizational influences. The aim of this work is the application of the
HFACS model to a case study of a plane crashed on August 6th, 2005 near
the coast of Capo Gallo, Palermo (Italy), a tragic event occurred at 13:37
UTC which involved an ATR72 aircraft , which operated the flight TUI in
1153 with thirty-nine people on board and which caused the death of sixteen
people. The analysis carried out shows that the incident in question, is a
typical accident involving people in a complex organizational context,
where they were to face numerous elements at the same time that caused a
situation turned into tragedy. The official investigation of the accident was
conducted by ANSV, the National Agency for the Safety of Flight, which is
the investigating authority for the safety of civil aviation of the Italian State.
ANSV not only investigated the technical factors that had caused the event,
but also identified a number of organizational errors. On the basis of the
official report produced by the Italian agency, after having presented a
description of what happened with particular reference to actions that led to
the disaster, we will investigate the event using the HFACS model, trying to
identify and highlight the latent factors that impacted on this event. The day
before the accident, the aircraft had been used to run five flights on routes
between Djerba, Tunis and Catania, and the same commander involved in
the event, had noticed and reported the failure of a Fuel Quantity Indicator
(FQI) . On the evening of the same day, the instrument was replaced with a
more efficient one, but with a different Part Number, although with an
identical design, and, it was understood by subsequent investigations, a
different indicator for measuring capacity, suitable to be used on another
type of aircraft: the ATR42, an aircraft with smaller capacity of fuel. The
technician in charge of the replacement, consulted the Illustrated Part
Catalogue (IPC) and he identified three different alternative Part Numbers
that could be mounted in place of the original. Then he made other research
on the database, and found one of a different numerical designation,
according to the computer system used was suitable to installation on the
aircraft ATR72. Information was wrong but the technician, trusting in what
he read on the terminal left the instrument to his colleague who in the next
shift, performed the installation following operational tasks listed in the Job
Instruction Card, instructions that did not include a verification of the
information measurement of the instrument, but only a test of the lights of
the display. He also did not check the real applicability of the instrument by
consulting the IPC. The next day, the plane had to make routes from Tunis
to Bari and from Bari to Djerba, and all the necessary refuelling operations
were implemented. The crew of the first flight, informed the Flight
Dispatcher (FD) the required amount of fuel in order to make the first flight,
and exactly 1400 kg of fuel was loaded. There were therefore, the activities
of the refuelling transaction involving the use of a tanker and two
technicians. The supply was accomplished by setting up an electronic
instrument, the amount of block fuel needed, the line mechanic input 3800
kg on the panel, but in reality only 465 kg was loaded, compared to the 700
kg needed; this was because the FQI indicated on the display the desired
amount. The system was automatic, and when FQI detects the amount of
fluid set, closed through the valves, the supply of fuel. Completed the
document, this was delivered by mechanics for the commander's inclusion
with the documentation on board, but no one noticed the discrepancy. In
addition, the maintenance manual procedure, did not provide for the
inspection of the actual amount of fuel through the drip stick. Before
carrying out the mission, the Commander verified the flight documentation,
assisted by FD who had reported a previous filling the night before, an
operation that would bring the fuel level to 3100 kg, but the bill related to
this activity was not found. The FD, however, informed the Commander that
the receipt could probably have been left somewhere by the previous team
assigned to the supply, and that it intended to supply it to the return flight,
although he was not sure of this claim. The pilot decided, however, to fly,
trusting the information received. No one noticed in fact, that the quantity of
fuel in the tanks, was considerably less than what it should be. The plane
took off normally, and landed in Bari at 24:05. No one of the members of
the crew paid attention to the fuel consumption indicated on Fuel Used
(FU). In Bari, however, another supply was made according to the estimated
quantity for the next question. Here, too, no one noticed that the amount
uplifted was less than that actually required, because the FQI reported a
different but corresponding value calculated for the second flight. The
operational flight plan was also not compiled, where time and fuel
consumption is transcribed, and the fuel consumption was not checked at the
different points of flight. This was a widespread common attitude in the
airline. It is believed that neither was the Performance Record (PR), where
replenished and fuel consumption are transcribed, compiled. Subsequently,
the operations were carried out boarding passengers, all thirty-five, along
with the pilot and co-pilot, and two other members of the crew. At 12:32
received the order of clearance from the control tower and flew. During the
first phase, at a certain altitude, the captain got in communication with a
control tower in Rome changing radio frequency devices, and exchanged
some information related to the mission. At 13:21:36, the pilot of the ATR
asked to Rome permission to descend to a lower altitude for technical
problems, without specifying the type, but received a negative response
because of high traffic. The right engine had shutdown. Just 100 seconds
later, the left engine shut down, and at this point permission was requested
to make an emergency landing at the Punta Raisi Airport of Palermo. The
two engines went out because aeroplane was out of fuel. The commander
gave a first MAYDAY, but did not give the order to carry out any procedure
provided for Both Engines Flame Out, which provides for this type of
aircraft to feather the propeller, in order to reduce the friction with the air
and allow the aircraft to glide longer distances. From Rome, meanwhile, the
opportunity was given to land in Palermo, but radio communications
appeared to be unclear, and only at 13:24:19, was referred the loss of control
of the two engines and transmitted a second MAYDAY. Rome, rather than
managing via the radar vectoring at the airport of Palermo, invited the
Commander to make contact with the control tower at Punta Raisi, because
at that distance it was difficult to give assistance via radar, and called on
Palermo, asking to get in touch with the aircraft. During communications
between Palermo and the ATR, there were misunderstandings due to the
English language, which delayed awareness of what was happening. The
Commander requested information three times regarding the distance from
another airport where he can land, information given to him by another
plane in flight because the controller in Palermo still did not understand the
demands of ATR. At 13:33:53 Palermo began to understand what was
happening and told the Commander and all crew, who were at an altitude of
about 4000 feet, and at a speed of 20 NM from Punta Raisi. The pilot
ordered to perform the ditching procedure and also spotted two boats toward
which to direct the aircraft in order to speed up the rescue once at sea. It also
indicated its current altitude of 2200 feet and the desire to land near the
boats. At 13:37, the ATR72 crashed into the sea, the plane broke into three
pieces and killed a member of the crew and fifteen passengers.
4 Application of the HFACS model to the case study.
The accident in question, as in the majority of aircraft accidents, has been
determined by a series of events that led to a final splashdown. The primary
cause that caused the disaster, is the erroneous substitution of FQI due to a
human error, but the event in question is also characterized by active and
latent factors that have pioneered the accident. We can identify these factors,
using the Human Factors Analysis and Classification System (Douglas A.
Wiegmann; Scott A. Shappell), which as explained above, allows us to
identify the various flaws of a system at different organizational levels.
Fig. 1. Human Factors Analysis and Classification System Model (Douglas A.
Wiegmann; Scott A. Shappell).
4.1 Step 1: Unsafe Acts.
Fig. 2. The Unsafe Acts Analysis.
At the level of dangerous acts, we can identify several violations classified
as routine. The technician responsible for the replacement of the fuel
performed in fact a wrong procedure, he did not inspect the actual
applicability of the part. He was wrong to use the documents in possession
to him, he checked on the Illustrated Parts Catalogue, but omitted a
fundamental rule that prevents all aviation operator to install any Part
Number which is not in the catalogue. In these cases he would have to
report the problem to the relevant technical department. He committed a
violation of situational type rule-based, in fact omitted to apply a rule, acting
in good faith also influenced by the belief that the part was sufficient for the
service, because the database consulted reported an error. Even the refuel
truck omitted to control, twice the amount of fuel that was entered as block
fuel demand. He compiled the document, but did not realise and paid no
attention to the difference in fuel, instead of a violation he committed a
mistake, a slip due to the frequent and routine activities taking place. Both
the Commander, and the Flight Dispatcher, committed violations, and did
not find the real reasons for the lack of document relating to supply up to
3100 kg. If the FD had in-depth research, perhaps someone would have
noticed the inconsistencies. The FD provided ambiguous information,
knowledge-based, because he found himself in an unfamiliar situation, rare,
and suggested that the document was somewhere else, but in reality he was
not aware of the document’s location. During the route Tunis - Bari, nobody
paid attention to Fuel Used as an error of skills due to a lack of attention of
the crew involved in flight operations. At the level of dangerous acts, errors
were also committed caused by incorrect decisions. The Commander, when
the first engine turned off, did not declare the emergency situation, and took
care to ask the co-pilot to understand why shutdown. Only after the
subsequent flame-out of the second motor informed the Roma control tower
of the problems. He also did not give orders to perform the procedure for
landing due to the particular situation in which he and the crew were to
find, he had not lost situational awareness, but had to manage an event of
considerable complexity, he had also too little information from on-board
instruments and by the control tower of Palermo. The whole sequence of
errors and violations in the dynamics of accident, are active factors preceded
by a number of latent factors. We can find out through the other stages of
analysis: we start from the level of ”precondition for unsafe acts”.
4.2 Step 2: Precondition for Unsafe Acts.
Fig. 3. The Precondition for Unsafe Acts Analysis.
We have already pointed out, that the main reason that caused this accident,
was the wrong installation of a FQI different from the original. This error is
also to be classified in the category of inadequate technology of the system.
The manufacturer of this instrument, suitable for the ATR42 aircraft, had
designed almost identical in design to the one installed on ATR72. He had
never thought that this similarity could cause confusion. In aeronautics each
component, device, instrument, must be designed with features that prevent
it can be used in different locations. It is said that these parts have to be
”fool-proof“, obviously without taking anything away from all people’s
intelligence. This category also comprises the computerized management
system of spare parts in use by the airline, which featured a matter of
applicability of the non-verified parts. The consultation of the database was
instrumental in the decision to install the fuel gauge found. The
investigations of ANSV, also identified the presence of a device “Not of
Low Fuel” level between the instrumentation of the cabin, a lack of the
manufacturer of this aircraft. If there had been this tool, perhaps the
Commander or a member of the crew would have noticed of actual amount
of fluid in the tanks. The National Agency for the Safety of flight, also took
over the investigations, that the maintenance staff had not received formal
training regarding the proper use of the system of inventory management, a
factor that falls into the category of personal preparation. There were also
particular problems of communication between crew and the control tower
of Rome and Palermo, factors which influenced the coordination of the
activities foreseen in case of emergency. After switching off the engine first,
Rome did not receive detailed information about the real issues, and did not
allow the authorization to descend in altitude. Some radio interference, then,
did not allow the controller to immediately speak to Rome, to understand
that both engines were damaged, and not accomplished vectoring towards
the Punta Raisi Airport, but it is nonetheless put in contact with Palermo.
Palermo took too long to understand the gravity of what had happened
because of misunderstandings due to language: English. All this delayed the
receipt of the relevant information from the Commander and crew, who
decided to land in the sea because he was too far from Palermo. The
procedure for feathering the propellers then, was not performed because
unordered, because of the understandable concern of the crew, who were
paying attention above all to understand the distance from the place of
landing, and engaged in an attempt to restart engine. All this information
was recorded by listening to the conversations recorded on the Voice
Recorder, and the analysis of the data downloaded from the flight data
recorder recovered after all had happened. Other abnormal behaviours are
to be found on the third level of the model HFACS: ”unsafe supervisions”.
4.3 Step 3: Unsafe Supervisions.
Fig. 4. The Unsafe Supervisions Analysis.
The improper action that we can place under this heading is a procedural
violation committed by a supervisor, in this case the Commander of the
crew. In fact, in checking the documentation on board, he noticed the lack of
supply, but he decided to take off without investigating. If he had done so,
perhaps the anomaly would have jumped out and the accident could have
been avoided. Finally, we can also identify other latent factors in the system,
using the level of ”organizational influences”.
4.4 Step 4: Organizational Influences.
Fig. 4. The Organizational Influences Analysis.
As we have already had occasion to specify, flight crews were accustomed
to not fill flight plans or the Performance Record, which these operations
required, but that was found to have been violated throughout Tuninter, the
flight company owner of the aircraft. Lack of a system for monitoring flight
data, a Flight Data Monitoring, while not mandatory, but only recommended
by “Annex 6” of the ICAO. An habitual behaviour from organizational
climate where they fit even the poor training of staff to use of the database
and, as he was able to detect the ANSV, also a level of standard maintenance
and organizational inadequate for the proper management of the aircraft. In
fact, the airline used an Operations Manual Maintenance which is not
approved by the “Directorate General for Civil Aviation” (DGAC), as well
as using a database with the data entered not thoroughly. In the category of
organizational processes, lies the use of an inadequate Job Card Instruction,
the visual and manual control of the computer system for the management
of spare parts, an absence of a system of security management and
assurance quality. The surveys conducted by ANSV, noticed that the Job
Card Instruction did not provide a cross-check between the reading of the
amount of fuel the instrument replaced and the amount shown on the
documentation on board, as well as verification by the rods placed under the
graded wings. Also lacked a Safety Management System, not required at the
time or in accordance with the national legislation of operator, nor by
international standards, as well as a Quality Assurance System, still in the
implementation phase at the time of' the event. There was only a system of
Inspection System, envisaged in the “Annex 6” of the ICAO, which
included quality checks by auditors / inspectors. The analysis carried out
shows that the accident in question, is a typical accident involving persons
in a complex organizational context, where they were faced with numerous
elements that turned situation into a tragedy. As Reason teaches, active
faults committed by operators of front-line, were generated by something
that had to be searched upstream of the system. It proves in fact, that a
whole series of wrong behaviours, procedures, tools unsuitable deficiencies
on the part of the executive management, have formed the basis to make
sure that the latent factors inherent and dormant in organization were
presented, which paved the way to a ”trajectory of opportunity“ leading to
the accident. With the use of the HFACS model, it was possible to identify
and classify these factors and understand what is actually happened. This
model in fact allows us therefore to identify areas where corrective actions,
are needed to get a system capable of ensuring the safety and the prevention
of technological accidents.
Conclusions.
In our project, we wanted to follow a path with the objective to present and
to outline the structure of Human Factors, trying to bring the reader to the
basic concepts of the discipline, but also to provide the necessary elements
for the understanding of those particular errors, with the aim of preventing
technological accidents. We do not pretend to be exhaustive, because the
study of Human Factors, is enriched with the tools and knowledge over
time, taken from other disciplines, experiences, methods of investigation
and technologies, that can pinpoint the error probability. Today the study of
Human Factors in fact, includes medical and physiological research and
surveys, the improvement of working conditions, with particular attention to
the environments, the instruments used, procedures, training. Human
Factors tries to use and disseminate techniques of risk management and risk
assessment, and to intervene in the dynamics of communication and group
work, with a specific interest in feedback, from which they can benefit in a
perspective of bottom down. It is also ergonomic and cognitive ergonomic,
which is mainly engaged in designing and perfecting the man-machine
interface, it is technology, it is engineering, is bio-mechanics. But as we
have seen, it is primarily a ”man“, the main element of which is built around
the skeleton of this discipline, and is, the man, that particle that interacts and
which must relate, with a multitude of factors, which characterizes both
himself, and the habitat in which it is located: the organizations. We have
also used the HFACS model to analyze the case of a flight, and we arrived at
the following conclusions. This model of analysis, can to be used to
understand the causes of an accident and to improve the safety of the flight,
but it is a descriptive model and not prescriptive, it is in fact, a reactive
safety model, because it is possible to analyze an accident, only after this
has happened, and not before. It is a proactive safety model, but at the same
time, a valuable tool to investigations. Many strides have been made since
its introduction in aviation, and for this reason, it would be appropriate to
use also in others contexts that involve the organization and the mix of
technological and human components, such as marine disasters, rail
accidents, (i.e. Costa Concordia, or Formula1- Bianchi accident) and in all
those situations where the Reason Model is already applied.
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