The effect of management practices on aircraft incidents |
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Institution: | 1. Technological Institute of Aeronautics (ITA), Civil-Aeronautical Engineering Division, Department of Air Transport and Airports, Pr. Marechal Eduardo Gomes, 50 - Vila Das Acacias, 12228-900 São José Dos Campos, SP, Brazil;2. University of São Paulo (USP), Naval Architecture and Ocean Engineering Department, LabRisco – Analysis, Evaluation and Risk Management Laboratory, Av. Prof. Mello Moraes, 2231, 05508-030 Cidade Universitária, São Paulo, SP, Brazil |
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Abstract: | Many models have been put forward in order to examine the human factors in aircraft accidents and incidents. Human Factors Analysis and Classification System (HFACS) which is the most widely used in literature is one of these models. HFACS is based on Reason's Swiss Cheese Model. The biggest disadvantage of the Reason's model is its post-accident applicability. Mostly HFACS aviation applications are usually based on accident data. This is a reagent (result-focused) approach. In this study, however, HFACS which is an improved version of Reason's model, was applied to aircraft incidents that did not result in an accident. This is a proactive approach. Thus, with this approach, the biggest disadvantage of Reason's model is turned into an advantage. In addition, a realistic application of this approach has been demonstrated in this study, focusing on aircraft incidents that took place between 2000 and 2018. The year 2000 forms a milestone in the manufacture of more technically advanced aircraft models which significantly reduced occurrence of technical errors in aircrafts, hence the choice of 2000 as base year. A total of 328 aircraft incident reports from the National Transportation Safety Board (NTSB) database were studied and among these reports cockpit crew related incidents were analyzed using HFACS. As a result of the analyzes, the root causes of incidents have been identified. In addition, unlike traditional HFACS analysis, the relationship between errors occurred at management levels of HFACS and the unsafe acts of the cockpit crew in aircraft incidents was statistically revealed. |
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Keywords: | Aircraft incidents Proactive approach Human factors Management HFACS |
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