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This is a report of an investigation to examine perceptions of "cause" within the investigation community. The reason for preparing this summary of references to accident "cause" or "causation" of accidents is to demonstrate the diversity of perceptions within the air safety investigator community. The list was compiled by doing a word search for "cause" in the digitized proceedings of the Seminar, and copying the text from each hit on cause or causation to this document.

Ludwig Benner, Jr. April 8, 1998


Australia as a Case Study of a Safe System

Graham R. Braithwaite ST3644
Loughborough University, England

Accidents occur as a result of the combination of several causal factors.

accident cause statistics indicate 70-80% of accidents are the results of human error. But....There is a great deal we still do not understand about the causes of incidents and accidents.
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Impact Reconstruction: Flight Path to Causation

Paul Bray, Jr. M02072
President, Aviation Technical Consultants, Inc.
Westport, CT 06880
Jack Lipscomb, M02290
President, Lipscomb Associates
Moneta, VA 24121

The aircraft type, the equipment, and pilot capability all enter into the equation of accident causation.

There is a repeating scenario that shows that an equipment malfunction, which can not be overcome by the pilot, may be the most probable cause of many of these accidents attributed to pilot error. aircraft.

When combined with the flight track, the combination begins to tell us something about the crash causation.
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Using Voluntary Incident Reports for Human Factors Evaluations

Sheryl L. Chappell
NASA Ames Research Center
Moffett Field, CA USA

In tracing the causal chains of aviation accidents, safety investigators and researchers have generally been effective in determining what happened. They have been less effective in determining the why of events--why people acted as they did, why a system failed, why a human erred. Aeronautical incident reports come from many sources, including pilots, air traffic controllers, flight attendants, mechanics, and airport ground personnel.

When a safety hazard is suspected, incident data can often provide facts that prove or disprove its existence. These data are ideally suited for understanding the possible causes of safety hazards, defining potential intervention strategies, and tracking the safety consequences once intervention has begun.
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International Accident Investigation in the Asia Pacific Region

An Airline Pilot's Perspective
Captain Richard Duxbury
Northwest Airlines

Found no reference to causes
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Adding Value to Aviation Operations: New Directions for the 21st Century Investigator

Thomas A. Farrier M03763
Chief, Flight Safety Issues, Office of the Chief of Safety
Headquarters, United States Air Force

* We must expand our own horizons to seek out the synergies that we might realize through more effective interaction with other professionals; in doing so, we will undoubtedly find new ways of getting our message through to the decisionmakers, as well as a new body of allies with a common cause.
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American Eagle Flight 4184 An Icing Crisis

Gregory A. Feith, MO2342
Senior Air Safety Investigator
National Transportation Safety Board
Washington, D.C. 20594

the National Transportation Safety Board adopted the final report of facts, conditions and circumstances, and determined that the probable causes of this accident were the loss of control attributed to a sudden and unexpected aileron hinge moment reversal that occurred after a ridge of ice accreted beyond the deice boots because:...

The Safety Board also found that contributing to the accident were:....

The investigation of the American Eagle ATR 72 involved numerous investigators spending hundreds of manhours identifying and analyzing thousands of documents to identify the causes of this accident. To say that after 20 months of investigating, the Safety Board's final analysis and determination of probable cause was no t readily accepted by all parties, organizations, or individuals is a monumental understatement.

--respective training programs might be insufficient to demonstrate the cause for and the recovery from aircraft attitudes that are not considered to be "normal."
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Helicopter Logging Mishaps:

Applying Lessons In An Expanding Industry
Douglas R. Herlihy MO3194

yet engine failure/power loss were not necessarily dominant causal factors...

While the laboratory teardown identified the "proximate cause" of the accident, the operational factors revealed a more complete picture.

When it has gone wrong and an accident has resulted, meticulous investigation has often identified a visible cause and the lesson has been learnt. accidents. 1990 was a record year with the 300 mark being passed for the first time; since then we have
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Incidents: the Route to Human Factors in Engineering?

David King M03393
Principal Inspector of Air Accidents (Engineering)
Air Accidents Investigation Branch, United Kingdom

When it has gone wrong and an accident has resulted, meticulous investigation has often identified a visible cause and the lesson has been learnt.

Having eliminated some of the more obvious causes of accidents, we are left with those causes that are more difficult to identify and address.

Human factor related causes to accidents are not restricted to the flight deck.

Does it matter that his actions and the final consequences are separated in time by hours, even days, if in that intervening period there was no attempt or opportunity to discover the mistake? Time was real enough throughout the task for the individual and only a sterile period separates cause and effect.

The investigation identified the following causal factors:

I believe that the incidents cited in this paper, along with others that I have investigated, indicate that many of the factors that came together to contribute to their causes are with us most, if not all, of the time.
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Bogus PartsMyth or Fact?

James F. Leggett, Attorney at Law MO0847
Managing Partner, Leggett & Kram

Thus, there is no jury verdict determining the cause of the crash.

The questions were 1) what caused this hole; and 2) whether this hole existed before the crash. A hole such as this would cause the fire and loss of the right engine within seconds.
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Applying Perrows Complexity Model to Aviation Hazard Identification

Robert S. Ratner (M03703)

Aircraft accident research and investigation has shown that many accidents "are no accident." That is, in the leadup to many accidents are factors that can predispose a situation toward a human error or system or component failure, and these can directly contribute to the cause of the accident.

What has been done to reduce SIMOPS hazards is to establish specific training programs and operational procedures that recognize that cause and effect are very tightly coupled in SIMOPS and attempt to increase vigilance, and to define runway signing and lighting requirements for the same purposes.
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Accident Investigation and Amateur Built Experimental Aircraft

Michael L. Stockholm
Senior Air Safety Investigator, NTSB

sharp corners or edges, protrusions, knobs and similar objects that may cause injury to the pilot or passengers in the event of an accident. routinely accepted for primary structural applications by FAA for certificate aircraft, due to concerns

He stated that the engine continued to surge even after the throttle was reduced to idle; this caused him to overshoot his intended landing spot.

...NTSB determined that the direct cause of this accident was an improperly functioning fuel boost pump. kit airplane.
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Management of Aviation Operations Was the Board Room Active in

Preventing the Accident?
Richard B. Stone WO0837
Scott T. Young, Ph.D.,
Salt Lake City, Utah, USA.

For a number of years the aviation accident investigation community has been wrestling with the concept of evaluating what role airline management plays in the cause of an accident.

The issue of individual accountability arose in a dissenting opinion of an investigation of a runway collision between a Boeing 727 and a Beech King Air A100 (5): "I also disagree with the notion that agencies cause accidents. Failure of people and failure of equipment cause accidents. Shifting the cause from people to agencies blurs and diffuses the individual accountability that I believe is critically important in the operation and maintenance of the transportation system."

..This incident is typical of the mentality of military style organizations, where errors are cause for discipline rather than an indication of a problem in need of correction.

Reason, James T. "Identifying the Latent Causes of Aircraft Accidents Before and After the Event."

forum 24, 1991. ISASI, Sterling, VA.
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Latent Failure and Human Factors

Richard White
Civil Aviation Authority
New Zealand

As the new rules are introduced, it is anticipated that better reporting may cause an initial upward trend. all relevant Civil Aviation Rules (and thus remain in the "green" safety space).

In these cases, the causal factors, or reasons, for the fault need to be determined, corrective action planning undertaken, and the causes of the fault removed by implementation of the corrective action.

cause of each deficiency is identified, and appropriate corrective actions are initiated..

Initially the ICAO ADREP cause codes were used. Unfortunately, these gave unsatisfactory results and did not really identify the true root cause.
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The Airplane Safety Awareness Process

Sarah C. Williams
Airplane Safety Engineering
Boeing Commercial Airplane Group
Seattle, Washington

The SRP team assigned to each issue is then responsible for determining the root cause and managing the resolution of the issue within the SRP process.
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Reporting Human Factors Accidents

Dmitri V Zotov, MBE, MRAeS MO2981

' If the accident could still have occurred without C, then C could not have been a causal factor.

Add into this the legal concept of `Remoteness of Damage' -- other intervening events make A too remote to have been a material factor -- and we are going to have difficulty presenting the concept of a complex network of interacting events having caused the accident.

Consider the Erebus Report by Mr Justice Mahon (13). After a masterly overview of all the things that came together to cause the disaster, Mahon felt impelled for (as he said) purely legal reasons, to ascribe it all to the "single dominant and effective cause..." (the airline's failure to notify the flight crew that the route had been changed) (p. 159). Had he not done this, the Report would probably have been seen for what it was -- the first study of the systemic causes of accidents, ten years before Reason.
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