GUIDE TO THE CONSIDERATION OF HUMAN FAILINGS
  (Ref Chap 8, para 90)

INTRODUCTION

  1.  The board's consideration of human failings by individuals in the performance of their duties will require considerable thought. A board of inquiry is a fact-finding assembly primarily concerned with discovering the causes of the accident and, broadly speaking, these fall into three categories: technical faults; natural, operating or medical hazards (NOM); and human failings (human factors). If the diagnosis of the causes reveals some human factor which caused or contributed to the accident, the board must consider all the evidence and any mitigating circumstances which may have influenced human conduct. The board must determine if that factor constituted error of judgement or negligence, as defined in this Annex. These matters must be resolved conclusively and recorded in the proceedings (see Chap 8, para 103). The board is not concerned with punishment; this can result only from formal disciplinary proceedings as the result of executive action. Any conclusion that human failing is involved may reflect on the character or professional reputation of the person concerned and it is essential, therefore, that his rights under QRs are observed (see Chap 8, para 90).

APPLICABILITY OF HUMAN FAILINGS

  2.  Before making a detailed assessment of human failings the board must distinguish between those irregularities which had no direct connection with the cause of the accident and those which had. This can be resolved by the answers to two questions:

(a)  Was the person's act which is under consideration an essential link without which the final event would not have happened?

(b)  Ought the person to have foreseen that their action or their failure to take action would in all probability occasion the final event? In answering this question the board must use their general knowledge of the world and of human behaviour. Furthermore they should consider elementary matters, which may have a direct connection with the cause of an accident, such as:

(i)  The creation of circumstances which may result in an accident.

(ii)  The failure to ensure that orders which are designed to prevent accidents are obeyed.

(iii)  The failure of a superior to ensure that an order is actually carried out, where he has a specific duty to see that it is complied with.

  If the board determines that human factors had a direct connection with the cause, it will be necessary to assess such failings in accordance with the guidance in the paragraphs below (and as illustrated diagrammatically at Appendix I).

ERROR OF JUDGEMENT

  3.  It is important that the correct interpretation is given to "errors of judgement". Because the element of judgement is frequently present in matters of flying, it is important not to confuse the term "error of judgement" with negligence. The term "error of judgement" involves a finding of an honest mistake accompanied by no lack of zeal. It should accordingly be confined to those cases where a person through no fault of his own, and whilst exercising the degree of skill which can reasonably be expected (see para 6) makes an inappropriate response.

  Note: The results of a person's actions should be regarded as an accident although arising from human error. "Error of Judgement" does not arise where there is negligence, whether or not such negligence is accompanied by mitigating circumstances. For there to be a finding of "Error of Judgement" the evidence must show that the person acted with reasonable care taking into account both the level of training and degree of proficiency reached and the difficulties which arose due to the circumstances of the incident, such as an exceptional workload placed on them and, in particular, the time available in a crisis to make decisions and act upon them. No action should be taken under QR(RAF)1269(6) and, under the terms of QR(RAF)1270(2), the president is therefore to make a recommendation that the person concerned be absolved from blame.

NEGLIGENCE

  4.  It is often extremely difficult to decide whether or not a person has been negligent and the board must rely on its own knowledge of human behaviour and acceptable Service standards in reaching its decision. When considering if a person acted negligently, the board must be quite clear in its own minds as to what constitutes negligence and what amounts to "Error of Judgement" (see para 3 above). Negligence may be defined as:

(a)  The omission to do something which, in the circumstances, a reasonable person would do or,

(b)  The doing of something which, in the circumstances, a reasonable person would not do or would do differently.

  5.  When related to flying aircraft or to aircraft maintenance, neglect means a breach of duty to take care or, in other words, carelessness in a matter where care is demanded. The duty to take care varies according to the operation being performed and a duty to take a very high degree of care is rightly imposed upon a person flying an aircraft or responsible for its maintenance or its control. In such circumstances what might be trivial in other fields may, when associated with aircraft operations, amount to negligence which justifies severe criticism. Boards should beware, however, of confusing responsibility with blameworthiness. This confusion arises most frequently during investigations into taxying accidents, when the wrong interpretation is placed on the word "responsible" as used in JSP 318. Responsible means "liable to be called to account" and, provided that the captain can be shown to have taken all reasonable steps to ensure the safety of his aircraft, he can be said to have fulfilled his responsibility and to be free of blame. Equally, since a pilot must, in certain circumstances, rely on outside help to taxi his aircraft, it follows that those charged with providing this help should also be called to account for the safety of the aircraft and, in certain cases, found to blame.

  6.  Skilful pilots exercising due care can make genuine mistakes under the pressure of modern military flying and it is the board's duty to identify the causes of such pressure and make recommendations for its alleviation. If the board finds that the pressure of circumstances is such as to overwhelm a skilful and careful pilot then the pilot would not be negligent and the appropriate finding would be "Error of Judgement" because there is no suggestion of lack of care. Where such circumstances do not apply, the two factors which a board must consider when deciding upon negligence are:

(a)  Whether the person had the necessary degree of skill and/or knowledge, or should have had that skill and/or knowledge, to make the right decision and act upon it.

(b)  Whether the person failed to exercise the degree of skill and/or knowledge required.

Note: When covering these questions boards must have regard to circumstances which may amount to Errors of Judgement (see para 3).

  7.  Where a person fails, whether negligent or not, the board should consider the possible human failings of others who placed that person in the situation eg by authorising a flight or task which the person was not properly skilled or experienced to perform. Attributing blame to any person can arise only from a finding of negligence against that person, and therefore action under QR 1269(6) should be taken only when such a finding is likely to be made.

  8.  If a board finds negligence, it is also to express an opinion upon its degree. Boards are to consider and record any mitigating circumstances, and indicate whether or not such circumstances—in the board's view—reduce the degree of blame attaching to an individual. Conversely, where no such circumstances are apparent, the board should express a view as to whether any negligence was blameworthy to a minor degree, to a gross degree or whether it constituted recklessness or disobedience. Higher authority will determine what, if any, disciplinary or administrative action is to be taken.

  9.  Only in cases in which there is absolutely no doubt whatsoever should deceased aircrew be found negligent.