The causes of causes: determinants and background variables of human factor incidents and accidents.

Abstract 1448 German Air Force pilots took part in an anonymous investigation of critical flight incidents. A 315-item questionnaire was applied, which included relevant preflight and inflight data, physiological and psychological parameters (behaviour variables, subjective state ratings before and during critical situations, pilot errors and their consequences) as well as environmental factors. Extensive data analysis revealed various human errors, which can be intepreted as a four-dimensional error-structure: vigilance errors, perception errors, information processing errors and sensorimotor errors. Determinants and background variables of human factor incidents and accidents were discussed in a model of basic man–machine system interaction patterns. Preventive measures to limit and control human factor incidents and accidents are proposed in a four-step programme.