A comprehensive, multidimensional investigation of the characteristics of unsafe events

摘要

A fundamental characteristic of unsafe events is that they occur when an episode involving various latent danger factors in the area in question combine with human error in a time series under coincidental conditions, in irrational, illogical chains of events. Furthermore, a large number of minor accidents or incidents involving equivalent or similar factors take place before a major accident occurs. With a view toward these considerations, we conducted a comprehensive, multidimensional investigation focusing on the analytical results of multiple incident reports gathered independently in the aviation field, using the Quantification Method III statistical method. Through this investigation, we clearly show the interrelationships among the many latent danger factors in this field and the interrelationships between various danger factors and the conditions of the human error involved. We also show which factors demonstrate the highest level of danger.