APPENDIX C Consideraton of Human Factors
The most significant reason for the lack of human factors data for input into marine risk analysis models is that human factors have not been adequately evaluated in the investigation, analysis, and coding of accidents and incidents. This problem has been widely recognized in other modes of transportation and in other environments. However, efforts have been made in the last few decades to improve the investigation and coding of human performance factors and factors that contribute to human errors. The International Civil Aviation Organization (ICAO) published a digest on integrating human factors into accident and incident investigations (ICAO, 1993) using James Reason’s model of accident causation (Reason, 1990), which stresses an organizational framework. This approach was further defined in another ICAO digest on human factors, management, and organization (ICAO, 1994) and in a book by Reason and others, Beyond Aviation Human Factors (Maurino et al., 1995). In recent years, a human factors group was formed at the Kennedy Space Center to analyze incidents in space shuttle processing (up to launch) using a human factors event evaluation model modeled after a team effectiveness leadership model developed by Robert C.Ginnett and J.Richard Hackman (Bath and Medina, 1996).
In 1994, a group from Lockheed Martin Idaho Technologies published a report for the U.S. Coast Guard that recommended ways to take human factors data into account in marine casualty investigations. (Byers et al., 1994) The report included recommendations for training investigators, collecting human factors data, developing classification schemes, and developing computer interfaces for data entry. Further steps taken by the Coast Guard to change its casualty investigation program and human factors coding, as recommended by this report, would be valuable for future risk analyses.
The Air Transport Association of the United States has attempted in the past several years to reanalyze reports of major aviation accidents to assess the contributing factors of crew noncompliance with operating procedures. This reanalysis has required going back to raw written reports of investigations to collect relevant data that was lost because classifi-
cation schemes did not have codes for critical human factors. The reanalysis will focus not only on underlying human factors, such as procedural designs and organizational deficiencies, but will also provide support for changing investigation and coding procedures to capture critical human performance factors. A similar process of redesigning investigation and coding procedures could be used by the Coast Guard and other organizations involved in the investigation of marine casualties, incidents, and accidents.
Barth, T., and J.Medina. 1996. Kennedy Space Center Human Factors Program. Pp. 23–34 in Proceedings of NASA Ames Research Center-Kennedy Space Center Human Factors Workshop I: The Analysis of Errors (Incidents, Mishaps, and Close-Calls) in Aerospace and Aircraft Maintenance Domains, Ames Research Center, Moffett Field, California, September, 24–25, 1996.
Byers, L., D.James, R.Hill, and S.Rothblum. 1994. U.S. Coast Guard Marine Casualty Investigation and Reporting: Analysis and Recommendations for Improvement USCD Report No. CG-D-13-95. Washington, D.C.: U.S. Coast Guard.
ICAO (International Civil Aviation Organization). 1993. Investigation of human factors in accidents and incidents. Human Factors Digest 7. 240-AN/144. Montreal: ICAO.
ICAO. 1994. Human Factors, management and organization. Human Factors Digest 10. 247 AN/148. Montreal: ICAO.
Maurino, D., J.Reason, N.Johnston, and R.B.Lee. 1995. Beyond Aviation Human Factors. Aldershot, U.K.: Ashgate Publishing Limited.
Reason, J. 1990. Human Error. Cambridge, U.K.: Cambridge University Press.