Ricketson D S, Brown W R, Graham K N
Aviat Space Environ Med. 1980 Sep;51(9 Pt 2):1036-42.
Human error is the largest cause of U.S. Army aircraft accidents. An approach to this problem is presented which is based on a model of the human-error accident. This 3W approach identifies what task error (TE) caused or contributed to the accident, what inadequacy (I) in the aviation system caused or allowed the TE to occur, and what remedial measure (R) is required to correct the I. There were 82 human-error accidents analyzed to identify TEIR information. Statistically important is were identified which could be remedied based on accident costs. Then, potentially cost-effective remedial actions were ranked on a cost-benefit totem pole. The totem pole was given to the aviation system manager as a management tool to assist in determining priorities for corrective actions.
人为失误是美国陆军飞机事故的最大原因。本文提出了一种基于人为失误事故模型的解决该问题的方法。这种3W方法确定了导致事故或促成事故的任务失误（TE）、航空系统中导致或允许任务失误发生的不足之处（I）以及纠正不足之处所需的补救措施（R）。对82起人为失误事故进行了分析，以确定TEIR信息。确定了具有统计学意义且可根据事故成本进行补救的因素。然后，根据成本效益对潜在的具有成本效益的补救行动进行排序。这个排序结果作为管理工具提供给航空系统经理，以协助确定纠正行动的优先级。
