Understanding Human Error Based on Automated Analyses vol 1

A proactive approach to identifying and alleviating life-threatening conditions in the aviation system entails a well-defined process of identifying threats, evaluating causes, assessing risks, and implementing appropriate solutions. This process is not a trivial undertaking. It requires continuous monitoring of system performance in a non-punitive culture; learning from normal operational experience; comparing actual performance to expected performance; identifying the precursor events and conditions that foreshadow most accidents; designing appropriate interventions to minimize the risk of their occurrence; and having a system in place to monitor the efficacy of the interventions.