Human Factors- The Journal of the Human Factors and Ergonomics Society-2007-Shappell-227-42 - SPECIAL SECTION Human Error and Commercial Aviation

Human Factors- The Journal of the Human Factors and Ergonomics Society-2007-Shappell-227-42

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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.
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