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investigation. The book is divided into four parts. The first part investigates the who, what, why
and when aspect of accident investigation. The second part examines the roles and interactions of
man, environment, and systems. The third part reviews specific analytical techniques such as
fault trees, failure mode and effect analysis (FMEA), the technique for human error rate
prediction (THERP), the management oversight and risk tree (MORT), and the technic or
operations review (TOR). The fourth part covers related topics to accident investigation. Some
examples of these are mishap reports, management overview and mishap investigation, legal
aspects of investigation, and the future of accident investigation. Fifteen general types of
methodological approaches are identified in the accident investigation domain. These are
epidemiological, clinical, trend forecasting, statistical inference, accident reconstruction,
simulation, behavioral modeling, systems approach, heuristic, adversary, scientific, Kipling
method (investigates who, what, when, where, why, and how), Sherlock Holmes method (events
sequencing integrated in the investigator’s mind), and traditional engineering safety.
Firenze, R. J. (1971, August). Hazard control: Safety, security, and fire management.
National Safety News, 39-42.
Error is looked at in the context of three integrated groups. The first group is physical equipment
(the machine) which examines poorly designed or poorly maintained equipment that leads to
accidents. The second group is man. In this group, faulty or bad information causes poor
decisions. The third group is environment. Here failures in the environment (toxic atmospheres,
glare, etc.) affect man, machine, or both. It is also noted that stressors that appear during a
decision making process cloud a person’s ability to make sound, rational decisions.
Fitts, P. M. (1954). The information capacity of the human motor system in controlling the
amplitude of movement. Journal of Experimental Psychology, 47(6), 381-391.
Fitts found that the rate of performance in a given type of task is approximately constant over a
considerable range of movement amplitudes and tolerance limits, but falls off outside this
optimum range. It was also found that the performance capacity of the human motor system plus
its associated visual and proprioceptive feedback mechanisms, when measured in information
units, is relatively constant over a considerable range of task conditions. This paper came as a
result of information theory and applied its concepts.
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Fussell, J. B. (1976). Fault tree analysis – Concepts and techniques. In E. J. Henley & J. W.
Lynn (Eds.), Proceedings of the NATO Advanced Study Institute on Generic Techniques in
Systems Reliability Assessment (pp. 133-162). Leyden, The Netherlands: Noordhoff
International Publishing.
Fault tree analysis is a technique of reliability analysis that can be applied to complex dynamic
systems. The fault tree is a graphical representation of Boolean logic associated with the
development of a particular system failure to basic failures. Fault tree analysis has numerous
benefits. It allows the analyst to determine failures deductively. It points out important aspects of
the system in regards to the failure of interest. It provides a graphical aid giving clarification to
systems management people. It provides options for qualitative or quantitative system reliability
analysis. It allows the analyst to focus on one particular system failure at a time. Finally, it
provides the analyst with genuine insight into system behavior. Three disadvantages of fault tree
analysis include the high cost of development, the fact that few people are skilled in its
techniques, and the possibility of two different people developing two different trees for the
same system. The fault tree has 5 basic parts to it. The first parts, components, are the basic
system constituents for which failures are considered primary failures during fault tree
construction. The second parts, fault events, are failure situations resulting from the logical
interaction of primary failures. The third parts, branches, are the development of any fault event
on a fault tree. The fourth parts, base events, are the events being developed. The fifth and final
parts, gates, are Boolean logic symbols that relate the inputs of the gates to the output events.
Gerbert, K. & Kemmler, R. (1986). The causes of causes: Determinants and background
variables of human factor incidents and accidents. Ergonomics, 29(11), 1439-1453.
An investigation was done with German Air Force pilots to examine critical flight incidents. The
authors are interested in examining whether a possible cause of a failure can be traced to
　
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