Human Factors Incident Reporting — Page 310, Lesson 507

I want to walk you through the Human Factors Incident Reporting chapter. This is a critical topic because it deals with how we learn from mistakes in aviation without punishing the people who make them. Let's start with the introduction. It was first calculated back in 1940 that three out of every four aircraft accidents — that's 75% — are due to what was called "human failure of one kind or another." That figure was confirmed thirty-five years later by the International Air Transport Association, which we call IATA. Now, during that same year IATA was publishing its figures — 1977 — two aircraft collided at Tenerife. That accident cost 583 lives and about £100 million. It was the greatest disaster in aviation history, and it resulted entirely from a series of human factor deficiencies. Today, the calculation is that over 70% of all civilian aircraft accidents are the result of human error of some kind. So the core message here is that human error has always been, and remains, the dominant cause of aviation accidents — not technical failures. Now, because of this, various reporting schemes have been established. Their purpose is to publicise the human factor in aviation accidents. These schemes allow not only pilots but also other agencies — such as Air Traffic Controllers — to report incidents anonymously. The key word is "anonymously." The idea is that if someone reports an incident where human factors were a contributing cause — or even the sole cause — they can do so without fear of punishment. The very first scheme of this kind was established by NASA in 1976. It was called the Confidential Aviation Safety Reporting System, or ASRS for short. This system recognised something that had never been officially acknowledged before: it is unrealistic to expect to get adequate information for analysing human behaviour and lapses in human performance if you're simultaneously holding the threat of punitive action against the people making the reports. In other words, you can't punish people and expect them to tell you honestly what went wrong. That change in attitude was justified by the results. In the first ten years of operation, the ASRS accumulated a data bank of more than 52,000 reports. To give you a sense of the scale, during 1985 alone, 9,280 reports reached the ASRS offices at NASA — the majority of those from airline pilots. About six years after the ASRS programme was set up, a similar scheme was established. That scheme is called the Confidential Human Factors Incident Reporting Programme — and we'll continue with that in a moment.