<p>Composite materials used in the aviation industry are known to be more complex than their metallic predecessors. This impacts not only the design and manufacturing of composite structures, but also the failure studies when these structures fail and break (as may be the case in an aircraft accident). Additionally, when under combustion, composite materials introduce potential health hazards. At elevated temperatures, the fibers can be released, presenting an inhalation hazard. Similarly, the matrix decomposition results in a series of potentially toxic byproducts. When encountering composite fires at aircraft accident sites, a series of protocols have been delineated by the corresponding agencies. These include wearing personal protective equipment as well as the application of so-called fixant solutions over the burning composites, with the latter being the focus of this study. The purpose of the fixant solutions is to provide a film of protection that – in essence – holds down small fibers and prevents them from becoming airborne. While the use of fixant solutions is necessary to protect the health of individuals in the vicinity of burnt composites, the potential detrimental impact the application thereof has on fractographic evidence should also be considered. Experts in the field have voiced concerns regarding the use of fixants, outlining that these chemicals may wash evidence away, cover up evidence, or interfere with imaging methods needed during the failure analysis. The purpose of the conducted research, thus, was to compare the relative impact of four commonly used fixant solutions – namely water, wetted water, polyacrylic acid (PAA), as well as a mixture of water and floor wax – on fractographic features of failed carbon fiber/epoxy composite specimens. Specifically, fractographic evidence of two forms of damage – impact and tension – were evaluated. With this goal, the methodology included steps to manufacture the specimens of interest, introduce the two forms of damage, burn the specimens, apply fixants, and perform the microscopic analysis via a scanning electron microscope (SEM). The fractographic evidence prior and after the application of fixant was evaluated qualitatively and quantitatively. The results showed that the evaluated fixants did influence the fracture surfaces imaged, and in certain cased obscured evidence of interest. Additionally, differences between the fixants were ascertained for both forms of damage evaluated. The water treatment was found to perform the best, minimizing the disruption of evidence. Nonetheless, while the study did answer the research questions and the different treatments were compared, additional areas of research and factors that should be considered were identified. </p>

Reported is an exploratory study of problems and conditions within the organizational work context that influence posttraining use of training outcomes. Training is widely perceived and supported as an effective means for facilitating planned change in organizational performance. Little empirical evidence is available to support such supposition. Of the several studies of training impact, few have focused on why training does or does not produce behavioral change back on-the-job. Accordingly, training management is often incomplete and ineffective. This study employed a questionnaire methodology, directed to a national sample of 391 local, county, and state law enforcement personnel who graduated from a two-week accident investigation training program. Questions elicited ratings on 29 problem/conditions hypothesized within the literature as influential to organizational work behavior. A Likert type scale was used to rate the perceived influence of each problem/condition on the application of specific training outcomes during investigation of a recent most serious accident. An index was used to measure level of training use. Analysis of Variance (ANOVA), Scheffe's comparisons test, and multiple regression analysis were used to answer study questions. Problem/conditions identified by more than 30% of the respondents as a Moderate or Major impediment to their use of training outcomes were: lack of rewards or incentives to conduct thorough investigations or to use knowledge and skill acquired through training; lack of time to apply investigative techniques by training; lack of resources and equipment necessary to apply training; lack of follow through by agency decision makers to see that training was put into use; and, lack of communication from top administrators indicating how the training was to be used. Isolated as predictors of training use were: the relative seriousness of the situational context within which training was applied; the trainee's opinion of the course; level of specialized training received; relative frequency of investigative assignment; and, level of conflict perceived to exist between behaviors specified by training and agency standard operating procedures. / Ed. D.

Human - Technology - Organization (HTO) is a well-established, general unifying concept in the Swedish Accident Investigation Authority (SHK) that represents an approach, knowledge and use of various tools regarding interactions between people, technology and organizational factors. The HTO-perspective is well described in literature but there are few studies on how SHKs staff experiences working according to this method in their investigations. The aim of this study was therefore to describe their HTO-perspective, examine how it is used in the investigations at SHK and describe the investigators experience of working with the HTO-perspective as well as the method's usefulness compared to old methods in accident investigations. A literature study has been conducted in the areas of HTO, Theory of planned behavior (TPB) and safety culture. TPB and safety culture are described in this paper since they highlight the different aspects of a HTO-perspective. The hypothesis was answered by using semi-structured interviews. The interviews were analyzed by a content analysis and themes were identified. Furthermore the material from the interviews was subsequently structured through a Strength – Weakness – Opportunities – Threats analysis (SWOT), i.e. the informants' view on the HTO-perspective was structured based on the strengths, weaknesses, opportunities and threats SHKs staff experience that the method has in the investigative work. The informants consisted of two investigators at SHK who 3have worked with accident investigations for a long time in various roles. The results yielded that the investigators had a positive attitude towards conducting investigations according to the HTO-perspective because they feel that this perspective provides them with cross-competence. A flaw is though that the perspective lacks a structured approach. As a result of this, the investigators own experiences and expertise play a major role in the quality of the investigation. As the study's aim is met and the informants are considered to be experts the validity requirements are also fulfilled.

This project examines the safety management of civil aircraft accident investigation authorities in International Civil Aviation Organization (ICAO) Member States, with particular emphasis on the independence of the investigations. The research aims to establish the current level of resources and methodology adopted by Member States’ accident investigation authorities. The output of this work not only identifies the current situation but informs initiatives for some of the States in the process of establishing their investigation capability. ICAO Annex 13 was analysed and found to be based on the principle of independent accident investigations. Also, a four dimensional measuring index (4DMI) has been developed to measure the independence of accident investigations in ICAO Member States. Data were collected from 45 States and are presented in the thesis. As a result of applying the 4DMI to the collected data, the States were ranked according to their scores, and divided into four categories of independence. Analysis of the four categories and the scores from the four dimensions revealed that States approach the concept of investigation independence in different ways; however, there are several practices that are common within the highest independence category and several other practices that are common within the lowest independence category. The research recommends that States should work towards improving their overall investigation independence by implementing the seven identified practices in the High-Independence category and distance themselves from the five practices identified as common in the Low-Independence category.

Objetivos. Analisar investigações de acidentes e materiais didáticos e educativos, explorando aspectos da construção das análises e de atribuição de culpa. Métodos. Registros de investigações e materiais didáticos de empresas de Botucatu-SP, em 1997, obtidos de instituições e empresas, foram analisados, identificando-se fatores causais, recomendações e referências a comportamentos faltosos ou características da vítima. Árvores de causas foram checadas quanto a cuidados de linguagem, desenhos, interrupções da investigação, tipos de relações entre fatos e exploração para prevenção. Materiais educativos foram analisados, identificando-se concepções de acidente, orientações para investigações e recomendações. Bancos de dados foram formados e gerenciados com EPIinfo. Resultados. Foram analisadas 203 investigações. A média de “causas" por AT foi 1,68 e a de recomendações foi 1,4 por AT, com predomínio de referências a comportamentos ou características da vítima. A maioria das análises baseava-se em formulário obrigatório. Todas as árvores analisadas mostravam desrespeito flagrante a regras e princípios do método. Materiais didáticos veiculavam mesma concepção de acidente das investigações, método de análise centrado em comportamentos faltosos do operador, estímulo ao medo de lesões e recomendações para obediência a regras e uso de equipamentos de proteção. Conclusão. As investigações adotam concepção de acidente baseada na identificação de situações de desrespeito a regras idealizadas, atribuem culpa ao acidentado e não subsidiam a gestão de riscos nas empresas. A atribuição de culpa ocorre independentemente da natureza e/ou tipo de perigo presente nos acidentes. Tentativas de uso do método de árvore de causas mostraram distorções, revelando insuficiência no seu domínio. A construção da culpa foi reforçada por materiais didáticos e educativos. Descritores: Acidentes do trabalho, investigações de acidentes, vigilância de acidentes. / Objectives: To analyze accident investigations and teaching and educational materials exploring aspects of analysis construction and blame attribution. Methods: Investigation reports and educational materials of companies in Botucatu, SP, in 1997, obtained from institutions and companies were analyzed and causal factors, recommendations and references to faulty behavior or victim characteristics were identified. Causal tree were checked in regard to language, design, investigation interruptions, types of relations between facts and exploration for prevention. Educational materials were analyzed identifying the conception of accident, orientation for investigations and recommendation. Data banks were formed and managed by EPIinfo. Results: 203 investigations with an average of 1,68 causes and 1,4 recommendations were analyzed and revealed that references to victim’s behavior or characteristics prevailed. Most analyses were based on an obligatory form. All analyzed trees showed evident disrespect to rules and methodological principles. The educational and teaching materials convey the same accident concept as the investigations, the analyses method centered in the faulty behavior of the operator, stimulus of fear to injury and recommendation for obedience to rules and use of protection equipment. Conclusion: The investigations studied use an accident concept based on the identification of situations of disrespect to idealized rules, blame the injured subjects, and do not support the risk management in the companies. The blame bias occurs independently of the nature or kind of danger involved in the accidents. The attempts to use the causal tree method revealed distortions due to insufficient command. Educational materials strengthened the construction of blame.

There are many pieces of flight deck research on general use of written English language technical information and problem solving using technical documentation. Contributory causes of aircraft accidents have been due to misunderstandings of crew alerts and procedural divergence by English as-a-second language flight crewmembers (ESL). Research was conducted to understand impact of written English language technical information on ESL flight crewmembers’ performance. Two types of systems were evaluated, technical documentation and crew alerting systems that contain technical information, with respect to their impact on ESL flight crewmember performance. Preliminary analysis results indicated written English language technical information can be confusing, difficult to read and interpret, and leads to misunderstandings by ESL flight crewmembers during aircraft nonnormal conditions. English as-a-second language flight crewmembers indicated they often experience problems executing written English language technical procedures after outset of crew alerts. Conversely, experimental trials revealed ESL flight crewmembers did not experience many cognitive performance issues with use of crew alerting systems and technical information designed with an English language emphasis. English as-a second language flight crewmembers’ English language proficiency, background knowledge, and use of use of metacognitive strategies to read and comprehend written English language on crew alerting and information systems, indicated they utilized written English technical information with ease. Particularly, ESL flight crewmembers’ workload was low, they had fast response times to system faults, and they experienced minimal procedural deviations. On the contrary, when ESL flight crewmembers utilized written English language technical procedures translated into their native language during non-normal conditions, they experienced several cognitive performance challenges. English as-a second language flight crewmembers’ background knowledge of written English language technical information translated into their native language, use of metacognitive strategies to read and comprehend written English language translated into their native language, indicated they experienced difficulties with reading and comprehending translated technical information on information systems. Particularly, ESL flight crewmembers were challenged cognitively when they responded to crew alerts through execution of decision-making processes. They indicated translation of written English language technical information into their native language was a pre-cursor to procedural deviation, long response times to system issues, as well as high workload during experimental trials. It is recommended that further research focus on design and use of written English language technical documentation by ESL flight crewmembers during non-normal conditions. It is also recommended that if deemed practical by the aviation industry, further research should focus on design, integration, and utilization of technical documentation in a language(s) other than English, and measurement of ESL flight crewmembers performance on the flight deck.

Objetivos. Analisar investigações de acidentes e materiais didáticos e educativos, explorando aspectos da construção das análises e de atribuição de culpa. Métodos. Registros de investigações e materiais didáticos de empresas de Botucatu-SP, em 1997, obtidos de instituições e empresas, foram analisados, identificando-se fatores causais, recomendações e referências a comportamentos faltosos ou características da vítima. Árvores de causas foram checadas quanto a cuidados de linguagem, desenhos, interrupções da investigação, tipos de relações entre fatos e exploração para prevenção. Materiais educativos foram analisados, identificando-se concepções de acidente, orientações para investigações e recomendações. Bancos de dados foram formados e gerenciados com EPIinfo. Resultados. Foram analisadas 203 investigações. A média de “causas” por AT foi 1,68 e a de recomendações foi 1,4 por AT, com predomínio de referências a comportamentos ou características da vítima. A maioria das análises baseava-se em formulário obrigatório. Todas as árvores analisadas mostravam desrespeito flagrante a regras e princípios do método. Materiais didáticos veiculavam mesma concepção de acidente das investigações, método de análise centrado em comportamentos faltosos do operador, estímulo ao medo de lesões e recomendações para obediência a regras e uso de equipamentos de proteção. Conclusão. As investigações adotam concepção de acidente baseada na identificação de situações de desrespeito a regras idealizadas, atribuem culpa ao acidentado e não subsidiam a gestão de riscos nas empresas. A atribuição de culpa ocorre independentemente da natureza e/ou tipo de perigo presente nos acidentes. Tentativas de uso do método de árvore de causas mostraram distorções, revelando insuficiência no seu domínio. A construção da culpa foi reforçada por materiais didáticos e educativos. Descritores: Acidentes do trabalho, investigações de acidentes, vigilância de acidentes. / Objectives: To analyze accident investigations and teaching and educational materials exploring aspects of analysis construction and blame attribution. Methods: Investigation reports and educational materials of companies in Botucatu, SP, in 1997, obtained from institutions and companies were analyzed and causal factors, recommendations and references to faulty behavior or victim characteristics were identified. Causal tree were checked in regard to language, design, investigation interruptions, types of relations between facts and exploration for prevention. Educational materials were analyzed identifying the conception of accident, orientation for investigations and recommendation. Data banks were formed and managed by EPIinfo. Results: 203 investigations with an average of 1,68 causes and 1,4 recommendations were analyzed and revealed that references to victim’s behavior or characteristics prevailed. Most analyses were based on an obligatory form. All analyzed trees showed evident disrespect to rules and methodological principles. The educational and teaching materials convey the same accident concept as the investigations, the analyses method centered in the faulty behavior of the operator, stimulus of fear to injury and recommendation for obedience to rules and use of protection equipment. Conclusion: The investigations studied use an accident concept based on the identification of situations of disrespect to idealized rules, blame the injured subjects, and do not support the risk management in the companies. The blame bias occurs independently of the nature or kind of danger involved in the accidents. The attempts to use the causal tree method revealed distortions due to insufficient command. Educational materials strengthened the construction of blame.

The requirement to operate vehicles in low light and/or night environments whilst wearing night vision goggle (NVG) systems has become increasingly common during military operations. There is very limited research investigating injury risks associated with these systems during ground vehicle collisions. This study examined the injury risks associated with wearing the Australian Defence Force - Enhanced Combat Helmet (ECH) and NVG system, in frontal vehicle collisions. This project consisted of two components: (1) crash tests using a sled and (2) numerical simulations of impacts. Four dynamic sled tests were conducted using a 50th percentile, male, Hybrid III dummy positioned on a rigid seat. Frontal impact tests were performed at a 40 km/h change in velocity (*v) and 20 g deceleration. The test configurations were as follows: (a) Base; (no helmet or additional equipment); (b) ECH; and, (c) ECH and NVG. Condition (c) was carried out twice, to determine repeatability. The sled test protocols were reconstructed precisely with the numerical simulation package MADYMO and the simulations were shown to correlate well with the experimental results. Using this validated model, four parametric studies were undertaken to assess the influence of counterweights, seat cushion, seatbelt pre-tensioner, and the vehicle's *v and acceleration on injury risks. The study found that neck loads were within acceptable limits, with the exception of the neck extension moment, which was exceeded for all NVG conditions. Based on the parametric studies, no major improvements were observed in the neck extension moments with the use of counterweights or a seat cushion. In contrast the use of a seatbelt pre-tensioner was observed to decrease greatly this neck injury risk in certain scenarios. The study also identified that a *v of 15 km/h and peak acceleration of up to 14 g were required to keep the neck extension moment below the prescribed injury criteria. However, the high neck extension moment values may have been partially attributable to the stiff Hybrid III neck. This study identified a possible injury mechanism for soldiers using the ECH and NVG system during specific impact scenarios. The method applied in this project was designed to be repeatable.

Technogeninės avarijos Lietuvoje – mažai ir retai nagrinėjama tema, todėl rasta mažai straipsnių ir medžiaga darbui atlikti buvo renkama iš labiausiai visuomenei prieinamų šaltinių – teisės aktų ir internetinių institucijų tinklapių. Darbe pateikta ūkinės veiklos teisinė samprata, klasifikacija, avarijos kaip visumos elementai, nagrinėtas bendras šalies ir atskirų ūkio sričių avaringumas, tirtos inspektuojančių institucijų metinės veiklos ataskaitos, ištirti technogeninių avarijų valdymo ypatumai. Darbo tikslas buvo pasiektas, nes nustatytos labiausiai pavojingos ir nepavojingos ūkinės veiklos sritys, pagal jas – objektai, įvardintos probleminės sritys ūkinės veiklos ir pavojinguose objektuose, įvardintos grėsmės ekologiniam saugumui Lietuvoje, suskaičiuotos kelerių metų avarijų tendencijos skirtingose ūkio šakose, pateiktos dažniausios technogeninių avarijų priežastys, padarytos išvados. / Technogenic accidents in Lithuania – a low and rarely the issue in question, therefore found few articles and material work was collected from most public soures – legislation and on the institucions website. The work on the legal concept of economic activity, breakdown, accident as a whole, the elements examined, the country and individual economic sectors accident, investigated inspection authorities annual activity report, investigate technogenic accidents in handling qualities. The goal was achieved, as the most hazardous and non-hazardous areas of economic activity, according to them – objects named problem areas of economic activity and critical facilities, named environmental threats to security in Lithuania, an estimated number of years of accidents in different trends industries, the most common sauses of technogenic accidents, the conclusions drawn.

This project examines the safety management of civil aircraft accident investigation authorities in International Civil Aviation Organization (ICAO) Member States, with particular emphasis on the independence of the investigations. The research aims to establish the current level of resources and methodology adopted by Member States’ accident investigation authorities. The output of this work not only identifies the current situation but informs initiatives for some of the States in the process of establishing their investigation capability. ICAO Annex 13 was analysed and found to be based on the principle of independent accident investigations. Also, a four dimensional measuring index (4DMI) has been developed to measure the independence of accident investigations in ICAO Member States. Data were collected from 45 States and are presented in the thesis. As a result of applying the 4DMI to the collected data, the States were ranked according to their scores, and divided into four categories of independence. Analysis of the four categories and the scores from the four dimensions revealed that States approach the concept of investigation independence in different ways; however, there are several practices that are common within the highest independence category and several other practices that are common within the lowest independence category. The research recommends that States should work towards improving their overall investigation independence by implementing the seven identified practices in the High-Independence category and distance themselves from the five practices identified as common in the Low-Independence category.