Validation of the JANUS Technique: Causal Factors of Human Error in Operational Errors

摘要

Human error has been identified as a dominant risk factor in safety- oriented industries such as air traffic control (ATC). However, little is known about the factors leading to human errors in current ATM systems, in particular those human errors contributing to violation of separation standards. This paper reports on work conducted jointly by Eurocontrol and the FAA as part of Action Plan 12 - Management and Reduction of Human Error in Air Traffic Management (ATM). The goal of this phase of work was to test JANUS, a technique for identifying incident causal factors, and to assess the technique's value in relation to current investigation methods. FAA and Eurocontrol scientists worked with air traffic personnel to analyze several incident cases and to test the technique against several validation criteria. Taken together, the Eurocontrol and FAA results yield converging evidence that the JANUS technique appears to be more sensitive, useful, comprehensive, and practical than the current processes to identify incident causal factors.