Browsing by Author "Zotov, Dmitri Victorovitch"

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    Grappling with complexity : finding the core problems behind aircraft accidents : a thesis presented in partial fulfilment of the requirements for the degree of Doctor of Philosophy in Aviation at Massey University, Palmerston North, New Zealand
    (Massey University, 2006) Zotov, Dmitri Victorovitch
    The purpose of accident investigation is the discovery of causal factors, so that they may be remedied, in order to avert the recurrence of accidents (ICAO, 1994). However, experience has shown that the present intuitive methods of analysis do not always achieve this aim. Investigation failure may come about because of failure to discover causal factors, or to devise effective remedies, or to persuade those in a position to act of the need to do so. Each of these types of failure can be made less likely by the use of formal analytical methods which can show whether information gathering has been incomplete, and point to the sources of additional information that may be needed. A formal analysis can be examined by formal logical tests. Also, the use of formal change mechanisms can not only devise changes likely to be effective, but can present these changes in such a way that the case for them is compelling. Formal methods currently available are concerned with what happened, and why it happened. To produce generic remedies which might avert future accidents of similar type, some formal change mechanism is needed. The Theory of Constraints has become widely adopted in business as a way of replacing undesirable effects with desired outcomes. The Theory of Constraints has not previously been used for safety investigation, and a principal object of this thesis is to see whether it can usefully be employed in this area. It is demonstrated that the use of formal methodology can bring to light factors which were overlooked during an official accident investigation, and can ‘tell the story’ in a more coherent manner than is possible with present methods. The recommendations derived from the formal analysis are shown to be generic in nature, rather than particular to the airline involved and the accident studied, and so could have a wider effect in improving safety.
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    Pilot error : cognitive failure analysis : a thesis presented in partial fulfilment of the requirements for the degree of Master in Aviation at Massey University
    (Massey University, 1997) Zotov, Dmitri Victorovitch
    Rasmussen (1982) suggested that there was a need for a taxonomy of human errors based on the operator performing the task, rather than upon the task itself; the "internal human malfunction" (p. 323). This proposal was adopted by O'Hare, Wiggins, Batt & Morrison (1994) in a study of pilot errors derived from the New Zealand official Accident Reports. O'Hare et al. (1994) found differences in the types of errors that led to major and minor accidents. These differences were at variance with the proposition by Billings and Reynard (1981) that the errors in accidents and incidents came from a common population, the outcome being due to chance. The results of O'Hare et al. (1994) cast some doubt on the validity of investigating incidents as a means of forestalling accidents. Some of the accident reports used by O'Hare et al. (1994) had not been the result of independent investigation, but were self-reports by the pilots involved. The inclusion of these reports had the potential to produce the apparent dichotomy between the distributions of error types in major and minor accidents, found by O'Hare et al. (1994). It was therefore decided to revisit their work, using as a database the entire population of New Zealand official Accident Reports since 1965, which had been the subject of official investigation. With the large database available, variability in the distribution of error types was also examined between different classes of aircraft, and between pilots of different levels of experience. Some variability between major and minor accidents was found, but not enough to be of practical significance. No variability was found between pilots of different levels of experience. There was little difference between classes of aircraft, except in the case of fixed-wing agricultural aircraft. In the latter case, the difference in the distribution of error types from other classes of aircraft was marked, and further study to identify the reasons might assist in reducing the accident rate for agricultural aircraft.