Serious Accidents and Human FactorsBreaking the Chain of Events Leading to an Accident [Hardcover]

M. Miyagi (Author)

Book Description

Publication Date: January 1, 2005 | ISBN-10: 1563477459 | ISBN-13: 978-1563477454

There is growing concern globally over issues of aviation safety. Awareness of previous failures and their causes is one of the most important factors in determining risks and hazards in any new operational systems. This requires experience of accidents and failures across a broad spectrum of complex systems. Every accident occurs as a result of a chain of errors, and if one of the "links" making up that chain can be broken, the accident might be prevented - and becomes merely an "incident." If you collect detailed data from a range of "incidents," relating to how they occurred, and develop a consistent method for analyzing that data, you can create a potentially valuable resource to assist in accident prevention. Serious Accidents and Human Factors proposes an original and structured approach to accident prevention. In an interesting and readable collection of accounts of major accidents, drawn mainly from the aviation industry, Masako Miyagi investigates incident reports analytically and reveals the critical information hidden therein that could avert a full-blown accident or disaster. She applies an innovative analytical technique - multidimensional analysis of incident reports (MAIR), using Quantification Method III to validate the results and focus upon individual components identified within the causal chain of events that precede an accident. She advocates wider acceptance and use of the Incident Report Analysing System, ideally administered by a neutral and independent body, to help prevent accidents not only in aviation but in relation to all complex systems, such as nuclear power plants. Serious Accidents and Human Factors offers aviation industry personnel, as well as those involved more generally with safety, risk assessment, and accident prevention in other industries, a comprehensive understanding of the accident causation chain, events contributing to that chain, and a method for identifying and eliminating causal factors in a pro-active way. Copublished with Professional Engineering Publishing. For orders from Europe and the Middle East, please contact Professional Engineering Publishing, tel [phone] or fax [phone].

Editorial Reviews

About the Author

Masako Miyagi is Executive Director of the Japan Research Institute of Air Law. An earlier edition of her book is previously published in the Japanese language under the title Seeking Out the Signs of Major Accidents. She has presented her work at numerous academic meetings for the benefit of mechanical engineers and scientists, reliability engineering associations, aeronautical societies, health and safety organizations, and the chemical, process, and power industries.

Product Details

• Hardcover: 320 pages
• Publisher: AIAA (January 1, 2005)
• Language: English
• ISBN-10: 1563477459
• ISBN-13: 978-1563477454
• Product Dimensions: 9.6 x 6.4 x 0.9 inches
• Shipping Weight: 1.4 pounds (View shipping rates and policies)
• Average Customer Review: 4.0 out of 5 stars  See all reviews (1 customer review)
• Amazon Best Sellers Rank: #3,936,695 in Books (See Top 100 in Books)

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4.0 out of 5 stars IRAS, MAIR, And Quantification Method III, July 25, 2007

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Robert I. Hedges - See all my reviews
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This review is from: Serious Accidents and Human FactorsBreaking the Chain of Events Leading to an Accident (Hardcover)

"Serious Accidents And Human Factors: Breaking The Chain Of Events Leading To An Accident: Lessons Learned From The Aviation Industry" is an important addition to the library of people interested in aviation and industrial safety and Human Factors (HF). Masako Miyagi, a longtime HF researcher, uses this book to present a lot of data on HF and decision making in critical situations, and ultimately makes several recommendations for analysis and distribution of safety related data, most notably the use of Incident Reporting Analyzing Systems (IRAS). She makes extensive use of Multidimensional Analysis of Incident Reports (MAIR) and a statistical methodology called "quantification method III" throughout the book. For the mathematically inclined, it may help to read Appendix A, which explains quantification method III, before reading the book. I am fairly mathematically literate, but the methodology is cumbersome to understand and ultimately rather confusing unless you have been exposed to extensive graduate level statistics.

The illustrations are generally good (especially the color plates), but they do require careful study as they are two-dimensional results positioned in multidimensional Euclidean space. The quantitative data is expressed in terms of symbolic logic, deriving the eigensolution for latent equations that use as their coefficients the degree to which the varying factors exist simultaneously. (See p. xxii for more information on this analytical method.) Correspondence Analysis based on the "anti-test-estimation-mathematical statistics" philosophy of data analysis in Japan is also touched on (p. 240): it has striking similarities to cluster analysis in the United States, and is functionally similar to quantification method III. The resultant spatial relationships in this book are sometimes hard to conceptualize, so be prepared to read and re-read certain sections. Even for the less mathematically inclined, however, the book is a very valuable work, and is good at exploring the relationships between different factors in accidents and incidents.

Parts of the book separates data into categories labeled "degrees of danger." I am unsure exactly how the category assignments were made, but after reading descriptions of the incidents involved, I think many pilots would frequently disagree with the categorization of specific incidents. I gave the book four stars instead of five largely due to this issue. Other problems in the book are fairly minor. The author makes erroneous statements about crosswind landings (p. 91), windshear (p. 92), and the safety of go-arounds (p. 167). Other detractors are extremely peculiar word choice (e.g. "conchoidal") and frequently odd grammatical structure. I believe that some of these problems, if not all, are caused by translation errors.

In all, I found this to be a very valuable book for any safety professional, especially those specializing in aviation HF programs. There are many excellent lessons contained in this book, but sometimes deliberate pondering is required to understand them all.