Safety and Accident Investigation MSc

To provide accident investigators with the fundamental knowledge and skills to conduct a general transport accident investigation.

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a) Accident response and management

1. Accident response

• Investigation case studies exercise and debrief
• Roles and responsibilities of different interested parties
• Accident notification processes
• Deployment considerations
• Investigation site management and procedures
• Health and safety at the accident site
• Initial appraisal of land- and sea-based sites 


2. Investigation management 

• The purpose of safety investigations
• Regulatory requirements
• Group system of investigation
• Managing high-profile, complex and large investigations
• Accident pathology
• Working with the media
• Liaising with victims and families
• Court procedures for investigators


b) Conduct of an investigation

1. Evidence collection

• Defining evidence
• Evidence within the investigation process
• Types of evidence
• Principles of identifying and recording of evidence
• Evidence harvesting and preservation
• Wreckage and evidence photography
• Site survey techniques, including remote site surveys and underwater surveys
• Investigative interviewing techniques
• Working with data recorders and other sources of electronic data, including different types of memory
• Understanding crashworthiness and survivability issues 


2. Human factors in accidents 

• Human factors aspects in accident investigation
• Passenger behaviour


3. Analysis of evidence

• Fundamentals of analysis
• Analytical approaches
• Organisational accidents
• Applying analysis tools
• Application of analysis methods in investigation simulation 


4. Developing safety recommendations

• Relations with the regulator and other parties
• Developing and managing recommendations
• Follow-up actions


5. Report writing 

• Purpose of an investigation report
• Planning and preparation of a report
• Report structure and format


c) Practical workshops 

• Evidence collection workshop
• Site tutorial workshop (field)
• Accident simulation exercise (field)
• Courtroom procedures workshop

On successful completion of this module you will be able to:

1. 1. Demonstrate an understanding of the investigation process for a transport accident - including elements of accident response, site management, working with other interested parties.  
2. 2. Evaluate the regulatory factors affecting an accident investigation, including the purpose of an investigation and the relevant legislation/regulations; the degree of empowerment/independence of investigators; and the protection of key evidence.
3. 3. Work safely under supervision at an accident site, including the identification of hazards and management of associated risks.  
4. 4. Compare and evaluate different techniques for preserving and gathering physical, people, documentary and data evidence from a variety of relevant sources following an accident.  
5. 5. Perform an analysis of available evidence to identify and present the factors contributing to an accident and develop effective evidence-based recommendations to prevent future accident occurrences.

Industrial roles which draw on skill sets in safety and human factors demand the skill sets developed in this module in support of the course level learning outcomes.      

Collecting data

• • Doing research (research ethics, the research story, the thesis, the hypothesis).
• • Introduction to experimental design - basic designs, experimental control, and minimising error variance.
• • Qualitative data analysis.
• • Questionnaire design (content, phrasing, response formats and analysis).


Analysing quantitative data

• • Exploring data (descriptive statistics, levels of measurement).
• • Examining differences (parametric and non-parametric statistical tests).
• • Examining relationships (bivariate correlation).
• • Introduction to modelling data.   

On successful completion of this module you should be able to:

1. 1. Be able to develop, plan and communicate research in a structured way.
2. 2. Be able to identify ethical issues when using human participants in research.
3. 3. Be able to develop effective questionnaires and subjective-rating scales to answer research questions.
4. 4. Be able to select and conduct appropriate qualitative and quantitative research methods and apply methods to different research needs.

The aim of this module is to introduce you to analysis techniques based on conventional as well as contemporary accident causation theories, and provide you with the approach to selecting the techniques and the opportunity to apply them in a learning environment.


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Pre-read (online learning via VLE):

• • Selected accident analysis techniques and their underlying theories. This includes sequential, epidemiological, and systemic techniques with emphasis on systemic techniques, with case studies/example application.
• • Factors to be considered in selecting analysis techniques e.g. system structure, system component relationships, system behaviour.

Contact time:

• • Discussions: critical evaluation of selected techniques based on case studies.
• • Practical application of techniques, including developing timeline/sequence of events, evaluation of evidence, and identifying safety issues.
• • Translating analysis models into written report – guidelines and tips.

On successful completion of this module you will be able to:

1. 1. Appraise different accident analysis techniques in context of their underlying theories.  
2. 2. Determine technique(s) to be used in analysing evidence in accident investigation appropriately.  
3. 3. Synthesise evidence, identify areas of further investigations, and draw conclusions using selected accident analysis technique(s).  
4. 4. Identify areas to be addressed by safety recommendations and develop the recommendations in accordance with applicable standards and good practice guidelines.  
5. 5. Compose a written work that reflects the analysis, conclusions and recommendations conducted using the analysis technique in accordance with applicable standards and good practice guidelines.

This module builds on the Fundamentals of Accident Investigation module to develop specialist skills for the investigation of aircraft accidents.




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Investigation of fixed and rotary wing aircraft accidents

• Impact and flight path assessment.
• The operations investigator’s approach.
• The engineering investigator’s approach.
• Sources of physical, data, documentary and people evidence.
• Conduct of complex/major investigations.
• Aircraft structural failure (metal/composites).
• Aircraft performance.
• Crew and maintenance performance and human factors aspects.
• Flight data recorders.
• Cockpit voice recorders.
• Use of recorded data.
• Survivability factors.
• Investigation approach - case studies.

Air traffic control

• ATC investigations and case studies.

State investigation bodies


• Overview of a civil air accident investigation organisation.
• Overview of a military air accident investigation organisation.

Powerplants and propulsion

• Piston engine operations.
• Turbine engine operations.
• Role of manufacturer in investigation.
• Engine teardown on site/at base.
• Birdstrikes/FOD.
• Case studies.

Major investigation simulation 

• Hazard identification at an aircraft accident site.
• Management of risk at an aircraft accident site.
• Physical examination of wreckage.
• Accident site photography.
• Accident site management.
• Wreckage plotting.
• Witness interviewing.
• Application of analysis techniques.
• Preparation of recommendations.
• Formal report writing.
• Debriefing.

Investigation management 

• Dealing with other agencies.
• Accredited representatives/technical advisors.
• Participating in an overseas investigation.
• Managing an investigation.
• Managing the politics.
• Managing the news media.
• Preparing to release an investigation report.
• The role of the Investigator in Charge.
• The role of the Chief Inspector.

 

On successful completion of this module you will be able to: 

1. 1. Demonstrate that they can work safely without supervision at an aircraft accident site coordinating, where necessary, with other interested parties.  
2. 2. Describe aircraft accident operational and technical common failure/error types in terms of the human element and complex/less complex operational and technical systems.
3. 3. Demonstrate that they can successfully manage an aircraft accident investigation including, efficient time management, working to set deadlines and targets, demonstrating self-discipline, creative thinking and critical reflections of their own performance and effectively communicate their conclusions and safety recommendations via a formal report.
4. 4. Analyse information / evidence collected from a variety of physical, data, documentary and people sources to support investigations and research. 
5. 5. Appraise and critique their own work and that of other practitioners/specialists and collaborate effectively during group workshops, simulations and group assignments.

• Alan Parmenter

This module builds on the Fundamentals of Accident Investigation module to develop specialist skills for the investigation of marine accidents. 




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Marine accident investigation legal and management issues


The international legal basis for marine accident investigation and the practical application of the rules, recommendations and guidance:

• Historical background and the role of the IMO.
• UNCLOS, SOLAS, MARPOL and other relevant conventions.
• The Casualty Investigation Code.
• National laws.
• VDR ownership and recovery.
• EU Directive.
• Databases.
Case studies as appropriate.


Managing a marine accident investigation:

• Notification of and coordination and communication with other agencies/parties.
• Using technical advisors.
• Time/resource management.
• Managing the news media.
• Cultural aspects.
• Preparing to release an investigation report.
• Managing recommendations.
• Possible litigation aspects.
• The role of the Investigator-in-Charge.
• The role of the Chief Inspector.
• Case studies and simulations, as appropriate.

Marine specific investigation techniques


Site risk assessment and hazard identification for common marine accident scenarios:

• Access to the accident site.
• The presence of dangerous substances and atmospheres.
• Bio hazards in the marine environment.
• The safety of the ship platform.
Case studies e.g. CP Valour (Bermuda), MSC Napoli (UK).


Evidence preservation and collection issues in common marine accident scenarios:

• Access issues.
• Commercial pressures.
• Legal considerations.
• Technical evidence- VDRs, AIS, ECDIS, VTS, CCTV.
• Evidence collection strategies.
• Various case studies, as appropriate.


Human performance, human factors and marine accidents:

• Risk and risk-taking behaviour.
• Analysis of errors in the marine context.
• Multi-national crewing, social and cultural issues.
• Language and communication.
• Distraction.
• Fatigue, leadership and complacency.
• Safety culture.
• Master/pilot relationship.
• Commercial pressures.
• Uncovering the organisational and systemic factors.
• Case studies, as appropriate.

Investigating marine collisions, contacts and grounding accidents:

• Displaying and analysing VDR and other electronic evidence, MADAS.
• Collision regulations and their effectiveness.
• Investigating competence, fatigue and other human performance issues.
• Collisions in poor visibility, safe speed issues.
• Casualties in harbour areas, master/pilot relationship.
• Case studies e.g.  Cosco Busan (US) Lykes Voyager/Washington Senator (UK), Royal Majesty (Panama).


Investigating ship fires: 

• Site risk assessment and hazard identification.
• Engine room fires.
• Cargo fires.
• Accommodation fires.
• Fire detection, firefighting, fire protection and evacuation issues.
• Case studies, as appropriate.


Investigating structural/material failures, loading and stability problems: 

• Maintenance and operational history.
• Practical evidence gathering problems and potential solutions.
• Corrosion, fatigue and other failure modes.
• Forensic analysis methods.
• Case studies, as appropriate.


Investigating machinery failures:

• Overview of different types of engineering and machinery failures.
• Sources of evidence.
• Non-destructive & destructive testing.
• Trials and reconstructions.
• Failure mode analysis.
• Case studies, as appropriate.


Investigating occupational health and safety accidents:

• Analysis of common marine occupational accidents, eg.
• Enclosed space entry accidents.
• Accidents involving use/misuse of machinery – watertight doors, cranes.
• Mooring accidents.
• Lifeboat, rescue craft and evacuation equipment accidents.
• Safety Management issues.
• Case studies as appropriate.

General investigation techniques


Enhanced investigative interviewing techniques:

• General recap of investigative interviewing and memory theory.
• Overview of cognitive interviewing.
• Introduction to SE3R methodology.
• Quadrant Behaviour.


Investigation analysis techniques:

• General recap of analysis methods.
• Principals and pitfalls of no-blame marine investigations.
• Application of systemic models in marine investigations.
• Overview of selected accident analysis models, eg. SHELL, AIBN model, STEP.
• Case studies and mentored practical workshops.


Investigation report writing and recommendation development:

• Purpose of writing an investigation report.
• Guidance on report writing.
• Report planning and preparation.
• Report structure.
• Principles of writing an effective report.
• Critiquing accident investigation reports.
• Principles of developing effective recommendations.

Major investigation simulation 


A major marine accident investigation exercise which examines:

• Team and investigation management.
• Team working.
• Cooperation and coordination with other interested parties (including other investigations, the media etc.).
• Securing the accident site.
• Health and safety and risk assessment at the accident site.
• Physical examination and accident site photography.
• Physical and documentary evidence collection.
• Technical evidence identification and collection.
• Witness interviewing.
• Evidence analysis.
• Preparation of recommendations.
• Formal report writing.
• Debriefing.

On successful completion of this module you will be able to: 

1. 1. Demonstrate you can work safely and effectively without supervision at a marine accident site, coordinating where necessary with other interested parties.
2. 2. Demonstrate a thorough understanding of the different approaches to the investigation of different types of marine accidents and safely and effectively collect information/evidence from a variety of electronic, hard copy and witness sources to support investigations and research.
3. 3. Describe marine accident operational and technical common failure/error types in terms of the human element and complex/less complex operational and technical systems.
4. 4. Demonstrate that you can successfully manage a marine accident investigation, including efficient time management, working to set deadlines and targets, demonstrating self-discipline, creative thinking and critical reflections of your own performance and effectively communicate your conclusions and safety recommendations via a formal report.
5. 5. Appraise and critique your own work and that of other practitioners/specialists and collaborate effectively during group workshops, simulations and group assignments.

This module builds on the Fundamentals of Accident Investigation module to develop specialist skills for the investigation of rail accidents.




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Advanced investigative skills

• Rail accident site management and dealing with other agencies.

• Rail accident site risk management.

• Advanced interviewing skills.

• Advanced investigative photography.

• Advanced analysis methods.

• Investigating Safety Management System.

 

Investigating Railway Operations Accidents.

• Investigation approach and overview of factors contributing to level crossing accidents, Signal Passed at Danger, over speeding, track worker/maintenance staff fatalities and near-misses, platform safety including platform-train interface and train door irregularities, train/vehicle runaways and authorised movements, and train/rail vehicle collision.

• Relevant safety systems in train control.

• Relevant human factors aspects.

• Rail crashworthiness and passenger survivability.

• Investigations related to light rail (tram) and driverless operations.

 

Investigating derailment accidents

• Overview of factors contributing to derailment accidents and case studies.

• Collecting, inspecting and interpreting evidence (on site).

• Dynamic modelling of wheel/rail interface response.

• Relevant human factors aspects.

• Rail crashworthiness and passenger survivability.

 

Accident investigation simulation

A five-day practical exercise in a simulated accident investigation scenario where delegates can apply the skills and knowledge acquired in the Fundamentals of Accident Investigation course and other workshops in the Applied Rail Accident Investigation series. The simulation takes the delegate through the entire investigation process from notification, site investigation, interviews, analysis, report writing and formulating recommendations.

• Team and investigation management.

• Securing the accident site.

• Managing news media.

• Health and safety at the accident site.

• Risk assessment of the accident site.

• Physical examination of wreckage/track.

• Documentation investigation (procedures, manuals, logs, etc).

• Accident site photography.

• Accident site management.

• Witness interviewing.

• Application of analysis techniques.

• Developing recommendations.

• Formal report writing.

On successful completion of this module you will be able to:

1. 1. Identify potential hazards at a rail accident site and assess the risks and mitigation methods in order to work safely whilst conducting an investigation.  
2. 2. Identify and evaluate common failure types and their symptoms in terms of structures, rolling stock, railway systems and human factors.  
3. 3. Describe the role of the different parties in the accident investigation process and manage the relationships between these parties. 
4. 4. Successfully manage an accident investigation, both on-site and through to the publication and acceptance of recommendations.  
5. 5. Compose an accident report and develop feasible safety recommendations.

This module builds on the Fundamentals of Accident Investigation to develop specialist skills for the investigation of road based accidents and safety investigations.

Investigation of road accidents:

• Collision scene examination.

• The road investigator’s approach.

• Sources of physical, data, documentary and people evidence.

• Conduct of complex/major investigations.

• Vehicle structural failure.

• Vehicle performance.

• Driver performance and human factors aspects.

• Digital Data in Vehicles and associated data recorders.

• Survivability factors.

• Investigation approach - case studies.

State Investigation Bodies:

• Overview of a civil road accident investigation organisation.

• Overview of a military land accident investigation organisation.

Powerplants & Mechanical:

• Vehicle propulsion systems - ICE / Electric / Hybrid.

• Role of manufacturer in investigation.

• Mechanical examination of vehicle on site/at base.

• Case studies.

Major Investigation simulation:

• Hazard identification at a road accident site.

• Management of risk at a road accident site.

• Physical examination of site and wreckage.

• Accident site photography.

• Accident site management.

• Wreckage plotting.

• Witness interviewing.

• Application of analysis techniques.

• Preparation of recommendations.

• Formal report writing.

• Debriefing.

Investigation management:

• Dealing with other agencies.

• Accredited technical advisors.

• Participating in other investigations.

• Managing an investigation.

• Managing the interaction between agencies and competing priorities.

• Managing the news media.

• Preparing to release an investigation report.

• The role of the Investigator in Charge.

• The role of the Chief Inspector of Road Safety.

On successful completion of this module you will be able to:

1. 1. Demonstrate that they can work safely without supervision at a road accident site coordinating, where necessary, with other interested parties. 
2. 2. Describe road accident common failure/error types in terms of the human element and complex/less complex operational and technical systems.  
3. 3. Demonstrate that they can successfully manage a road accident investigation including efficient time management, working to set deadlines and targets, demonstrating self-discipline, creative thinking and critical reflections of their own performance and effectively communicate their conclusions and safety recommendations via a formal report.
4. 4. Analyse information / evidence collected from a variety of physical, data, documentary and people sources to support investigations and research.  
5. 5. Appraise and critique their own work and that of other practitioners/specialists and collaborate effectively during group workshops, simulations and group assignments.

To provide you with the fundamental skills required to manage operational safety within the aviation industry.


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• • The fundamentals of a Safety Management System, and introduction to associated guidance material provided by the International Civil Aviation Organisation (ICAO) and other State safety regulatory bodies.
• • Safety data, safety information and analyses; including reporting systems, investigation and Flight Data Monitoring (FDM).
• • Hazard identification and risk management, including an introduction to Enterprise Risk Management (ERM).
• • Safety performance and safety health; including guidance on audits and safety promotion.
• • Safety organisations, including guidance on effective management of safety teams.

On successful completion of this module you will be able to: 

1. 1. Describe the fundamental concepts behind Safety Management Systems (SMS), as defined by ICAO and other regulatory bodies.
2. 2. Select and implement techniques for the identification, quantification and management of hazards and risks.
3. 3. Critically assess strategies for developing and enhancing safety culture including the role of leadership, structure and reporting systems.
4. 4. Identify techniques for measuring safety performance

To provide an understanding of the role and responsibilities of expert witnesses in domestic and international criminal and civil cases and how they can present their evidence to the court effectively. To apply knowledge gained in previous modules to strengthen arguments presented in expert witness reports.


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• • Role and legal responsibilities of the forensic expert.
• • Civil and Criminal Procedure Rules.
• • Excellence in report and statement writing.
• • Presentation of evidence in court.
• • Preparation for examination-in-chief and cross-examination.

On successful completion of this module you will be able to:

1. 1. Compare and contrast between the various legal systems and the concepts of criminal prosecution and civil litigation.
2. 2. Evaluate the role and responsibilities of an expert witness in the UK legal system.
3. 3. Construct, formulate and appraise an effective expert witness report in compliance to legal requirements for such a document.
4. 4. Construct a case to present oral evidence in court effectively and respond successfully to cross-examination, with an insight into how cross-examination is prepared.

Crisis management is a topic area relevant to airlines, airports and other organisations involved with delivering air transport. These organisations typically have dedicated personnel and departments to emergency response and crisis planning. The aim of this module is to provide you with an overview of how to plan for crises, what to expect when they happen, and how to deal with practicalities such as dealing with media, survivors and in the longer term, insurers.

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• • Crisis management planning.
• • Crisis communications.
• • Critical function and risk analysis.
• • Business continuity development and strategy.
• • Crisis management exercise.

On successful completion of this module you will be able to:

1. 1. Describe the key elements of a crisis.
2. 2. Analyse the importance of effective crisis management.
3. 3. Critically evaluate past aviation crisis management.
4. 4. Facilitate business continuity planning.

To provide an understanding of Flight Data Monitoring within a commercial organisation and to detail the uses, processes and responsibilities of a successful FDM programme.

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• • The history of FDM and an overview of its objectives.
• • CAP739, EASA and ICAO regulatory frameworks.
• • Integration of FDM within a safety system.
• • FDM technology.
• • Data recovery and analysis tools.
• • Principles of data validation and assessment.
• • Trace interpretation, with both theoretical and practical sessions.
• • Database management.
• • The use of statistics in data analysis.
• • Animations and visualisation in data presentation.
• • FDM in accident and incident investigation.
• • The interface between the analyst and crews.
• • Legal aspects of FDM data collection, retention and use.

On successful completion of this module you should be able to:

1. 1. Describe the typical activities in flight data monitoring.
2. 2. Analyse basic flight data traces and listings, and understand the sequence of the underlying events.
3. 3. Assess the quality of flight data and FDM generated information (e.g. FDM results and trends).

The module aims to provide a broad overview of the nature and management of human error in the aviation maintenance domain. Key theories and frameworks for investigating maintenance human error, contributing factors and effects on operations are introduced. The challenges associated with practical application of currently available safety tools are examined together with the latest strategies to enhance understanding and management of maintenance error. This module does not require previous background in aviation maintenance and engineering.

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• • The nature of the maintenance environment: this includes both civil and military environments.
• • Maintenance management: organisation, line and base maintenance, planning, maintenance control, error management systems, shift handover, blame cycle, communication in the workplace, workplace environment, work/job design. Regulatory framework: Legal requirements. EASA/Part 145 Maintenance Human factors. 
• • Designing for human factors: what can be done by the designer to reduce and mitigate human error. Design philosophies and human-centred design. 
• • Human error management in maintenance: the benefits and challenges associated with the use and application of reporting systems and safety tools. 

On successful completion of this module you should be able to: 

1. 1. Analyse the regulatory framework and the environment within which aviation maintenance takes place.
2. 2. Evaluate current methods for maintenance error management (reactive, proactive and predictive).
3. 3. Appraise the links between human factors, aircraft maintenance and safety.
4. 4. Analyse ways in which maintenance errors can be reduced at the design stage.

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The Interviewing for Accident Investigators module is designed to provide delegates with an enhanced level of theoretical and practical skills to effectively interview various types of witness to gather evidence in support of successful safety accident investigations. 

The module adopts a balanced curriculum of theoretical learning and practical sessions involving interviews of live witnesses, with video debriefing, to deliver a practical learning experience supported by the latest academic thinking in investigative interviewing.

The module is intended to build on the interviewing skills developed during the Fundamentals of Accident Investigation, Applied Aircraft Accident Investigation, Applied Marine Accident Investigation and Applied Rail Accident Investigation modules. However, it can also be attended as a standalone module for delegates who wish to gain an enhanced qualification in investigative interviewing, and would be particularly suited to delegates with previous experience of conducting investigative interviews.

The module will have an emphasis on interviews forming part of no-blame safety  investigations of accidents. Its content will be applicable to investigators from other safety critical domains and high reliability organisations, such as healthcare, process industries, and energy utilities.

1. Refresher of the fundamentals of investigative interviewing:

• • Basic principles of investigative interviewing.
• • Basic interviewing models:
  • - Conversation Management.
  • - Conducting a PEACE interview.

Use of different questioning techniques – Open v. Closed, Directed, Confirmatory, etc.

• • Fundamentals of cognitive interviewing.
• • Basic theory of memory and recall.

 

2. Enhanced theory of investigative interviewing

• • Enhanced theory of memory and psychology applied during investigative interviewing.
• • SE3R methodology for managing and recording interviews.
• • Introduction to concept of enhanced cognitive interview techniques, including free recall.
• • Biases and heuristics – investigator and witnesses.
• • Introduction to non-cognitive interview techniques for interviewees who have not directly witnessed the accident.

 

3. Preparation for the interview

• • Assessment of the emotional and psychological state of witnesses.
• • Awareness of the characteristics of potentially vulnerable witnesses and the challenges faced when interviewing them.
• • Consideration of cultural, religious, social factors that may have an effect on the witness interview.
• • Strategies for planning and structuring different types of interviews.
• • Identification of the most appropriate interview technique to apply.

 

4. Conducting the interview

• • Management of the initial phases of the interview to build rapport and ensure that all legal and ethical aspects have been considered.
• • Implementation of the appropriate interviewing model in accordance with the interview strategy/plan.
• • Adopting a meaningful, effective and consistent strategy for summarising and recording witness evidence.
• • Introduction to strategies for dealing with challenging/difficult witnesses, including obstructive and inappropriate behaviour.
• • Identifying and employing appropriate challenge techniques for any inconsistencies/omissions during an interview.
• • Dealing with other third party attendees at the interview, e.g. legal representatives, trade union representatives, friends/family.
• • Effective interview closure strategies.

 

5. Post-interview phase

• • Recording and summarising of the interview information.
• • Strategies for conducting an effective self-critique of the interview process to ensure continuous performance improvement.

On successful completion of this module you will be able to:

1. 1. Demonstrate an understanding of the underlying interviewing theories, including memory theory and psychological factors affecting witness recall, and biases and heuristics of both witnesses and investigators. 
2. 2. Describe and critically assess the most appropriate interview technique(s) to be adopted during an accident safety investigation to ensure the effective gathering of witness evidence, including cognitive/non-cognitive interview techniques.  
3. 3. Develop an appropriate and effective interview strategy and plan to ensure the efficacy of the interview and optimise the gathering of the available information.
4. 4. Conduct an effective witness interview with regard to the selection of the most appropriate interview methodology, the welfare of the witness, the quality of the evidence collected and the accuracy of note taking, and effective self-critique of interview process.
5. 5. Develop an awareness of the characteristics of potentially vulnerable witnesses and the challenges faced when interviewing them.

The Investigating Human Performance module encourages students to look critically at the contribution humans make in high reliability organisations (HROs). Using psychological theory and analysis, the human contribution (positive and sometimes negative) is addressed. Theories and approaches of human performance explored on this module should help the student understand the human factors affecting those involved with accidents or incidents, as well as the investigator.

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Introduction to human factors:

• • The role of human performance in accidents.
• • Objectives of the course.
• • Assignment briefing.

Individual factors:
• Human error
- Slips.
- Lapses. 
- Mistakes. 
- Violations.
- Skill-based errors.
- Rule-based errors.
- Knowledge-based errors.

• Human cognition 
- Human performance and limitations.
- Perception.
- Memory.
- Attention and vigilance.
- Information processing.
- Decision making.
- Situational awareness.

• Medical factors 
- Physiology and its effect on performance 
- The role of the pathologist 
- The role of the general practitioner 
- Ethics of accessing medical information 

• Workload, fatigue and tiredness 

- Tiredness versus fatigue 
- Effects of fatigue 
- Things that look like fatigue but aren’t 
- Building up a valid history 
- Using fatigue assessment tools  

Job / Workplace Factors 
• Evaluating ergonomics.
• Assessing task / workload.
• Interpreting error prediction tools.
• Environmental factors.
• Team factors.
• Teamwork. 
- Communications.
- Leadership / followership.
- Cultural factors.

Organisational and management factors 
• The role of culture in causation 
• The role of management in causation 
• Measuring safety culture 
• Assessing responses to previous events 
• Case study investigations 

Human performance evidence collection tools 
• Checklists 
- Commonly used checklists and tools 
- Benefits and limitations 
- Case studies of use 
 
Analysis of human factors 
• Biases and heuristics
• Ethical issues 
• Interpretation of recorded data 
• Interpretation of witness / interview data 

On successful completion of this module you will be able to:

1. 1. Describe the key areas of consideration for an accident investigator in terms of human performance in transport operations.
2. 2. Identify suitable techniques for the collection of accurate evidence relating to human performance.
3. 3. Critically assess the effectiveness of contemporary human factors evidence collection and analysis tools.
4. 4. Identify at what point an expert should be approached about the collection or analysis of human performance evidence.  
5. 5. Evaluate the human performance aspects of contemporary accident investigations.

The aim of this module is to provide you with an understanding of the design of crashworthy aircraft structures and the considerations necessary when designing safe and crashworthy aircraft. The main purpose of crashworthy design is to eliminate injuries and fatalities in mild impacts and minimise them in severe but survivable impacts.

• Overview of Aircraft Crashworthiness.
  - Objectives and Approach.
  - Regulations.
  - Human Tolerance.
 
• Crash Energy Management.

• Structural Collapse.
   - Collapse of metallic and composite structural components.
   - Component collapse vs. structural collapse.

• Introduction to methods for crash analysis.
   - Hand calculations.
   - Hybrid analysis methods.
   - Detailed analysis methods.
 
• Role and capability of testing and simulation in the crashworthiness field.

On successful completion of this module you should be able to:

1. 1. Examine relevant crashworthiness regulations.
2. 2. Analyse the key issues of structural crashworthiness.
3. 3. Examine the collapse of thick and thin-walled sections.
4. 4. Evaluate the global collapse of structures.
5. 5. Critically evaluate the crashworthiness of structures.

To familiarise you with the various approaches to the problems of assessing the safety of increasingly complex aircraft systems.

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Introduction and background
Outline of relevant accidents and system design philosophy.  Discussion of acceptable accident rates and recent advances in systems.  Introduction to probability methods.

Regulatory background 
The development of requirements for safety assessment, FAR / EASA CS25—1309.

Methods and techniques
Introduction to the more common safety analysis techniques. Influence of human factors.  Common mode failures, traps and pitfalls of using safety assessment and examples of mechanical systems and power plants.

Use of safety assessment techniques
Determination of correct architecture of safety critical systems.  Fault Tree Analysis, Dependence Diagrams and Boolean algebra for quantification of system reliability.  Zonal safety analysis (ZSA), Particular Risk Analysis (PRA) and Failure Mode and Effect Analysis (FMEA) of aircraft systems.

Practical examples of the application of safety assessment techniques
Minimum Equipment Lists (MEL), Safety and Certification of digital systems and safety critical software.  Application of Aerospace Recommended Practice (ARP) 4761.  Typical safety assessment for a stall warning and identification system.

Current and future issues
Integrated and modular systems and their certification.  Certification maintenance requirements.  Flight-deck ergonomics.

 

On successful completion of this module you should be able to:

1. 1. Demonstrate an understanding of the regulatory background behind the Safety Assessment of Aircraft Systems. 
2. 2. Evaluate and apply the technique(s) which is most appropriate for the system under consideration. 
3. 3. Explain the theory behind each technique, including the strengths and weaknesses of each one, and be aware of possible pitfalls. 
4. 4. Appreciate the role of safety assessment in the overall context of aircraft certification. 
5. 5. Illustrate the issues to be faced for the certification of new systems and aircraft.