Computer-Related Incidents with Commercial Aircraft
is the Australian accident investigation authority. Their reports are
very-high quality documents and recent ones are available on the WWW
in PDF format. Accident investigation specialists explicitly use
James Reason's model of human error for determining not only the
which contribute to an accident, but also
the latent errors
, the organisational, managerial and oversight
errors, which Reason and others have identified as being major
contributors to complex system accidents - aviation, encompassing
regulation, oversight authorities, air traffic control and communication,
as well as pilots and aircraft, is a complex system in this sense.
Reason, of the University of Manchester in England, is a reknowned
specialist in human error who has done considerable work with ICAO.
Those wanting good examples of Reason's methods in practice would do
well to surf around this site.
The Transportation Safety Board of Canada