Browse Publications Technical Papers 2000-01-2104
2000-04-11

The Role of Pilot Error in Civil Aviation Accidents - A Causal Analysis using the HFACS and ASAFE Frameworks 2000-01-2104

A causal analysis of aviation accidents that involved pilot error is presented. The analysis employs a top-down methodology that investigates the relationship between pilot errors and other causal factors with accidents. The Human Factors Analysis and Classification System (HFACS) framework is utilized to produce a comprehensive causal analysis of accident groups. This analysis will compare and evaluate causal factor patterns for both accidents induced by pilot errors and those where pilot error was a contributor but not the initiating event. Pilot induced accidents are those initiated by an inappropriate action of the aircrew. That is, the National transportation Safety Board (NTSB) report cited pilot error first within its analysis defining accident causes, factors, and findings. Pilot contributed accidents are those that are initiated by some other causal factor (weather, aircraft failure, etc.) and the pilot’s inappropriate action played a part in the outcome. That is, the NTSB report cited pilot error within its analysis but not as the first causal factor. These accidents should have been recoverable, but the aircrew failed to take appropriate actions or took inappropriate actions. Analysis results of accidents adjudicated by the National Transportation Safety Board (NTSB), both fatal and nonfatal, that occurred during the period of 1990-1998 are presented.

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