Customer Reviews

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

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"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.