Aviation Safety and Security Commons^™

Root-Cause Analysis Of Rsaf Maintenance-Related Flight Safety Mishaps, Heaf H. Alqahtani

Theses and Dissertations

Poor maintenance is a major factor in many aviation mishaps. This is due to the fact that some maintenance activities are carried out improperly or overlooked as a result of human error. It is important to acknowledge that maintenance mistakes are a visible sign of deeper organizational issues. Therefore, adequate solutions to maintenance issues must consider organizational influences. Despite efforts to reduce the accident rate within the Royal Saudi Air Force (RSAF), the RSAF suffers from an increasing trend in mishaps attributed to maintenance. Therefore, safety data was analyzed to examine trends. Additionally, the Human Factors Analysis and Classification System …

An Hfacs Analysis Of German F-104 Starfighter Accidents, Steven Esser, Hans-Joachim K. Ruff-Stahl

Journal of Aviation Technology and Engineering

From 1961 onwards, Germany acquired 916 Lockheed F-104 Starfighters, of which 292 aircraft crashed and 116 pilots lost their lives. The purpose of this research project was to find out why these aircraft crashed and whether the Starfighters crashed for reasons different from those for other military aircraft in Germany. Seventy-one German F-104 accidents between 1978 and 1986 were analyzed by reviewing the original accident files. A Human Factors Analysis and Classification System (HFACS) Level-1 analysis was used as methodology. It was found that more than 50% of the reviewed German F-104 accidents occurred due to technology and/or physical environment. …

Quantum Safety Metrics Framework For Commercial Unmanned Aircraft Operators, Tracy L. Lamb, Nathan A. Phillips, Trong Van Nguyen

International Journal of Aviation, Aeronautics, and Aerospace

Commercial unmanned aircraft systems continue to increase in applications and diversity; however, mishaps and accidents erode safety, investment return, and efficiency. Most unmanned aircraft accidents are preceded by leading indicators; the ability to forecast and quantify these may provide increased safety and profitability. This mixed-method research study used a non-experimental parallel convergence approach with multiple instruments, multiple-case study n = 22, and one exemplar case design to develop a quantum safety metric program. This study used a combination of previously validated methods as development instruments, including; the HFACS, STAMP, 'Sierra Scale,' and Accident Prevention Effort equations. The study extended the …

Human Factors Analysis And Classification System (Hfacs): As Applied To Asiana Airlines Flight 214, Alex Small

The Journal of Purdue Undergraduate Research

The Human Factors Analysis and Classification System (HFACS) is a safety tool that aids in the identification and analysis of organizational factors that contribute to aircraft accidents. By using the HFACS model, safety investigators can better understand the existing conditions that contribute to accidents, which then allows for the development and implementation of safety programs to prevent these conditions. In this study, the HFACS framework was utilized to identify the human factors that contributed to the Asiana Airlines flight 214 accident that occurred on July 6, 2013. The results of this study indicate that inadequate pilot training, lack of upper-level …

Applying And Evaluating A Taxonomy Of Resilient Performance Among Certified Flight Instructors, Kristine M. Kiernan Ph.D., David S. Cross Ph.D., Ed.D., Mark Scharf Ph.D.

National Training Aircraft Symposium (NTAS)

Human error in aviation has been well studied, but the contribution of human performance to system resilience in aviation has not been as well explored. Resilient performance is the ability of a system to make accommodations before, during, and after a disturbance to ensure continued system functioning. Resilient performance is enabled by the ability to anticipate, monitor, learn, and respond. Certified flight instructors will be interviewed using the critical incident debrief method. Interviews will be transcribed and analyzed to explore resilient behavior and evaluate whether the taxonomy of success developed in commercial airline operations is applicable to the flight instruction …

An Attribute Agreement Method For Hfacs Inter-Rater Reliability Assessment, Teddy Steven Cotter, Veysel Yesilbas

Engineering Management & Systems Engineering Faculty Publications

Inter-rater reliability can be regarded as the degree of agreement among raters on a given item or a circumstance. Multiple approaches have been taken to estimate and improve inter-rater reliability of the United States Department of Defense Human Factors Analysis and Classification System used by trained accident investigators. In this study, three trained instructor pilots used the DoD-HFACS to classify 347 U.S. Air Force Accident Investigation Board (AIB) Class-A reports between the years of 2000 and 2013. The overall method consisted of four steps: (1) train on HFACS definitions, (2) verify rating reliability, (3) rate HFACS reports, and (4) random …

Human Error Analysis Of Helicopter Emergency Medical Services (Hems) Accidents Using The Human Factors Analysis And Classification System (Hfacs), Paul E. Cline

Journal of Aviation/Aerospace Education & Research

Helicopter Emergency Medical Services (HEMS) is among the most dangerous type of flying in commercial aviation. This research utilized the Human Factors Analysis and Classification System (HFACS) to understand the errors, preconditions and violations that contribute to these accidents. Drawing upon source data from the National Transportation Safety Board’s Aviation Accident Database, HEMS accidents from 2000-2016 were analyzed according to the HFACS framework.

An Analysis Of Airport Surface Deviations Using The Human Factors Analysis And Classification System (Hfacs), James H. Cistone

Doctoral Dissertations and Master's Theses

An analysis of accident and incident data from the Federal Aviation Administration Runway Safety database and the National Transportation Safety Board (NTSB) database was performed to determine causal factors for airport surface deviations over a 12-year period, from January 1, 2001 through December 31, 2012. The Human Factors Analysis and Classification System was used as the framework to analyze the NTSB data for causal factors.

Analysis of the NTSB data produced 289 airport surface deviation cases, which were analyzed for causal evidence, and the results indicated that skill-based errors occurred at least once in the largest frequency of airport surface …

Nurturing Systems Thinking: Developing A Framework Based On The Human Factors Analysis And Classification System (Hfacs) To Improve Systems Development Processes, Arjun Vijayanarayanan

Doctoral Dissertations and Master's Theses

Large systems engineering projects have an astonishingly high failure rate. The reasons hypothesized for such a high failure rate include the neglect of nonsalient system elements such as social and human or organizational aspects of systems. Social and human factors have long been known to be critical elements of systems that are frequently ignored (e.g., Goguen, 1994). Systems engineering processes can benefit and be improved by effective utilization of a framework that helps developers expand their attention and efforts beyond the salient aspects of the system and the development process. In the aviation field, the Human Factors Analysis and Classification …

Developing A Methodology For Assessing Safety Programs Targeting Human Error In Aviation, Scott Shappell, Douglas Wiegmann

Publications

There is a need to develop an effective methodology for generating comprehensive intervention strategies that map current and proposed safety programs onto well-established types of human error. Two separate studies were conducted using recommendations from NTSB accident investigations and several joint FAA and industry working groups. The goal of the studies was to validate a proposed framework for developing and examining safety initiatives that target human error in aviation. The results suggest five approaches to reducing human factors associated with aviation accidents. When combined with the Human Factors Analysis and Classification System, the resulting Human Factors Intervention Matrix will provide …

Human Error And Commercial Aviation Accidents: A Comprehensive, Fine-Grained Analysis Using Hfacs, Scott Shappell, Cristy Detwiler, Kali Holcomb, Carla Hackworth, Albert Boquet, Douglas Wiegmann

Publications

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 …

Human Error And General Aviation Accidents: A Comprehensive, Fine-Grained Analysis Using Hfacs, Douglas Wiegmann, Troy Faaborg, Albert Boquet, Cristy Detwiler, Kali Holcomb, Scott Shappell

Publications

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. …

A Human Error Analysis Of Commercial Aviation Accidents Using The Human Factors Analysis And Classification System (Hfacs), Douglas A. Wiegmann, Scott A. Shappell

Publications

The Human Factors Analysis and Classification System (HFACS) is a general human error framework originally developed and tested within the U.S. military as a tool for investigating and analyzing the human causes of aviation accidents. Based upon Reason’s (1990) model of latent and active failures, HFACS addresses human error at all levels of the system, including the condition of aircrew and organizational factors. The purpose of the present study was to assess the utility of the HFACS framework as an error analysis and classification tool outside the military. Specifically, HFACS was applied to commercial aviation accident records maintained by the …