Understanding Flight Crew Adherence to Procedures: The Procedural Event Analysis Tool (PEAT)

摘要

A reduction in crew error related accidents can be achieved by developing countermeasures based on a better understanding of the contributing factors and the underlying reasons for the occurrence of similar incidents. Currently there is no industry tool or method available to focus incident investigations in a consistent and structured manner so that findings can be compared and integrated. PEAT is a safety tool designed to meet this need while specifically addressing crew procedural error incidents. These types of errors have played a major role in past airplane hull-loss accidents. With the effective implementation and application of PEAT, the industry's ability to share data will be enhanced as will the early and effective development of preventative countermeasures.