ABSTRACT
InDecember1983thefirstauthorwascalledtoassistintheinvestigationofa multiplefatalityaircraftaccidentnearRAAFBaseEastSaleinruralVictoria, Australia.AsapsychologistworkingwiththeRAAF(RoyalAustralianAirForce), hewastaskedwithexaminationofthe'humanfactors'aspectsofthistragicevent. Theaccidentinvolvedamid-aircollisionbetweentwoMacchiMB326Haircraftof the'Roulettes',theRAAF'saerobaticdisplayteambasedattheCentralFlying SchoolatEastSale.Inthemonthsprecedingtheaccidentthisauthorhad developedaninterestintheinvestigationofhumanfactorsaspectsofaccidentsand commencedsomepersonalresearchintothearea.Amongstthoseconsultedwere thelateRogerGreenoftheInstituteofAviationMedicineatRAFFamborough, andRobLee,thenoftheAustralianBureauofAirSafetyInvestigation,bothstrong advocatesforthepotentialcontributionofhumanfactorsexpertisetoaccident investigation.Atthetimehowever,conventionalwisdomwasthat'aboutsixty-five toseventypercent'ofaccidentswere'causedbyhumanerror'.Inmanycaseswhat peoplemeantbythisstatementwas'piloterror',asofcoursethepilot,usuallyfirst onthescene,wasfrequentlyimplicatedinthesubsequentinvestigation.
