Human Error and Commercial Aviation Accidents: A Comprehensive, Fine-Grained Analysis Using HFACS

The Human Factors Analysis and Classification System (HFACS) is a theoretically based tool for investigating and analyzing human error associated with accidents and incidents. Previous research has shown that HFACS can be reliably used to identify general trends in the human factors associated with military and general aviation accidents. The aim of this study was to extend previous examinations of aviation accidents to include specific aircrew, environmental, supervisory, and organizational factors associated with 14 CFR Part 121 (Air Carrier) and 14 CFR Part 135 (Commuter) accidents using HFACS. The majority of causal factors were attributed to the aircrew and the environment, with decidedly fewer associated with supervisory and organizational causes. Comparisons were made between HFACS categories and traditional situational variables such as weather, lighting, and geographic region. Recommendations were made based on the HFACS findings presented

Human Error and General Aviation Accidents: A Comprehensive, Fine-Grained Analysis Using HFACS

The Human Factors Analysis and Classification System (HFACS) is a theoretically based tool for investigating and analyzing human error associated with accidents and incidents. Previous research performed at both the University of Illinois and the Civil Aerospace Medical Institute has successfully shown that HFACS can be reliably used to analyze the underlying human causes of both commercial and general aviation (GA) accidents. These analyses have helped identify general trends in the types of human factors issues and aircrew errors that have contributed to civil aviation accidents. The next step was to identify the exact nature of the human errors identified. The purpose of this research effort therefore, was to address these questions by performing a fine-grained HFACS analysis of the individual human causal factors associated with GA accidents and to assist in the generation of intervention programs. This report details those findings and offers an approach for developing interventions to address them

Beneath the Tip of the Iceberg: A Human Factors Analysis of General Aviation Accidents in Alaska Versus the Rest of the United States

Historically, general aviation (GA) accidents have been overlooked and their impact under-appreciated when compared with those in the commercial or military sector. Recently however, the Federal Aviation Administration and other governmental and civilian organizations have focused their attention on one piece of this proverbial “iceberg,” that being GA accidents occurring in Alaska. This study examines more than 17,000 GA accidents using the Human Factors Analysis and Classification System. Comparisons of Alaska to the rest of the U.S. (RoUS) included traditional demographic and environmental variables, as well as the human errors committed by aircrews. Overall, categorical differences among unsafe acts (decision errors, skill-based errors, perceptual errors, and violations) committed by pilots involved in accidents in Alaska and those in the RoUS were minimal. However, a closer inspection of the data revealed notable variations in the specific forms these unsafe acts took within the accident record. Specifically, skill-based errors associated with loss of directional control were more likely to occur in Alaska than the rest of the U.S. Likewise, the decision to utilize unsuitable terrain was more likely to occur in Alaska. Additionally, accidents in Alaska were associated with violations concerning Visual Flight Rules into Instrument Meteorological Conditions. These data provide valuable information for those government and civilian programs tasked with improving GA safety in Alaska and the RoUS

A Laboratory Comparison of Clockwise and Counter-Clockwise Rapidly Rotating Shift Schedules, Part I. Sleep

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Understanding the human factors associated with Visual Flight Rules (VFR) into Instrument Meteorological Conditions (IMC) (DOT/FAA/AM-08/12). Washington DC: Office of Aerospace Medicine

Work was accomplished under approved task AM-B-06-HRR 521. Abstract Visual Flight Rules (VFR) into Instrument Meteorological Conditions (IMC) accidents are a major concern in the aviation industry. More than 70% of the fatal weather-related accidents involved General Aviation (GA) pilots operating under visual flight rules (VFR) that continued into IMC. The purpose of this study was to pair GA accident causal factors that had been classified with the Human Factors Analysis and Classification System (HFACS) categories and traditional demographic data in an effort to present a more complete picture of VFR flight into IMC accidents. To accomplish this, GA accidents associated with VFR flight into IMC were examined to determine if there were any causal factors that set these accidents apart from the rest of GA (RoGA) accidents. GA accident data (14 CFR Part 91) from 1990-2004 were analyzed. The dataset was divided into accidents that had VFR into IMC (VFR-IMC; N = 609) cited as a cause or factor versus the rest of the GA accidents (RoGA; N = 18,528). Analyses were performed examining the human error associated with these accidents. The results indicated that skill-based errors were more prevalent in RoGA than in VFR-IMC (odds ratio = 4.167, 2 = 332.531, p <.001). VFR-IMC pilots were more likely to commit a decision error (odds ratio = 2.062, 2 = 77.961, p <.001); experience a perceptual error (odds ratio = 3.179, 2 = 118.350, p <.001); and commit a violation (odds ratio = 29.960, 2 = 2454.198, p <.001) than RoGA. The injury severity for VFR-IMC accidents was much greater than for RoGA (80.3% vs. 18.8%). RoGA pilots held a higher number of multiple certificates and earned more flight hours across the board than the VFR-IMC pilots. These data provide a more detailed view of the VFR into IMC accidents and will facilitate the development of future data-driven intervention strategies. Current interventions include weather cameras and other pilot aids for decision making with regard to weather

Human Error and Commercial Aviation Accidents: A Comprehensive, Fine-Grained Analysis Using HFACS

The Human Factors Analysis and Classification System (HFACS) is a theoretically based tool for investigating and analyzing human error associated with accidents and incidents. Previous research has shown that HFACS can be reliably used to identify general trends in the human factors associated with military and general aviation accidents. The aim of this study was to extend previous examinations of aviation accidents to include specific aircrew, environmental, supervisory, and organizational factors associated with 14 CFR Part 121 (Air Carrier) and 14 CFR Part 135 (Commuter) accidents using HFACS. The majority of causal factors were attributed to the aircrew and the environment, with decidedly fewer associated with supervisory and organizational causes. Comparisons were made between HFACS categories and traditional situational variables such as weather, lighting, and geographic region. Recommendations were made based on the HFACS findings presented

Human Error and General Aviation Accidents: A Comprehensive, Fine-Grained Analysis Using HFACS

The Human Factors Analysis and Classification System (HFACS) is a theoretically based tool for investigating and analyzing human error associated with accidents and incidents. Previous research performed at both the University of Illinois and the Civil Aerospace Medical Institute has successfully shown that HFACS can be reliably used to analyze the underlying human causes of both commercial and general aviation (GA) accidents. These analyses have helped identify general trends in the types of human factors issues and aircrew errors that have contributed to civil aviation accidents. The next step was to identify the exact nature of the human errors identified. The purpose of this research effort therefore, was to address these questions by performing a fine-grained HFACS analysis of the individual human causal factors associated with GA accidents and to assist in the generation of intervention programs. This report details those findings and offers an approach for developing interventions to address them

Human Error and Commercial Aviation Accidents: An Analysis Using the Human Factors Analysis and Classification System

The aim of this study was to extend previous examinations of aviation accidents to include specific aircrew, environmental, supervisory, and organizational factors associated with two types of commercial aviation (air carrier and commuter/on-demand) accidents using the Human Factors Analysis and Classification System (HFACS)

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This document is disseminated under the sponsorship of the U.S. Department of Transportation in the interest of information exchange. The United States Government assumes no liability for the contents thereof. ___________ This publication and all Office of Aerospace Medicine technical reports are available in full-text from the Civil Aerospace Medical Institute’s publications Web site: www.faa.gov/library/reports/medical/oamtechreports/index.cfm Technical Report Documentation Pag