The analysis and reporting of the human factors aspects of accidents in aviation and other complex systems continues to present difficulties for investigators and analysts alike. Reason's 'latent conditions' model has had a major impact on the way accidents are conceptualised but it has proven difficult to apply as a practical tool. Recent attempts to overcome these difficulties are discussed and an alternative conceptualisation is proposed. This conceptualisation is based on a blend of several well-supported theoretical models in cognitive engineering and can be used to formulate a parsimonious analysis system for the investigation and reporting of the human factors aspects of accidents. Two well-known examples of transportation disasters are briefly described and related to the proposed conceptual framework. The proposed framework serves three important functions in accident investigation and analysis: a heuristic function, an investigative function, and an integrative function. (A)
Abstract