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

Developing Proactive Methods for General Aviation Data Collection

Introduction. Over the last 20 years, nearly 40,000 general aviation (GA) aircraft were involved in accidents, roughly 20% of which were fatal. To address this safety concern, scientists have often relied on accident data. Because of the rare nature of accidents, commercial aviation incident and near miss data may prove to be useful sources of safety information. In one such study, the National Transportation Safety Board interviewed GA pilots that were flying near a weather-related accident in pursuit of a different perspective than that of the accident pilot. Interviewing GA pilots about their own weather-related event may provide similar benefits. Method. To understand factors leading GA pilots to encounter adverse weather conditions, pilots involved in an adverse weather encounter were interviewed using a one-hour structured interview. The interview was developed using surveys utilized by National Aeronautics and Space Administration and the Federal Aviation Administration (FAA). In total, 27 pilots who experienced an adverse weather encounter were interviewed, of which 25 were included in the final analysis. Results. Previous studies conducted by the FAA and others found many GA accidents involving flight into adverse weather were categorized as a willful disregard for the rules and regulations of safety; violations as defined by the Human Factors Analysis and Classification System. Contrary to what the accident record seems to suggest, flight into adverse weather may also be influenced by the lack of appreciation/understanding of the hazards associated with adverse weather. Perhaps some encounters with adverse weather were motivated by outside influences or exacerbated by some manner of mechanical failure that may have led to the willful acceptance of unnecessary hazards. Conclusions. These data suggest that current beliefs surrounding flight into adverse weather by GA pilots may be incomplete. The data presented here suggest that additional effort should be placed in training, both ab initio and recurrent. Emphasis should be placed on ensuring a full understanding of the adverse impact of weather, including the recognition of instrument meteorological conditions, icing, convective events, etc. Likewise, with the proliferation of commercial weather products and on-board weather equipment, it may be time to move toward some form of standard weather package that all pilots would review before flying

General Aviation Weather Encounter Case Studies

This study presents a compilation of 24 cases involving general aviation (GA) pilots’ weather encounters over the continental U.S. The project team interviewed pilots who had experienced a weather encounter, and we examined their backgrounds, flight experience, and weather encounter details. Results from meteorological data analysis for each weather encounter were consistent with findings of larger GA weather accident studies in terms of the types of hazards encountered and flight phase during which the encounters occurred. Investigation of pilot weather products and the sources from which they were obtained revealed a lack of uniformity of pre-flight data sources and underutilization of available en route flight information services. The team used these results to develop a set of pilot weather education and training recommendations intended to reduce the number and severity of weather encounters

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)