HFACS Analysis for Investigating Human Errors in Flight Training Accidents

Abstract

Training of pilots in civil aviation is the primary concern when dealing with accidents and incidents. There has been too little research into accidents during flight instruction. To advance the literature, the present study aims to analyze accidents during the instructional general aviation flights. This study examined investigation reports of 70 accidents involving instructional general aviation flights in the United States between 01.01.2018 and 12.12.2018. The data of those accidents was recorded by the national transportation safety board (NTSB).The causal factors of those accidents were statistically analyzed and classified by using the Human FactorsAnalysis and Classification System (HFACS). To the best of our knowledge, this paper is the first ever report analyzing contributing factors of training flight accidents by the analytical framework HFACS. According to the analysis results, it was revealed that across all accidents mentioned above, skill-based errors were ranked as the primary contributing factors, followed by environmental factors, and decision errors. Results showed that the most common skill-based errors are student pilots’ improper landing flare and failure to maintain directional control during landing and takeoff. The findings of this study provide intriguing insight that may be beneficial to people researching contributing factors of aviation accidents in academia and practice. Furthermore, the outcome of the current study may assist student pilots in completing safe flights.

Keywords

• Air Transportation,Accident Investigation,Ab-initio Pilots,Human Factors Analysis and Classification System (HFACS),organization

References

1. [1] ATAG-Air Transprt Action Group, “Aviation Benefits Beyond Borders,” 2018.
2. [2] BOEING, “Current market outlook 2017-2036,” 2017.
3. [3] FlightschoolList.com, “Airplane Flight Schools from all over the world,” https://www.flightschoollist.com/airplane-flight-schools/. [Accessed: 20-Mar-2019].
4. [4] FlightschoolList.com, “Aviation Collage and Universities from all over the world,” https://www.flightschoollist.com/aviation-college/. [Accessed: 20-Mar-2019].
5. [5] SACAA, “Approved Training Organizations-Pilot Training (South African Civil Aviation Authority),”http://www.caa.co.za/Aviation Personnel Standards/List of ATOs and AMTOs.pdf. [Accessed: 20-Mar-2019].
6. [6] FAA, “FAA-Pilot Schools.”http://av-info.faa.gov/PilotSchool.asp. [Accessed: 11-Apr-2019].
7. [7] ICAO, “ICAO-WORKING PAPER-REVIEW OF THE CLASSIFICATION AND DEFINITIONS USED FOR CIVIL AVIATION,” Montreal, 2009.
8. [8] D. D. Boyd, “A Review of General Aviation Safety (1984–2017),” Aerosp. Med. Hum. Perform., vol. 88, no. 7, pp. 657–664, 2017.

9. [9] BOEING, “Statistical Summary of Commercial Jet Airplane Accidents (Worldwide Operations 1959 – 2016),” 2017.
10. [10] Aviation Safety, “Problems with Flight Training.”http://www.aviationsafetymagazine.com/airplane/Flight-Training-Mistakes.html. [Accessed: 11-Apr-2019].
11. [11] B. Kilic and S. Soran, “How Can an Ab-Initio Pilot Avert a Future Disaster : A Pedagogical Approach to Reduce The Likelihood of Future Failure,” J. Aviat., vol. 3, no. 1, pp. 1–14, 2019.
12. [12] Electronic Code of Federal Regulations, “General Operating and Flight Rules,” https://www.ecfr.gov/cgi-bin/text-idx?node=14:2.0.1.3.10. [Accessed: 02-Apr-2019].[13] AOPA Air Safety Foundation, “State of General Aviation General,” 2019.
13. [14] AOPA Air Safety Foundation, “JOSEPH T. NALL REPORT General Aviation Accidents in 2015,” 2015.
14. [15] M. Aguiar, A. Stolzer, and D. D. Boyd, “Rates and causes of accidents for general aviation aircraft operating in a mountainous and high elevation terrain environment,” Accid. Anal. Prev., vol. 107, no. March, pp. 195–201, 2017.
15. [16] D. D. Boyd, “General aviation accidents related to exceedance of airplane weight / center of gravity limits,” Accid. Anal. Prev., vol. 91, pp. 19–23, 2016.
16. [17] Flight Global, “Pilot training is the key to preventing serious accidents,” 2019.
17. [18] Y. H. Chang, H. H. Yang, and Y. J. Hsiao, “Human risk factors associated with pilots in runway excursions,” Accid. Anal. Prev., vol. 94, pp. 227–237, 2016.
18. [19] ICAO, “ICAO Doc 9995 Manual of Evidence-based Training,” 2013.
19. [20] EHEST-European Helicopter Safety Tean, “The Principles of Threat and Error Management (TEM) for Helicopter Pilots, Instructors and Training Organisations,” 2014.
20. [21] W. Li, “The Casual Factors of Aviation Accidents Related to Decision Errors in the Cockpit by System Approach,” J. Aeronaut. Astronaut. Aviat., vol. 43, no. 3, pp. 159–166, 2011.
21. [22] Z. Göker, “Fatigue in The Aviation : An Overview of The Measurements and Countermeasures,” J. Aviat., vol. 2, no. 2, pp. 185–194, 2018.
22. [23] FAA, “Fatigue in Aviation,” 2018.
23. [24] M. R. Endsley and D. J. Garland, “Pilot Situation Awareness Training in General Aviation,” in Proceedings of the Human Factors and Ergonomics Society Annual Meeting, 2000, vol. 44, no. 11, pp. 357–360.
24. [25] H. Kharoufah, J. Murray, G. Baxter, and G. Wild, “A review of human factors causations in commercial air transport accidents and incidents: From to 2000–2016,” Prog. Aerosp. Sci., vol. 99, pp. 1–13, 2018.
25. [26] NTSB-National Transportation Safety Board, “Aviation Accident Database & Synopses,”https://www.ntsb.gov/_layouts/ntsb.aviation/index.aspx. [Accessed: 30-Mar-2019].
26. [27] A. Walton, C. Baumann, and R. C. Geske, “Fatal Flight Training Accident report 2000–2015,” 2015.
27. [28] B. Siyuan, M. Guindani, and D. D. Boyd, “Causes of fatal accidents for instrument-certified and non-certified private pilots,” Accid. Anal. Prev., vol. 72, pp. 370–375, 2014.
28. [29] W. C. N. Taneja, “Weather related fatal general aviation accidents : Can spatial disorientation training be an effective intervention strategy?,” Ind J Aerosp. Med, vol. 46, no. 2, pp. 59–64, 2002.
29. [30] AOPA Air Safety Foundation, “Accident Analysis-Accident Database,” https://www.aopa.org/asf/ntsb/search_ntsb.cfm. [Accessed: 03-Apr-2019].
30. [31] T. Diller, G. Helmrich, S. Dunning, S. Cox, A. Buchanan, and S. Shappell, “The Human Factors Analysis Classification System (HFACS) Applied to Health Care,” Am. J. Med. Qual., vol. 29, no. 3, pp. 181–190, 2014.
31. [32] N. Xia, P. X. W. Zou, X. Liu, X. Wang, and R. Zhu, “A hybrid BN-HFACS model for predicting safety performance in construction projects,” Saf. Sci., vol. 101, no. September 2017, pp. 332–343, 2018.
32. [33] M. Celik and S. Cebi, “Analytical HFACS for investigating human errors in shipping accidents,” Accid. Anal. Prev., vol. 41, no. 1, pp. 66–75, 2009.
33. [34] M. G. Lenné, P. M. Salmon, C. C. Liu, and M. Trotter, “A systems approach to accident causation in mining: An application of the HFACS method,” Accid. Anal. Prev., vol. 48, pp. 111–117, 2012.
34. [35] A. L. Aas, “The Human Factors Assessment and Classification System (HFACS) for the Oil & Gas Industry,” in International Petroleum Technology Conference, 2008, no. 4.
35. [36] Q. Zhan, W. Zheng, and B. Zhao, “A hybrid human and organizational analysis method for railway accidents based on HFACS-Railway Accidents (HFACS-RAs),” Saf. Sci., vol. 91, pp. 232–250, 2017.
36. [37] W. C. Li, D. Harris, and C. S. Yu, “Routes to failure: Analysis of 41 civil aviation accidents from the Republic of China using the human factors analysis and classification system,” Accid. Anal. Prev., vol. 40, no. 2, pp. 426–434, 2008.
37. [38] K. Dönmez and S. Uslu, “İnsan Faktörleri Analiz ve Sınıflandırma Sistemi’nin (HFACS) Literatürde Yaygın Kullanımının Değerlendirilmesi-Evaluation of the Widespread Use of Human Factors Analysis and Classification System ( HFACS) in Literature,” J. Aviat., vol. 2, no. 2, pp. 156–176, 2018.
38. [39] K. Donmez and S. Uslu, “THE RELATIONSHIP BETWEEN FLIGHT OPERATIONS AND ORGANIZATIONS IN AIRCRAFT ACCIDENTS; THE APPLICATION OF THE HUMAN FACTOR ANALYSIS AND CLASSIFICATION SYSTEM,” Anadolu Univ. J. Sci. Technol. A-Applied Sci. Eng., vol. 19, pp. 316–333, 2018.
39. [40] S. Shappell and D. Wiegmann, “The Human Factors Analysis and Classification System – HFACS,” 2000.
40. [41] J. T. Reason, Human Error. Cambridge: Cambridge University Press, 1990.
41. [42] C. A. Havle and B. Kılıç, “A hybrid approach based on the fuzzy AHP and HFACS framework for identifying and analyzing gross navigation errors during transatlantic flights,” J. Air Transp. Manag., vol. 76, pp. 21–30, 2019.
42. [43] AOPA Air Safety Institute, “ACCIDENTS DURING FLIGHT INSTRUCTION : A REVIEW,” 2014.