INTRODUCTION
“Flying is not inherently dangerous, but to an
even greater extent than the sea, it is terribly un-
forgiving….”
– Captain A. G. Lumplugh, British
Aviation Insurance Group
Since Silas Christofferson first carried passen-
gers on his hydroplane between San Francisco and
Oakland harbors in 1913, engineers and psychol-
ogists have endeavored to improve the safety of
passenger and cargo flights. What began as an in-
dustry fraught with adversity and at times tragedy
has emerged as arguably one of the safest modes
of transportation today.
Indeed, no one can question the tremendous
strides that have been made since those first pas-
senger flights nearly a century ago. However, little
improvement has been realized in the last decade
even though commercial aviation accident rates
have reached unprecedented levels of safety over
the last half century. Some have even suggested
that the current accident rate is as good as it gets –
or is it?
The challenge for the Federal Aviation Admin-
istration (FAA) and other civil aviation safety
organizations is to improve an already very safe
industry. The question is where to start when most
of the “low-hanging fruit” (e.g., improved power
plant and airframe technology, advanced avionics,
Human Error and Commercial Aviation Accidents: An Analysis
Using the Human Factors Analysis and Classification System
Scott Shappell,
Clemson University, Clemson, South Carolina,
Cristy Detwiler, Kali
Holcomb,
and
Carla Hackworth,
Civil Aerospace Medical Institute, Oklahoma
City, Oklahoma,
Albert Boquet,
Embry-Riddle Aeronautical University, Daytona
Beach, Florida, and
Douglas A. Wiegmann,
University of Illinois at Urbana-Champaign,
Champaign, Illinois
Objective:
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).
Background:
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.
Method:
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.
Results:
The majority of accident causal factors were attributed to aircrew
and the environment, with decidedly fewer associated with supervisory and organi-
zational causes. Comparisons were made between HFACS causal categories and tra-
ditional situational variables such as visual conditions, injury severity, and regional
differences.
Conclusion:
These data will provide support for the continuation, mod-
ification, and/or development of interventions aimed at commercial aviation safety.
