RECORRIDO HISTÓRICO INTERNACIONAL

The importance of integrating and applying human factors is not limited to air accident investigation. As identified previously, Rose (2009) and Evans (2013) conducted research on HF training for investigators and managers in the rail industry. Similarly,regarding accident investigation, the importance of taking a system approach and considering organisational factors is applicable to a range of industries beyond aviation. This is illustrated by the wide variety of research that has employed or adapted the Reason’s Swiss Cheese model (Larouzee and Guarnieri, 2015) or Wiegmann and Shappell’s tool HFACS. For example, Ren et al.

(2008) and Fukuoka and Furusho (2016) applied the latter in the context of the maritime industry whereas Jennings (2008) applied it in defence. Conversely, Kamoun and Nicho (2014) used a similar approach in a healthcare setting.

The challenges faced by human factors in air accident investigation are also common to other industries. Meister (1967) found that engineers and designers lacked interest in human factors due to the fact that it is a social science. Later research by Meister (1982) pointed out that engineers and government personnel were not convinced about the value of HF and were lacking training on the topic. More recently, Helander (2000) found that there were a number of possible reasons why HF was not implemented, including consideration of HF as common sense and being too abstract to be useful. Waterson and Kolose (2010) found that this attitude of considering HF as common sense still remains. In 2011, Peterson et al pointed out that in the maritime industry, engineers need to

that in order for HF to have more impact, HF experts need to understand the heuristic nature of engineering.

Perrow’s work (1983), cited by Jensen (2002) and Dul and Neumann (2005, 2009) attribute the difficulty of HF acceptance to organisational issues. Amongst these issues is the small number of ergonomists actually working for these companies and that it is not always accepted by business managers. These problems limit HF specialists’ influence and restrict their perspective.

Moreover, the integration of human factors is not only important in the investigation process (i.e. considering the human within a system) it is also essential from the design of a system to its manufacture and in turn to its operation and possible failure (i.e. investigation). As an example, Cullen (2007) highlights that it is essential for the designers in high hazard industries to integrate HF in the early design phase of a system, i.e. consider the system end users in order to avoid operational problems and in turn potential safety issues.

Thus, multiple sectors such as aviation, rail, nuclear, defence and also healthcare rely on quality Human Factors Integration (HFI) to produce safe systems.

Seeing that HFI is as essential in other industries as it is in aviation and in air accident investigation, and that many challenges are shared amongst these sectors, the benefits of the research for other industries are clear.

II-5 Conclusion of the literature

As demonstrated in this literature review, accident investigation is strongly related to safety and to human factors. The shift of focus, the evolution of the aviation system as well as the evolution of human factors occurred at the same time and are complementary. Addressing the challenges faced by investigation organisations such as independence, blame-free policy, dealing with relatives, quality of investigators, training, public trust and the improvement of safety could be greatly assisted and benefit from a full acknowledgement, understanding and integration of human factors.

Much has been developed on the importance of human factors, human factors integration and the need for more thorough HF investigations. A large part of the existing literature also focuses on accident investigation cases and methods and tools for accident analysis, in multiple high hazard industries. Numerous methods have been developed in order to assist accident investigators in their task. According the Sklet (2004) these analytical methods may be needed to help the investigators to organise and structure all the data from an accident and be able to understand the complexity of the system involved (multiple and inter related causal factors). Each of them can be used at the different stages of the investigation, have different areas of application and have strength and weaknesses as described by Sklet (2004). He therefore suggests the use of several analysis methods for a more thorough investigation and the necessity to have, within the multi-disciplinary team, one person familiar with these tools in order to make a relevant selection depending on the circumstances of the event.

In fact, whether the tools and methods created for accident analysis are human factors orientated or not, they are not always accessible or relevant to the needs of accident investigators who often don’t have the academic mind that the developers of these tools have. Although some efforts are being made, the industrial constraints are not always taken into account and there is a need to bridge the gap between academics and the industry (Dien et al, 2012). Some researchers such as Saleh et al (2010), Rollenhagen et al (2010), and Underwood and Waterson (2013) have identified the need for more partnership between academic and industry worlds so accident investigators are more aware of the tools available and how to use them. Such partnership could also enable the development of more practical tools. Underwood and Waterson (2013) insist on the fact that more effort should be made to ensure that systemic accident analysis tools meet the needs of practitioners.

This weakness in training is also present in the actual meaning of human factors (Rollenhagen et. Al., 2010).

But overall very little is made explicit about the type of knowledge investigators should acquire, the sort of training they should receive in HF in order to conduct relevant HF investigations and whether organisations should hire an expert.

(Rollenhagen et. al. 2010). Training requirements do exist but no standards have been defined and this creates different level of understanding and therefore disagreement on the depth into which HF should be looked into during an investigation. There is a need to keep asking why (Kletz, 2006), which naturally raises the challenge of the scope of the investigation: the depth to which accident investigators need to dig in order to understand why operators behaved the way they did at the time of the event and why it made sense to them.

Original human factors problems create new ones and this will continue to happen with, for example, the development of automation.

Human factors has been demonstrated as an essential part of accident and incident investigation. There are several guidelines provided by ICAO or regulators regarding the importance of these issues but there are no strict requirements regarding how to integrate them in investigation reports. This could be one of the reasons why it is not always acknowledged in a satisfactory way. It is likely that there are other factors involved, but they remain unclear.

Moreover, no practical solutions to address these issues have been provided.

This research is attempting to address these deficiencies and bridge this gap between research and industry, in other words providing practical recommendations on how to better integrate HF in an accident investigation.

Chapter III – Research design

III- 1 Introduction

Chapter III details the research design adopted for the thesis, which represents the plan to conduct the research (Creswell, 2009). It is influenced by three key related elements: the research paradigm, the research objectives and the research strategy. Each of these three elements is outlined in following section.

This is followed by addressing the methods of data gathering and the analysis employed to fulfil the aim of this research, which is:

To examine the training needs of air accident investigators in order to develop more thorough integration of human factors in accident investigations.

The final part of this chapter describes the role of the Training Needs Analysis (TNA) process and its application to the research.

III- 2 Research Design

Three important components are involved in constructing the research design:

the research paradigm (also commonly referred to as the philosophy or

‘worldview’ of the researcher), the research objectives that help accomplish the goal of this thesis, and research strategy. The research design for this thesis is presented in figure 9.