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

Shappell, Scott A.; Detwiler, Cristy; Holcomb, Kali; Hackworth, Carla A.; Boquet, Albert; Wiegmann, Douglas A.

doi:10.1518/001872007x312469

Cited by 323 publications

(120 citation statements)

References 13 publications

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“…Technical failure today is the cause of only about 10% of accidents, leaving a significant percentage as the implications of human factors. The exact values vary over years and sources and, as illustrated in Figure 1, approximately 60 to 80 percent of aviation accidents involve human error [2]. In particular, today's low rate of overall accidents is due to the introduction of automation [3].…”

Section: Introductionmentioning

confidence: 99%

The Neuroergonomics of Aircraft Cockpits: The Four Stages of Eye-Tracking Integration to Enhance Flight Safety

Peysakhovich

Lefrancois

Dehais

et al. 2018

Safety

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Abstract:Commercial aviation is currently one of the safest modes of transportation; however, human error is still one major contributing cause of aeronautical accidents and incidents. One promising avenue to further enhance flight safety is Neuroergonomics, an approach at the intersection of neuroscience, cognitive engineering and human factors, which aims to create better human-system interaction. Eye-tracking technology allows users to "monitor the monitoring" by providing insights into both pilots' attentional distribution and underlying decisional processes. In this position paper, we identify and define a framework of four stages of step-by-step integration of eye-tracking systems in modern cockpits. Stage I concerns Pilot Training and Flight Performance Analysis on-ground; stage II proposes On-board Gaze Recordings as extra data for the "black box" recorders; stage III describes Gaze-Based Flight Deck Adaptation including warning and alerting systems, and, eventually, stage IV prophesies Gaze-Based Aircraft Adaptation including authority taking by the aircraft. We illustrate the potential of these four steps with a description of incidents or accidents that we could certainly have avoided thanks to eye-tracking. Estimated milestones for the integration of each stage are also proposed together with a list of some implementation limitations. We believe that the research institutions and industrial actors of the domain will all benefit from the integration of the framework of the eye-tracking systems into cockpits.

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Section: Introductionmentioning

confidence: 99%

The Neuroergonomics of Aircraft Cockpits: The Four Stages of Eye-Tracking Integration to Enhance Flight Safety

Peysakhovich

Lefrancois

Dehais

et al. 2018

Safety

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“…(Examples: wrong configuration of the aircraft for takeoff, late retraction of the landing gear, premature flaps retraction, failure to start the anti-ice engine when necessary, failure in reprogramming the altimeter, failure to apply the parking brake on arrival at the gate) 7,27,29 .…”

Section: Discussion Discussion Discussion Discussion Discussionmentioning

confidence: 99%

“…Substantial data also suggest that at least half of all surgical complications are avoidable and attributed to human error [4][5][6] . However, there are no guidelines for the management of interruptions and distractions, which are strong factors influencing human errors in the operating room [7][8][9][10][11][12] .…”

Section: Introduction Introduction Introduction Introduction Introducmentioning

confidence: 99%

Interrupções e distrações na sala de cirurgia do trauma: entendendo a ameaça do erro humano

Pereira

Correia

et al. 2011

Rev. Col. Bras. Cir.

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OBJETIVO: Compreender o fator humano como ameaça à segurança do paciente vítima de trauma no centro cirúrgico, traduzindo para a sala de operação algumas regras importantes já aplicadas no campo da aviação. MÉTODOS: A amostra incluiu 50 casos de cirurgia de trauma coletados prospectivamente por observadores em plantões de 12 horas, ,durante seis meses, em um centro de trauma nível I nos Estados Unidos da América. Informações quanto ao tipo de trauma, escore de gravidade e mortalidade foram coletadas, assim como, determinantes de distrações/interrupções e o volume de ruídos na sala de cirurgia durante o ato cirúrgico. RESULTADOS: Ocorreram, em média, 60 interrupções ou distrações durante o ato cirúrgico, na maioria das vezes desencadeado pelo movimento de pessoas na sala. Em pacientes mais graves (ISS > 45), submetidos ao controle de danos, a incidência de distrações foi ainda maior. A média de ruídos na sala de cirurgia do trauma foi muito elevada, com barulho próximo ao de um secador de cabelos. CONCLUSÃO: Interrupções e distrações são frequentes e devem ser estudadas pelo cirurgião do trauma a fim de desenvolver estratégias de prevenção e linhas de defesa para minimizá-las e reduzir seus efeitos.

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“…The creation of CRM and alike programs does not always guarantee the absence of unsafe pilot behaviors [23][24][25][26][27]. However, effective crew performance depends on both technical proficiency and interpersonal skills.…”

Section: Recommendations For Industrymentioning

confidence: 99%

The Presence of Behavioral Traps in U.S. Airline Accidents: A Qualitative Analysis

Velázquez

2018

Safety

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Behavioral traps are accident-inducing operational pitfalls aviators may encounter as a result of poor decision making. The Federal Aviation Administration (FAA) identifies the existence of twelve of these negative pilot behaviors. These are: Peer Pressure; Get-There-Itis; Loss of Situational Awareness; Descent Below the Minimum En Route Altitude (MEA); Mind Set; Duck-Under Syndrome; Getting Behind the Aircraft; Continuing Visual Flight Rules (VFR) into Instrument Conditions; Scud Running; Operating Without Adequate Fuel Reserves; Flying Outside the Envelope; and Neglect of Flight Planning, Preflight Inspections, and Checklists. The purpose of this paper was to study the nature of their occurrence in the airline domain. Four Subject Matter Experts (SMEs) analyzed 34 National Transportation Safety Board (NTSB) accident reports. The SMEs were able to identify many pilot actions that were representative of the behavioral traps. Behavioral traps were found in all accidents with Loss of Situational Awareness and Neglect of Flight Planning, Preflight Inspections, and Checklists dominant. Various themes began to emerge, which played important roles in many accidents. These themes included Crew Resource Management (CRM) issues, airline management and fatigue. The findings of this study indicated that behavioral traps were prevalent in airline accidents including habitual noncompliance by pilots. Attitude management training is recommended.

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

Abstract: HFACS provides a tool for assessing human factors associated with accidents and incidents.

Cited by 323 publications

References 13 publications

The Neuroergonomics of Aircraft Cockpits: The Four Stages of Eye-Tracking Integration to Enhance Flight Safety

The Neuroergonomics of Aircraft Cockpits: The Four Stages of Eye-Tracking Integration to Enhance Flight Safety

Interrupções e distrações na sala de cirurgia do trauma: entendendo a ameaça do erro humano

The Presence of Behavioral Traps in U.S. Airline Accidents: A Qualitative Analysis

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