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7/28/2019 A Human Error Analysis of Commercial Aviation Accidents Using the Human Factors Analysis and Classification Sys
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DOT/FAA/AM-01/3
OfficeofAviationMedicineWashington,D.C.20591
A Human Error Analysis ofCommercial Aviation AccidentsUsing the Human Factors
Analysis and ClassificationSystem (HFACS)
DouglasA.WiegmannUniversityofIllinoisatUrbana-ChampaignInstituteofAviationSavoy,IL61874
ScottA.ShappellFAACivilAeromedicalInstituteP.O.Box25082OklahomaCity,OK73125
February2001
FinalReport
Thisdocumentisavailabletothepublic
throughtheNationalTechnicalInformation
Service,Springfield,Virginia 22161.
U.S. Departmentof Transpor tation
Federal Aviation
Administration
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NONONONOTICETICETICETICENOTICE
ThisdocumentisdisseminatedunderthesponsorshipoftheU.S.DepartmentofTransportationintheinterestofinformationexchange.TheUnitedStatesGovernment
assumesnoliabilityforthecontentsthereof.
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TechnicalReportDocumentationPage
1. Report No.
DOT/FAA/AM-01/3
2. Government Accession No. 3. Recipient'sCatalog No.
4. Title and Subtitle
A Human Error Analysis of Commercial Aviation AccidentsUsing the Human Factors Analysis and Classification System (HFACS)
5. Report Date
February 2001
6. Performing OrganizationCode
7. Author(s)
Wiegmann,D.A.1, andShappell, S.A.28. Performing OrganizationReportNo.
9. Performing OrganizationName and Address
1University of Illinois at Urbana-Champaign, Institute of Aviation,
Savoy, IL 618742FAA Civil Aeromedical Institute, P.O. Box 25082, Oklahoma City, OK 73125
10. Work Unit No. (TRAIS)
11. Contract orG rantNo.
99-G-00612. Sponsoring Agency name and Address
Office of Aviation Medicine
Federal Aviation Administration800 Independence Ave., S.W.Washington, DC 20591
13. Type of Report and Period Covered
14. Sponsoring Agency Code
15. Supplemental Notes
Work was accomplished under task # AAM-A-00-HRR-520.16. Abstract
The Human Factors Analysis and Classification System (HFACS) is a general human error frameworkoriginally developed and tested within the U.S. military as a tool for investigating and analyzing the humancauses of aviation accidents. Based upon Reasons (1990) model of latent and active failures, HFACSaddresses human error at all levels of the system, including the condition of aircrew and organizationalfactors. The purpose of the present study was to assess the utility of the HFACS framework as an erroranalysis and classification tool outside the military. Specifically, HFACS was applied to commercial aviationaccident records maintained by the National Transportation Safety Board (NTSB). Using accidents thatoccurred between January 1990 and December 1996, it was demonstrated that HFACS reliablyaccommodated all human causal factors associated with the commercial accidents examined. In addition, theclassification of data using HFACS highlighted several critical safety issues in need of intervention research.These results demonstrate that the HFACS framework can be a viable tool for use within the civil aviationarena.
17. KeyWordsAviation, Human Error, Accident Investigation,Database Analysis, Commercial Aviation
18. Distribution StatementDocument is available to the public through theNational Technical Information Service,Springfield, Virginia 22161
19. SecurityClassif. (of this report)
Unclassified20. SecurityClassif. (of thispage)
Unclassified21. No. of Pages
1722. Price
FormDOTF1700.7 (8-72) Reproductionofcompletedpageauthorized
i
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ACKNOWLEDGMENTS
The authors thank Frank Cristina and AnthonyPape for their assistance in gathering,
organizingandanalyzingtheaccidentreportsusedinthisstudy.
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A HUMAN ERRORANALYSIS OF COMMERCIALAVIATION ACCIDENTS USING THE
HUMAN FACTORS ANALYSIS AND CLASSIFICATION SYSTEM (HFACS)
INTRODUCTION
Humans,bytheirverynature,makemistakes;there-fore,itshouldcomeasnosurprisethathumanerrorhasbeenimplicatedinavarietyofoccupationalaccidents,including70%to80%ofthoseincivilandmilitaryaviation (OHare,Wiggins,Batt,&Morrison,1994;Wiegmann and Shappell, 1999; Yacavone, 1993). Infact,whilethenumberofaviationaccidentsattributablesolelytomechanicalfailurehasdecreasedmarkedlyoverthepast40years,thoseattributableatleastinpartto
humanerrorhavedeclinedatamuchslowerrate(Shappell&Wiegmann,1996). Given such findings, itwouldappearthatinterventionsaimedatreducingtheoccur-renceorconsequencesofhumanerrorhavenotbeenaseffectiveasthosedirectedatmechanicalfailures.Clearly,ifaccidentsaretobereducedfurther,moreemphasismustbeplacedonthegenesisofhumanerrorasitrelatestoaccidentcausation.Theprevailingmeansofinvestigatinghumanerrorin
aviationaccidentsremainstheanalysisofaccidentandincidentdata.Unfortunately,mostaccidentreportingsystemsarenotdesignedaroundanytheoreticalframe-workofhumanerror. Indeed,mostaccidentreportingsystemsaredesignedandemployedbyengineersandfront-lineoperatorswithonlylimitedbackgroundsinhumanfactors.Asaresult,thesesystemshavebeenusefulforidentifyingengineeringandmechanicalfailuresbutare relatively ineffective and narrow in scope wherehumanerrorexists.Evenwhenhumanfactorsaread-dressed,thetermsandvariablesusedareoftenill-definedand archivaldatabasesarepoorlyorganized.The endresultsarepost-accidentdatabasesthattypicallyarenotconducivetoatraditionalhumanerroranalysis,making
the identification of intervention strategies onerous(Wiegmann&Shappell,1997).
The Accident Investigation ProcessTofurtherillustratethispoint,letusexaminethe
accident investigation and intervention process sepa-ratelyforthemechanicalandhumancomponentsofanaccident.Consider first the occurrence of anaircraftsystemormechanicalfailurethatresultsinanaccidentor
injury(Figure1).Asubsequentinvestigationtakesplacethatincludestheexaminationofobjectiveandquantifi-ableinformation,suchasthatderivedfromthewreckageandflightdatarecorder,aswellasthatfromtheapplica-tionofsophisticatedanalyticaltechniqueslikemetallur-gical tests and computer modeling. This kind ofinformation is then used to determine the probablemechanicalcause(s)oftheaccidentandtoidentifysafetyrecommendations.Uponcompletionoftheinvestigation,thisobjec-
tive information is typically entered into a highly-
structuredandwell-defined accident database.Thesedata can then be periodically analyzed to determinesystem-widesafetyissuesandprovidefeedbacktoinves-tigators,therebyimprovinginvestigativemethodsandtechniques.Inaddition,thedataareoftenusedtoguideorganizations(e.g.,theFederalAviationAdministration[FAA],NationalAeronauticsandSpaceAdministration[NASA],DepartmentofDefense[DoD],airplanemanu-facturers and airlines) in deciding which research orsafetyprograms to sponsor. As a result, theseneeds-based, data-driven programs, in turn, have typicallyproduced effective intervention strategies that eitherpreventmechanicalfailuresfromoccurringaltogether,ormitigatetheirconsequenceswhentheydohappen.Ineithercase,therehasbeenasubstantialreductionintherateofaccidentsduetomechanicalorsystemsfailures.In stark contrast, Figure 2 illustrates the current
human factors accident investigation andpreventionprocess.Thisexamplebeginswiththeoccurrenceofanaircrewerrorduringflightoperationsthatleadstoanaccidentorincident.Ahumanperformanceinvestiga-tionthenensuestodeterminethenatureandcausesofsucherrors.However,unlikethetangibleandquantifi-
ableevidencesurroundingmechanicalfailures,theevi-denceandcausesofhumanerroraregenerallyqualitativeandelusive.Furthermore,humanfactorsinvestigativeand analytical techniques are often less refined andsophisticatedthanthoseusedtoanalyzemechanicalandengineering concerns.As such, the determination ofhumanfactorscausaltotheaccidentisatenuouspracticeatbest;allofwhichmakestheinformationenteredintheaccidentdatabasesparseandill-defined.
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Feedback
MechanicalFailure
- Catastrophicfailuresareinfrequentevents
- Whenfailuresdooccur,theyareoftenlesssevereorhazardousduetoeffectiveinterventionprograms.
Data-DrivenResearch
ResearchSponsors- FAA,DoD,NASA,&airplane
manufacturers provideresearchfunding.
- Research programsareneeds-basedanddata-driven.Interventions
are
therefore
veryeffective.
AccidentInvestigation
- Highlysophisticatedtechniquesandprocedures
- Informationisobjectiveandquantifiable
- Effectiveatdeterminingwhythefailureoccurred
AccidentDatabase
- Designedaroundtraditionalcategories
- Variablesarewell-definedandcausallyrelated
- Organizationandstructurefacilitateaccessanduse
DatabaseAnalysis
- Traditionalanalysesareclearlyoutlinedandreadilyperformed.
- Frequentanalyseshelp identifycommonmechanicalandengineeringsafetyissues.
Mitigation
Preve
ntion
EffectiveIntervention
andPreventionPrograms
Figure 1. General process of investigating and preventing aviation accidents involving mechanical orsystems failures.
As a result,when traditional data analyses areper-formedtodeterminecommonhumanfactorsproblems
acrossaccidents,theinterpretationofthefindingsandthesubsequentidentificationofimportantsafetyissuesareof limitedpractical use. Tomakematters worse,resultsfromtheseanalysesprovidelimitedfeedbacktoinvestigatorsandareoflimitedusetoairlinesandgovern-mentagenciesindeterminingthetypesofresearchorsafety programs to sponsor. As such, many researchprogramstendtobeintuitively-,orfad-driven,ratherthan data-driven, and typically produce interventionstrategiesthatareonlymarginallyeffectiveatreducingtheoccurrenceandconsequenceofhumanerror.Theoverallrateofhuman-errorrelatedaccidents,therefore,
hasremainedrelativelyhighandconstantoverthelastseveralyears(Shappell&Wiegmann,1996).
Addressing the ProblemIftheFAAandtheaviationindustryaretoachieve
theirgoalofsignificantlyreducingtheaviationaccidentrateoverthenexttenyears,theprimarycausesofaviationaccidents(i.e.,humanfactors)mustbeaddressed(ICAO,1993). However, as illustrated in Figure 2, simply
increasingtheamountofmoneyandresourcesspentonhumanfactorsresearchisnotthesolution.Indeed,a
greatdealofresourcesandeffortsarecurrentlybeingexpended.Rather,thesolutionistoredirectsafetyeffortsso that they address important human factors issues.However,thisassumesthatweknowwhattheimportanthuman factors issues are. Therefore, before researcheffortscanbesystematicallyrefocused,acomprehensiveanalysisofexistingdatabasesneedstobeconductedtodeterminethosespecifichumanfactorsresponsibleforaviationaccidentsandincidents.Furthermore,iftheseeffortsaretobesustained,newinvestigativemethodsandtechniqueswillneedtobedevelopedsothatdatagath-eredduringhumanfactorsaccidentinvestigationscanbe
improvedandanalysisoftheunderlyingcausesofhumanerrorfacilitated.Toaccomplishthisimprovement,ageneralhuman
errorframeworkisneededaroundwhichnewinvestiga-tivemethodscanbedesignedandexistingpostaccidentdatabasesrestructured.Previousattemptstodothishavemetwithencouraging,yetlimited,success(OHare,etal.,1994;Wiegmann&Shappell,1997).Thisisprima-rily because performance failures are influenced bya
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Feedback
HumanError
- Errorsoccurfrequentlyandarethemajorcauseofaccidents.
- Fewsafetyprogramsareeffectiveatpreventingtheoccurrenceorconsequencesoftheseerrors.
ResearchSponsors- FAA,DoD,NASA,&Airlines
providefundingforsafetyresearchprograms.
- Lackofgooddataleadstoresearch programsbasedprimarily
on
interests
and
intuitions.Interventionsarethereforelesseffective.
Fad-DrivenResearch
Mitigation
Preve
ntion
IneffectiveInterventionandPreventionPrograms
AccidentInvestigation
- Lesssophisticatedtechniquesandprocedures
- Informationisqualitativeandillusive
- Focusonwhathappenedbutnotwhyithappened
AccidentDatabase
- Notdesignedaroundanyparticularhumanerrorframework
- Variablesoftenill-defined
- Organizationandstructuredifficulttounderstand
DatabaseAnalysis
- Traditionalhumanfactorsanalysesareonerousduetoill-definedvariablesanddatabasestructures.
- Fewanalyseshavebeenperformedtoidentifyunderlyinghumanfactorssafetyissues.
Figure 2. General process of investigating and preventing aviation accidents involving human error.
varietyofhumanfactorsthataretypicallynotaddressedbytraditionalerrorframeworks.Forinstance,withfew
exceptions(e.g.,Rasmussen,1982),humanerrortax-onomiesdonotconsiderthepotentialadversementalandphysiologicalconditionoftheindividual(e.g.,fa-tigue,illness,attitudes)whendescribingerrorsinthecockpit.Likewise,latenterrorscommittedbyofficialswithinthemanagementhierarchysuchaslinemanagersandsupervisorsareoftennotaddressed,eventhoughitiswell known that these factors directly influence theconditionanddecisionsofpilots(Reason,1990).There-fore,ifacomprehensiveanalysisofhumanerroristobeconducted, a taxonomy that takes into account themultiplecausesofhumanfailuremustbeoffered.
Recently,theHumanFactorsAnalysisandClassifica-tionSystem(HFACS)wasdevelopedtomeettheseneeds(Shappell&Wiegmann,1997a,2000a,andinpress).Thissystem,whichisbasedonReasons(1990)modeloflatentandactivefailures,wasoriginallydevelopedfortheU.S.NavyandMarineCorpsasanaccidentinvestigationanddataanalysistool.Sinceitsoriginaldevelopment,however,HFACShasbeenemployedbyothermilitary
organizations(e.g.,U.S.Army,AirForce,andCanadianDefenseForce) as anadjunct topreexistingaccidentinvestigationandanalysissystems.Todate,theHFACSframeworkhasbeenappliedtomorethan1,000militaryaviationaccidents,yieldingobjective,data-driveninter-ventionstrategieswhileenhancingboththequantityandqualityofhumanfactorsinformationgatheredduringaccidentinvestigations(Shappell&Wiegmann,inpress).OtherorganizationssuchastheFAAandNASAhave
exploredtheuseofHFACSasacomplementtopreexist-ingsystemswithincivilaviationinanattempttocapital-izeongainsrealizedbythemilitary(Ford,Jack,Crisp,&Sandusky,1999).Still,fewsystematiceffortshaveexam-inedwhetherHFACSisindeedaviabletoolwithinthe
civilaviationarena,eventhoughitcanbearguedthatthesimilaritiesbetweenmilitaryandcivilianaviationout-weightheirdifferences.Thepurposeofthepresentstudywas to empirically address this issue by applying theHFACSframework,asoriginallydesignedforthemili-tary,totheclassificationandanalysisofcivilaviationaccidentdata.Beforebeginning,however,abriefover-viewoftheHFACSsystemwillbepresentedforthose
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readerswhomaynotbefamiliarwiththeframework(fora detailed description of HFACS, see Shappell andWiegmann,2000aand2001).
HFACSDrawinguponReasons(1990)conceptoflatentand
activefailures,HFACSdescribeshumanerrorateachoffourlevelsoffailure:1)unsafeactsofoperators(e.g.,aircrew), 2) preconditions for unsafe acts, 3) unsafesupervision, and4)organizational influences.A briefdescriptionofeachcausalcategoryfollows(Figure3).
Unsafe Acts of OperatorsTheunsafeactsofoperators(aircrew)canbeloosely
classifiedintooneoftwocategories:errorsandviolations(Reason,1990).Whilebotharecommonwithinmostsettings,theydiffermarkedlywhentherulesandregula-tionofanorganizationareconsidered.Thatis,errorscanbedescribedasthoselegalactivitiesthatfailtoachieve
theirintendedoutcome,whileviolationsarecommonlydefinedasbehaviorthatrepresentsthewillfuldisregardfor the rules and regulations. It iswithin these twooverarchingcategoriesthatHFACSdescribesthreetypesoferrors(decision,skill-based,andperceptual)andtwotypesofviolations(routineandexceptional).
ErrorsOneofthemorecommonerrorforms,decision errors,
representsconscious,goal-intendedbehaviorthatpro-ceedsasdesigned;yet,theplanprovesinadequateorinappropriate for the situation.Often referred to ashonestmistakes,theseunsafeactstypicallymanifestaspoorlyexecutedprocedures,improperchoices,orsimplythemisinterpretationormisuseofrelevantinformation.Incontrasttodecisionerrors,theseconderrorform,
skill-based errors,occurswithlittleornoconsciousthought.Just as little thought goes into turning ones steeringwheel or shifting gears in an automobile, basic flight
PerceptualErrorsSkill-BasedErrors
UNSAFEACTS
Errors
DecisionErrors ExceptionalRoutine
Violations
InadequateSupervision
PlannedInappropriate
OperationsFailedtoCorrectProblem
SupervisoryViolations
UNSAFESUPERVISION
PRECONDITIONSFOR
UNSAFEACTS
SubstandardConditionsof
Operators
PRECONDITIONSFOR
UNSAFEACTS
AdversePhysiologicalStates
Physical/Mental
LimitationsAdverseMental
States PersonalReadinessCrewResourceMismanagement
SubstandardPracticesofOperators
ResourceManagement
OrganizationalClimate OrganizationalProcess
ORGANIZATIONALINFLUENCES
Figure 3. Overview of the Human Factors Analysis and Classification System (HFACS).
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skillssuchasstickandruddermovementsandvisualscanningoftenoccurwithoutthinking.Thedifficultywith these highly practiced and seemingly automaticbehaviors is that they are particularly susceptible toattentionand/ormemoryfailures.Asaresult,skill-basederrorssuchasthebreakdowninvisualscanpatterns,
inadvertentactivation/deactivationofswitches,forgot-tenintentions, andomitted items inchecklists oftenappear.Eventhemanner(orskill)withwhichonefliesanaircraft(aggressive,tentative,orcontrolled)canaffectsafety.While, decision and skill-based errors have domi-
natedmostaccidentdatabasesandtherefore,havebeenincludedinmosterrorframeworks,thethirdandfinalerrorform,perceptual errors,hasreceivedcomparativelylessattention.Nolessimportant,perceptualerrorsoccurwhensensoryinputisdegraded,orunusual,asisoftenthecasewhenflyingatnight,intheweather,orinothervisuallyimpoverishedenvironments.Facedwithactingonimperfectorlessinformation,aircrewruntheriskofmisjudgingdistances,altitude,anddecentrates,aswellasarespondingincorrectlytoavarietyofvisual/vestibu-larillusions.
ViolationsAlthoughtherearemanywaystodistinguishamong
typesofviolations,twodistinctformshavebeenidenti-fiedbasedontheiretiology.Thefirst,routine violations,tendtobehabitualbynatureandareoftenenabledbya
systemof supervision andmanagement that toleratessuchdeparturesfromtherules(Reason,1990).Oftenreferredtoasbendingtherules,theclassicexampleisthat of theindividual who driveshis/her automobileconsistently5-10mphfasterthanallowedbylaw.Whileclearlyagainstthelaw,thebehavioris,ineffect,sanc-tionedbylocalauthorities(police)whooftenwillnotenforcethelawuntilspeedsinexcessof10mphoverthepostedlimitareobserved.
Exceptional violations,ontheotherhand,areisolateddeparturesfromauthority,neithertypicaloftheindi-vidual nor condoned bymanagement. For example,
whiledriving65ina55mphzonemightbecondonedbyauthorities,driving105mphina55mphzonecertainlywould not. It is important to note, that while mostexceptionalviolationsareappalling,theyarenotconsid-eredexceptionalbecauseoftheirextremenature.Rather,theyareregardedasexceptionalbecausetheyareneithertypicaloftheindividualnorcondonedbyauthority.
Preconditions for Unsafe ActsSimplyfocusingonunsafeacts,however,islikefocus-
ingonapatientssymptomswithoutunderstandingtheunderlyingdiseasestatethatcausedit.Assuch,investi-gatorsmustdigdeeperintothepreconditionsforunsafeacts.WithinHFACS,twomajorsubdivisionsarede-
scribed: substandard conditionsof operators and thesubstandardpracticestheycommit.
Substandard Conditions of the OperatorBeingpreparedmentally is critical innearly every
endeavor;perhapsitisevenmoresoinaviation.Withthisinmind,thefirstofthreecategories,adverse mentalstates,wascreatedtoaccountforthosementalconditionsthatadverselyaffectperformance.Principalamongtheseare the loss of situational awareness,mental fatigue,circadiandysrhythmia,andperniciousattitudessuchasoverconfidence,complacency,andmisplacedmotiva-tionthatnegativelyimpactdecisionsandcontributetounsafeacts.Equallyimportant,however,arethose adverse physi
ological statesthatprecludethesafeconductofflight.Particularlyimportanttoaviationareconditionssuchasspatialdisorientation,visualillusions,hypoxia,illness,intoxication,andawholehostofpharmacologicalandmedicalabnormalitiesknowntoaffectperformance.Forexample,itisnotsurprisingthat,whenaircrewsbecomespatiallydisorientedandfailtorelyonflightinstrumen-tation,accidentscan,andoftendo,occur.
Physical and/or mental limitationsoftheoperator,thethirdandfinalcategoryofsubstandardcondition,in-cludesthoseinstanceswhennecessarysensoryinforma-tion is either unavailable, or if available, individualssimplydonothavetheaptitude,skill,ortimetosafelydealwithit.Foraviation,theformeroftenincludesnotseeingotheraircraftorobstaclesduetothesizeand/orcontrastoftheobjectinthevisualfield.However,therearemany timeswhen a situationrequires such rapidmentalprocessingorreactiontimethatthetimeallottedtoremedytheproblemexceedshumanlimits(asisoftenthecaseduringnap-of-the-earthflight).Nevertheless,
evenwhenfavorablevisualcuesoranabundanceoftimeisavailable,thereareinstanceswhenanindividualsimplymaynotpossessthenecessaryaptitude,physicalability,orproficiencytooperatesafely.
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Substandard Practices of the OperatorOftentimes,thesubstandardpracticesofaircrewwill
leadtotheconditionsandunsafeactsdescribedabove.Forinstance,thefailuretoensurethatallmembersofthecrewareactinginacoordinatedmannercanleadtoconfusion(adversementalstate)andpoordecisionsin
thecockpit.Crew resource mismanagement,asitisre-ferredtohere,includesthefailuresofbothinter-andintra-cockpitcommunication,aswellascommunicationwithATCandothergroundpersonnel.Thiscategoryalsoincludesthoseinstanceswhencrewmembersdonotwork together asa team,orwhen individualsdirectlyresponsiblefortheconductofoperationsfailtocoordi-nateactivitiesbefore,during,andafteraflight.Equallyimportant,however,individualsmustensure
that they are adequately prepared for flight.Conse-quently,thecategoryofpersonal readinesswascreatedtoaccountforthoseinstanceswhenrulessuchasdisregard-ingcrewrestrequirements,violatingalcoholrestrictions,orself-medicating,arenotadheredto.However,evenbehaviorsthatdonotnecessarilyviolateexistingrulesorregulations(e.g.,runningtenmilesbeforepilotinganaircraft ornotobservinggooddietary practices)mayreducetheoperatingcapabilitiesoftheindividualandare,therefore,capturedhere.
Unsafe SupervisionClearly,aircrewsareresponsiblefortheiractionsand,
assuch,mustbeheldaccountable.However,inmany
instances, they are theunwitting inheritors of latentfailuresattributabletothosewhosupervisethem(Rea-son, 1990). To account for these latent failures, theoverarchingcategoryofunsafesupervisionwascreatedwithinwhich four categories (inadequate supervision,plannedinappropriateoperations,failedtocorrectknownproblems,andsupervisoryviolations)areincluded.The firstcategory, inadequate supervision,refersto
failureswithinthesupervisorychainofcommand,whichwasadirectresultofsomesupervisoryactionorinaction.Thatis,ataminimum,supervisorsmustprovidetheopportunityforindividualstosucceed.Itisexpected,
therefore,thatindividualswillreceiveadequatetraining,professionalguidance,oversight,andoperationalleader-ship,andthatallwillbemanagedappropriately.Whenthisisnotthecase,aircrewsareoftenisolated,astheriskassociatedwith day-to-day operations invariably willincrease.However,theriskassociatedwithsupervisoryfailures
cancomeinmanyforms.Occasionally,forexample,theoperationaltempoand/orscheduleisplannedsuchthat
individualsareputatunacceptableriskand,ultimately,performanceisadverselyaffected.Assuch,thecategoryofplanned inappropriate operationswas created to ac-countforallaspectsofimproperorinappropriatecrewschedulingandoperationalplanning,whichmayfocusonsuchissuesascrewpairing,crewrest,andmanaging
theriskassociatedwithspecificflights.Theremainingtwocategoriesofunsafesupervision,
thefailure to correct known problems and supervisoryviolations,aresimilar,yetconsideredseparatelywithinHFACS.Thefailuretocorrectknownproblemsreferstothose instanceswhendeficiencies among individuals,equipment, training,or other relatedsafetyareas areknowntothesupervisor,yetareallowedtocontinueuncorrected. For example, the failure to consistentlycorrect or discipline inappropriate behavior certainlyfostersan unsafe atmospherebut isnot consideredaviolationifnospecificrulesorregulationswerebroken.Supervisoryviolations,ontheotherhand,arereserved
forthoseinstanceswhenexistingrulesandregulationsarewillfullydisregardedbysupervisorswhenmanagingassets.For instance,permitting aircrew tooperate anaircraft without current qualifications or license is aflagrantviolationthatinvariablysetsthestageforthetragicsequenceofeventsthatpredictablyfollow.
Organizational InfluencesFallible decisions of upper-level management can
directlyaffectsupervisorypractices,aswellasthecondi-
tionsandactionsofoperators.Unfortunately,theseorganizational influencesoftengounnoticedorunreportedbyeventhebest-intentionedaccidentinvestigators.Traditionally,theselatentorganizationalfailuresgen-
erallyrevolvearoundthreeissues:1)resourcemanage-ment, 2) organizational climate, and 3) operationalprocesses.Thefirstcategory,resource management,refersto themanagement, allocation, and maintenance oforganizational resources, including human resourcemanagement (selection, training, staffing), monetarysafetybudgets,andequipmentdesign(ergonomicspeci-fications). In general, corporate decisions about how
suchresourcesshouldbemanagedcenteraroundtwodistinctobjectivesthegoalofsafetyandthegoalofon-time,cost-effectiveoperations.Intimesofprosperity,bothobjectivescanbeeasilybalancedandsatisfiedinfull.However,theremayalsobetimesoffiscalausteritythat demand some give and take between the two.Unfortunately,historytellsusthatsafetyisoftentheloserinsuchbattles,assafetyandtrainingareoftenthefirsttobecutinorganizationsexperiencingfinancialdifficulties.
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Organizational climatereferstoabroadclassoforga-nizationalvariablesthatinfluenceworkerperformanceandisdefinedasthesituationallybasedconsistenciesintheorganizationstreatmentofindividuals(Jones,1988).One telltale sign of an organizations climate is itsstructure,asreflectedinthechain-of-command,delega-
tion of authority and responsibility, communicationchannels,andformalaccountabilityforactions.Justlikein thecockpit, communication andcoordination arevitalwithinanorganization.However,anorganizationspoliciesandculturearealsogoodindicatorsofitscli-mate. Consequently, when policies are ill-defined,adversarial,orconflicting,orwhentheyaresupplantedbyunofficialrulesandvalues,confusionabounds,andsafetysufferswithinanorganization.Finally,operational processreferstoformalprocesses
(operationaltempo,timepressures,productionquotas,incentivesystems,schedules,etc.),procedures(perfor-mance standards, objectives, documentation, instruc-tionsaboutprocedures,etc.),andoversightwithintheorganization (organizational self-study, risk manage-ment,andtheestablishmentanduseofsafetyprograms).Poorupper-levelmanagementanddecisionsconcerningeach of these organizational factors can also have anegative,albeitindirect,effectonoperatorperformanceandsystemsafety.
SummaryThe HFACS framework bridges the gap between
theory and practice byproviding safetyprofessionalswithatheoreticallybasedtoolforidentifyingandclassi-fyingthehumancausesofaviationaccidents.Becausethesystemfocusesonbothlatentandactivefailuresandtheirinterrelationships,itfacilitatestheidentificationoftheunderlyingcausesofhumanerror.Todate,HFACShasbeenshowntobeusefulwithinthecontextofmilitaryaviation, as both a data analysis framework and anaccidentinvestigationtool.However,HFACShasyettobeappliedsystematicallytotheanalysisandinvestigationofcivilaviationaccidents.Thepurposeofthepresentresearchproject,therefore,wastoassesstheutilityofthe
HFACSframeworkasanerroranalysisandclassificationtoolwithincommercialaviation.Thespecificobjectivesofthisstudywerethree-fold.
ThefirstobjectivewastodeterminewhethertheHFACSframework,initscurrentform,wouldbecomprehensiveenoughtoaccommodatealloftheunderlyinghumancausal-factorsassociatedwithcommercialaviationacci-dents,ascontainedintheaccidentdatabasesmaintainedby the FAA and NTSB. In other words, could the
frameworkcapturealltherelevanthumanerrordataorwouldaportionofthedatabasebelostbecauseitwasunclassifiable?Thesecondobjectivewastodeterminewhether theprocess of reclassifying thehumancausalfactorsusingHFACSwasreliable.Thatis,woulddiffer-entusersofthesystemagreeonhowcausalfactorsshould
becodedusingtheframework?Finally,thethirdobjec-tivewastodeterminewhetherreclassifyingthedatausingHFACSyieldabenefitbeyondwhatisalreadyknownaboutcommercialaviationaccidentcausation.Specifi-cally,wouldHFACShighlightanyheretoforeunknownsafetyissuesinneedoffurtherinterventionresearch?
METHOD
DataA comprehensive review of all accidents involving
CodeofFederalAirRegulations(FAR)Parts121and135ScheduledAirCarriersbetweenJanuary1990andDecember1996wasconductedusingdatabaserecordsmaintainedbytheNTSBandtheFAA.Ofparticularinteresttothisstudywerethoseaccidentsattributable,atleastinpart,totheaircrew.Consequently,notincludedwereaccidentsduesolelytocatastrophicfailure,mainte-nanceerror,andunavoidableweatherconditionssuchasturbulence and wind shear. Furthermore, only thoseaccidentsinwhichtheinvestigationwascompleted,andthecauseoftheaccidentdetermined,wereincludedinthisanalysis.Onehundrednineteenaccidentsmetthese
criteria,including44accidentsinvolvingFARPart121operators and 75 accidents involving FAR Part 135operators.
HFACS ClassificationThe119aircrew-relatedaccidentsyielded319causal
factorsforfurtheranalyses.EachoftheseNTSBcausalfactorswassubsequentlycodedindependentlybybothanaviationpsychologistandacommercially-ratedpilotusingtheHFACSframework.OnlythosecausalfactorsidentifiedbytheNTSBwereanalyzed.Thatis,nonewcausalfactorswerecreatedduringtheerror-codingprocess.
RESULTS
HFACS ComprehensivenessAll319(100%)ofthehumancausalfactorsassociated
withaircrew-relatedaccidentswereaccommodatedus-ing theHFACSframework. Instances of all but twoHFACS categories (i.e., organizational climate andpersonal readiness)wereobservedasleastonceinthe
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accidentdatabase.Therefore,nonewHFACScategorieswereneededtocapturetheexistingcausalfactors,andnohumanfactorsdatapertainingtotheaircrewwereleftunclassifiedduringthecodingprocess.
HFACS ReliabilityDisagreementsamongraterswerenotedduringthe
codingprocessandultimatelyresolvedbydiscussion.Usingtherecordofagreementanddisagreementbe-tweentheraters,thereliabilityoftheHFACSsystemwasassessedbycalculatingCohenskappaanindexofagreementthathasbeencorrectedforchance.Theob-tainedkappavaluewas.71,whichgenerallyreflectsagoodlevelofagreementaccordingtocriteriadescribedbyFleiss(1981).
HFACS AnalysesUnsafe ActsTable1presentspercentagesofFARParts121and
135aircrew-relatedaccidentsassociatedwitheachoftheHFACScategories.Anexaminationofthetablerevealsthat at the unsafe acts level, skill-based errors were
associatedwiththelargestpercentageofaccidents.Ap-proximately60%ofallaircrew-relatedaccidentswereassociatedwithatleastoneskill-basederror.Thisper-centagewasrelativelysimilarforFARPart121carriers(63.6%)andFARPart135carriers(58.7%).Figure4,panel A, illustrates that the proportion of accidents
associatedwithskill-basederrorshasremainedrelativelyunchangedovertheseven-yearperiodexaminedinthestudy.Notably,however,thelowestproportionofacci-dentsassociatedwithskill-basederrorswasobservedinthelasttwoyearsofthestudy(1995and1996).Amongtheremainingcategoriesofunsafeacts,acci-
dentsassociatedwithdecisionerrorsconstitutedthenexthighestproportion(i.e.,roughly29%oftheaccidentsexamined,Table1).Again,thispercentagewasroughlyequalacrossbothFARPart121(25.0%)andPart135(30.7%)accidents.Withtheexceptionof1994,inwhichthe percentage of aircrew-related accidents associatedwithdecisionerrorsreachedahighof60%,thepropor-tion of accidents associated with decision errors re-mainedrelativelyconstantacrosstheyearsofthestudy(Figure4,panelB).
Table1.PercentageofAccidentsAssociatedwitheachHFACScategory.HFACSCategory FARPart121 FARPart135 TotalOrganizationalInfluencesResource
Management
4.5
(2)
1.3
(1)
2.5
(3)
OrganizationalClimate 0.0(0) 0.0(0) 0.0(0)OrganizationalProcess 15.9(7) 4.0(3) 8.4(10)
UnsafeSupervisionInadequateSupervision 2.3(1) 6.7(5) 5.0(6)PlannedInappropriateOperations 0.0(0) 1.3(1) 0.8(1)FailedtoCorrectKnownProblem 0.0(0) 2.7(2) 1.7(2)SupervisoryViolations 0.0(0) 2.7(2) 1.7(2)
PreconditionsofUnsafeActsAdverseMentalStates 13.6(6) 13.3(10) 13.4(16)AdversePhysiologicalSates 4.5(2) 0.0(0) 1.7(2)Physical/mentalLimitations 2.3(1) 16.0(12) 10.9(13)Crew-resource
Mismanagement
40.9
(18)
22.7
(17)
29.4
(35)
PersonalReadiness 0.0(0) 0.0(0) 0.0(0)
UnsafeActsSkill-basedErrors 63.6(28) 58.7(44) 60.5(72)DecisionErrors 25.0(11) 30.7(23) 28.6(34)PerceptualErrors 20.5(9) 10.7(8) 14.3(17)Violations 25.0(11) 28.0(21) 26.9(32)
Note:NumbersintablearepercentagesofaccidentsthatinvolvedatleastoneinstanceofanHFACScategory.Numbersinparenthesesindicateaccidentfrequencies.Becausemorethanonecausalfactorisgenerallyassociatedwitheachaccident,thepercentagesinthetablewillnotequal100%.
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0
10
20
30
40
50
60
70
80
90 91 92 93 94 95 96
Percentage
Year
A.
0
10
20
30
40
50
60
70
80
90 91 92 93 94 95 96
Percentage
Year
D.
0
10
20
30
40
50
60
70
80
90 91 92 93 94 95 96
Percentage
Year
C.
0
10
20
30
40
50
60
70
80
90 91 92 93 94 95 96
Percentage
Year
B.
Figure4.Percentage of aircrew related accidents associated with skill-based errors(Panel A), decision errors (Panel B), violations (Panel C) and CRM failures (Panel D)across calendar years. Lines represent seven year averages.
Similar to accidents associated with decision errors,those attributable at least in part to violations of rules andregulations were associated with 26.9% of the accidents
examined. Again, no appreciable difference was evidentwhen comparing the relative percentages across FARParts 121 (25.0%) and 135 (28.0%). However, anexamination of Figure 4, panel C, reveals that the relativeproportion of accidents associated with violations in-creased appreciably from a low of 6% in 1990 to a highof 46% in 1996.
Finally, the proportion of accidents associated withperceptual errors was relatively low. In fact, only 17 of the119 accidents (14.3%) involved some form of perceptualerror. While it appeared that the relative proportion ofPart 121 accidents associated with perceptual errors was
higher than Part 135 accidents, the low number ofoccurrences precluded any meaningful comparisons acrosseither the type of operation or calendar year.
Preconditions for Unsafe ActsWithin the preconditions level, CRM failures were
associated with the largest percentage of accidents. Ap-proximately 29% of all aircrew-related accidents wereassociated with at least one CRM failure. A relatively
larger percentage of FAR Part 121 aircrew-accidentsinvolved CRM failures (40.9%) than did FAR Part 135aircrew-related accidents (22.7%). However, the per-
centage of accidents associated with CRM failures re-mained relatively constant over the seven-year period forboth FAR Part 121 and 135 carriers (Figure 4, panel d).
The next largest percentage of accidents was associ-ated with adverse mental states (13.4%), followed byphysical/mental limitations (10.9%) and adverse physi-ological states (1.7%). There were no accidents associ-ated with personal readiness issues. The percentage ofaccidents associated with physical/mental limitation washigher for FAR Part 135 carriers (16%) compared withFAR Part 121 carriers (2.3%), but accidents associatedwith adverse mental or adverse physiological states were
relatively equal across carriers. Again, however, the lownumber of occurrences in each of these accident cat-egories precluded any meaningful comparisons acrosscalendar year.
Supervisory and Organizational FactorsVery few of the NTSB reports that implicated the
aircrew as contributing to an accident also cited someform of supervisory or organizational failure (see Table
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1).Indeed, only 16% ofallaircrew-relatedaccidentsinvolvedsomeformofeithersupervisoryororganiza-tionalinvolvement.Overall,however,alargerpropor-tionofaircrew-relatedaccidentsinvolvingFARPart135carriersinvolvedsupervisoryfailures(9.3%)thandidthoseaccidentsinvolvingFARPart121carriers(2.3%).
Incontrast,alargerproportionofaircrew-relatedacci-dentsinvolvingFARPart121carriersinvolvedorganiza-tionalfactors(20.5%)thandidthoseaccidentsinvolvingFARPart135carriers(4.0%).
DISCUSSION
HFACS ComprehensivenessTheHFACSframeworkwasfoundtoaccommodate
all319causalfactorsassociatedwiththe119accidentsinvolvingFARParts 121 and 135 scheduled carriersacross the seven-year period examined. This findingsuggeststhattheerrorcategorieswithinHFACS,origi-nallydevelopedforuseinthemilitary,areapplicablewithincommercial aviation aswell. Still, someof theerror-factorswithintheHFACSframeworkwereneverobservedinthiscommercialaviationaccidentdatabase.Forexample,noinstancesofsuchfactorsasorganiza-tionalclimateorpersonalreadinesswereobserved.Infact,veryfewinstancesofsupervisoryfactorswereevi-dentatallinthedata.Oneexplanationforthescarcityofsuchfactorscould
bethat,contrarytoReasonsmodeloflatentandactive
failuresuponwhichHFACSisbased,suchsupervisoryandorganizationalfactorssimplydonotplayaslargeofaroleintheetiologyofcommercialaviationaccidentsasonceexpected.Consequently,theHFACSframeworkmayneedtobepareddownorsimplifiedforusewithcommercialaviation.Anotherexplanation,however,isthatthesefactorsdocontributetomostaccidents,yettheyarerarelyidentifiedusingexistingaccidentinvesti-gationprocesses.Nevertheless,theresultsofthisstudyindicatethattheHFACSframeworkwasabletocaptureallexistingcausalfactorsandnonewerror-categoriesoraircrewcause-factorswereneededtoanalyzethecom-
mercialaccidentdata.
HFACS ReliabilityTheHFACSsystemwasfoundtoproduceanaccept-
able level of agreement among the investigatorswhoparticipatedinthisstudy.Furthermore,evenafterthislevelofagreementbetweeninvestigatorswascorrectedforchance,theobtainedreliabilityindexwasconsideredgoodbyconventionalstandards.Still,thisreliability
indexwassomewhatlowerthanthoseobservedinstudiesusingmilitary aviation accidentswhich, in some in-stances, have resulted in nearly complete agreementamonginvestigators(Shappell&Wiegmann,1997b).Onepossibleexplanationforthisdiscrepancyisthe
differenceinboththetypeandamountofinformation
availabletoinvestigatorsacrossthesestudies.Unlikethepresentstudy,previousanalystsusingHFACStoanalyzemilitaryaccidentdataoftenhadaccesstoprivilegedandhighlydetailedinformationabouttheaccidents,whichpresumablyallowedforabetterunderstandingoftheunderlyingcausalfactorsand,hence,producedhigherlevels of reliabilities. Another possibility is that thedefinitions and examples currently used to describeHFACSaretoocloselytiedtomilitaryaviationandarethereforesomewhatambiguoustothosewithinacom-mercial setting. Indeed,the reliabilityoftheHFACSframeworkhasbeenshowntoimprovewithinthecom-mercialaviationdomainwheneffortsaretakentopro-videexamplesandcheckliststhataremorecompatiblewith civil aviation accidents (Wiegmann, Shappell,Cristina&Pape,2000).
HFACS AnalysisGiven the large number of accident causal factors
contained in the NTSB database, each accident ap-peared,atleastonthesurface,toberelativelyunique.Assuch, commonalties or trends in specific error formsacrossaccidentswerenotreadilyevidentinthedata.Still,
therecodingofthedatausingHFACSdidallowforsimilarerror-formsandcausalfactorsacrossaccidentstobeidentifiedandthemajorhumancausesofaccidentstobediscovered.Specifically, theHFACSanalysis revealed that the
highest percentage of all aircrew-related accidents asassociatedwithskill-basederrors.Furthermore,thispro-portionwaslowestduringthelasttwoyearsofthisstudy,suggestingthataccidentsassociatedwithskill-baseder-rorsmaybeonthedecline.Tosome,thefindingthatskill-basederrorswerefrequentlyobservedamongthecommercialaviationaccidentsexaminedisnotsurpris-
inggiventhedynamicnatureandcomplexityofpilotingcommercial aircraft, particularlyin theincreasinglycongestedU.S.airspace.Thequestionremains,how-ever,astothedrivingforcebehindthepossiblereduc-tion in such errors. Explanations could includeimprovedaircrewtrainingpracticesorperhapsbetterselectionprocedures.Anotherpossibilitymightbetherecenttransitionwithintheregionalcommuterindus-tryfromturboproptojetaircraft.Suchaircraftare
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flyingaircraftoperatingunderFARPart135areyoungerandmuch less experienced. Furthermore, suchpilotsoftenflylesssophisticatedandreliableaircraftintoareasthatarelesslikelytobecontrolledbyATC.Asaresult,theymayfrequentlyfindthemselvesinsituationsthatexceedtheirtrainingorabilities.Suchaconclusionis
supportedbythefindingspresentedhere,sincealargerpercentageofFARPart135aircrew-relatedaccidentswereassociatedwiththephysical/mentallimitationsofthepilot.However,asmallerpercentageFARPart135aircrewaccidentswereassociatedwithCRMfailures,possiblybecausesomeFARPart135aircraftaresingle-piloted, which simply reduces the opportunity forCRMfailures.ThesedifferencesbetweenFARParts121and135
schedulecarriersmaybelessevidentinfutureaviationaccidentdatasincethefederalregulationswerechangedin1997.SuchchangesrequireFARPart135carriersoperatingaircraftthatcarrytenormorepassengerstonowoperateundermorestringentFARPart121rules.Thus,thehistoricaldistinctioninthedatabasebetweenFARPart135and121operatorshasbecomesomewhatblurredintheyearsextendingbeyondthecurrentanaly-sis.Therefore,futurehuman-erroranalysesandcom-parisons across these different types of commercialoperationswillthereforeneedtoconsiderthesechanges.
SUMMARY AND CONCLUSIONS
This investigation demonstrates that the HFACSframework,originallydevelopedforandproveninthemilitary,canbeusedtoreliablyidentifytheunderlyinghuman factors problems associated with commercialaviationaccidents.Furthermore,theresultsofthisstudyhighlight critical areas of human factors in need offurthersafetyresearchandprovidethefoundationuponwhich to build a larger civil aviation safety program.Ultimately,dataanalysessuchasthatpresentedherewillprovidevaluableinsightaimedatthereductionofavia-tionaccidentsthroughdata-driveninvestmentstrategiesandobjectiveevaluationofinterventionprograms.The
HFACSframeworkmayalsoproveusefulasatoolforguidingfutureaccidentinvestigationsinthefieldanddeveloping better accident databases, both of whichwould improve theoverall qualityandaccessibility ofhumanfactorsaccidentdata.
Still,theHFACSframeworkisnottheonlypossiblesystemuponwhichsuchprogramsmightbedeveloped.Indeed,thereoftenappearstobeasmanyhumanerrorframeworksas there are those interestedin thetopic(Senders&Moray,1991).Indeed,astheneedforbetterappliedhumanerroranalysismethodshasbecomemore
apparent,anincreasingnumberofresearchershavepro-posedothercomprehensiveframeworkssimilartoHFACS(e.g.,OHare,inpress).Nevertheless,HFACSis,todate,theonlysystemthathasbeendevelopedtomeetaspecificsetofdesigncriteria,includingcomprehensiveness,reli-ability,diagnosticity,andusability,allofwhichhavecontributedtotheframeworksvalidityasanaccidentanalysistool(Shappell&Wiegmann,inpress).Further-more,HFACShasbeenshowntohaveutilityasanerror-analysistoolinotheraviation-relateddomainssuchasATC(HFACS-ATC;Pounds,Scarborough,&Shappell,2000)andaviationmaintenance(HFACS-ME;Schmidt,Schmorrow,&Hardee,1998),andiscurrentlybeingevaluatedwithinothercomplexsystemssuchasmedi-cine(currentlyreferredtoasHFACS-MD).Finally,itisimportanttorememberthatneitherHFACSnoranyothererror-analysistoolcanfixtheproblemsoncetheyhavebeenidentified.Suchfixescanonlybederivedbythoseorganizations,practitionersandhu-manfactorsprofessionalswhoarededicatedtoim-provingaviationsafety.
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