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

Clemson University, Department of Industrial Engineering, 121 Freeman Hall, Box 340920, Clemson, SC 29634-0920, USA.
Human Factors The Journal of the Human Factors and Ergonomics Society (Impact Factor: 1.69). 05/2007; 49(2):227-42. DOI: 10.1518/001872007X312469
Source: PubMed


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).
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 human factors trends associated with military and general aviation accidents.
Using data obtained from both the National Transportation Safety Board and the Federal Aviation Administration, 6 pilot-raters classified aircrew, supervisory, organizational, and environmental causal factors associated with 1020 commercial aviation accidents that occurred over a 13-year period.
The majority of accident causal factors were attributed to aircrew and the environment, with decidedly fewer associated with supervisory and organizational causes. Comparisons were made between HFACS causal categories and traditional situational variables such as visual conditions, injury severity, and regional differences.
These data will provide support for the continuation, modification, and/or development of interventions aimed at commercial aviation safety.
HFACS provides a tool for assessing human factors associated with accidents and incidents.

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    • "HFACS was first developed for the aviation accident investigation (Shappell and Wiegmann, 2000, 2001). In the last decade, the HFACS model was not only successfully applied in the aviation industry by Shappell et al. (2007), but also in the railway (Reinach and Viale, 2006) and mining industry (Patterson and Shappell, 2010). For instance, the study of Rothblum et al. (2002) was the pioneer scientific research that aimed to investigate human factor in maritime accidents. "
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    ABSTRACT: This research proposes a proactive modelling approach that combines Fuzzy Cognitive Mapping (FCM) and Human Factors Analysis and Classification System (HFACS). Principally, the suggested model helps predicting and eliminating the root causes behind the frequently repeating deficiencies on board ships. Supported with qualitative simulations, the HFACS–FCM model is demonstrated on a fire related deficiency sample database. The findings indicate that the root causes of a fire related deficiency on board ship might be revealed in various levels such as unsafe acts, pre-conditions for unsafe acts, unsafe supervision, and organization influences. Considering the determined root causes and their priorities, the Safe Ship System Mechanism (SSSM), Safe Ship Operation Mechanism (SSOM), and Safe Ship Execution Mechanism (SSEM) are constituted. Consequently, the paper has added value to both predicting the root causes and enhancing fire-fighting potential which provides reasonable contributions to safety improvements at sea.
    Full-text · Article · Aug 2015 · Safety Science
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    • "The framework was further developed to also cover other causal factors than human factors, namely environmental factors like machinery failures and meteorological conditions (Wiegmann et al., 2005). The success of the method in detecting the contributing latent and active failures in the accident analysis made the method popular in the field of accident analysis that is vastly used in analysis of civil aviation accidents (Shappell et al., 2007) as well as the accidents in other domains like railroad (Reinach and Viale, 2006) and maritime (Chen and Chou, 2012; Chen et al., 2013). Reinach and Viale (2006) have further developed the method by adding the fifth level, namely ''external factors'', to the initial four levels in order to cover the latent failures that come from outside a particular domain. "
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    ABSTRACT: This paper presents study of 115 grounding accident reports from the Safety Investigation Authority of Finland and Marine Accident Investigation Branch of the UK, as well as 163 near-miss grounding reports from ForeSea and Finnpilot incident databases. The objective was to find the type of knowledge that can be extracted from such sources and discuss the usability of accident and incident reports for evidence-based risk modeling. A new version of Human Factors Analysis and Classification System (HFACS) is introduced as a framework to review the accident reports. The new positive taxonomy as Safety Factors, which are based on high level positive functions that are prerequisite for safe transport operations, is used for reviewing the incident reports. Accident reports are shown as a reliable source of evidence to extract the most significant contributing factors in the events. Mandatory incident reports are considered useful for understanding the effective barriers as risk control measures. Voluntary incident reports, though, are seen as not very reliable in their current form to be used for evidence-based risk modeling.
    Full-text · Article · Jul 2015 · Safety Science
    • "The percentage of each type of error varies every year but remains relatively constant; no obvious increasing or decreasing trend can be interpreted from the lines. However, when compared to previous work examining commercial aviation accidents from 1990 to 2002, the proportion of violations grows from around 20% -30% (Shappell, et al., 2007) to around 40%-50%. Since it is difficult to differentiate between routine and exceptional violations simply from the description of the investigation report for a single occurrence, violations are discussed together in the study. "
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    ABSTRACT: In order to provide insight into the emerging human factors risks in North American commercial aviation operations, this paper identifies the major aircrew human errors in recent airline operation accidents and incidents. The Human Factors Analysis and Classification System (HFACS) was used to categorize 267 accident and incident final reports, obtained from National Transportation Safety Board and Transportation Safety Board of Canada investigation report databases from 2006 to 2010. The results show that Unsafe Acts and Preconditions of Unsafe Acts are still the most prominent human factors risks, whereas trend analysis for 10 major HFACS categories shows that the violation increases compared to previous study. The study also finds that Crew Resource Management is still one of the prominent causal factors and that there is a growing demand for training. The study will support safety departments developing corresponding risk mitigation methods to improve aviation safety.
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