2024: Crisis Management Days Conference Proceedings
Security and Protection (National and International Security, Corporate and Information Security, Disaster Risk Reduction)

Understanding human error in aviation

Jadranka Majić
University of Applied Sciences Velika Gorica

Published 2024-12-01

Keywords

  • aviation,
  • human error,
  • mistake,
  • violation

How to Cite

Majić, J. (2024). Understanding human error in aviation. Crisis Management Days. Retrieved from https://ojs.vvg.hr/index.php/DKU/article/view/594

Abstract

Error is an integral part of human performance, resulting from physiological and psychological limitations inherent in humans. It has been a contributing factor to the majority of incidents and accidents in any field of human activity. Approximately 80% of aviation events are caused by a decrease in human performance.
As aviation safety depends on minimising error in all constituents of this compound system, it is primarily important to classify errors in order to better understand their nature and causes, and investigate them. A holistic approach to error also needs to be taken for its investigation and analysis, since humans do not act in isolation. Human performance is a complex process, influenced by work environment, technology, various cultural aspects and other participants in it. A mismatch in interaction of humans and other components in this process leads to error, and therefore it must be scrutinised in all facets of the aviation system.
While errors resulting in incidents, accidents and loss of life are mostly made by pilots or air traffic controllers and draw more attention, those made by maintenance staff also need to be taken seriously, since they can result in fatalities and damage to aircraft as well, and entail significant consequences to air traffic.
Methods of researching human error in the aviation context will range from studying event databases, self-reports and accident reports to case studies. Typical examples of human error that contributed to various safety occurrences will be analysed, with its causes, lessons learnt and remedies stated.
The aim of comprehending why people make errors is to elaborate safety recommendations and technological solutions that will decrease the likelihood of aviation events, and mitigate the consequences.
Errors can be managed and reduced primarily by creating an error-tolerant environment rather than punitive environment, improving error training, and using a number of technological models, aids and methods, including the threat and error management concept.
Human error cannot be eliminated, but by understanding its origin and cause, as well as learning from these experiences, the occurrence of incidents and accidents can be reduced, and the effects minimised.

References

  1. Adams, D. (2006). A Layman’s Introduction to Human Factors in Aircraft Accident and Incident Investigation. Canberra: Australian Transport Safety Bureau.
  2. Amalberti, R. (2001). La conduit des systemes a risques. Paris: Presses Universitaire de France.
  3. Boeing (2016). Maintenance Error Detection System (MEDA), User’s Guide., Seattle, WA: The Boeing Company.
  4. Dumitru, I. M., Boşcoianu, M. (2015). Human Factors Contribution to Aviation Safety. International Conference of Scientific Paper AFASES, pp. 1-5.
  5. Eurocontrol (2017). EVAIR Safety Bulletin 18 (2012-2016). Bruxelles: Eurocontrol.
  6. Eurocontrol (2002). Technical Review of Human Performance Models and Taxonomies of Human Error in ATM (HERA). Bruxelles: Eurocontrol.
  7. Hansen, F. D. (2006). Human Error: A Concept Analysis. In: Journal of Air Transportation, 3 (2), pp. 61-77.
  8. Helmreich, R. L. (2000). On Error Management: Lessons from Aviation. In: BMJ: British Medical Journal. 320 (7237), pp. 781-785, doi: https://doi.org/10.1136/bmj.320.7237.781
  9. ICAO (2012). Safety Management Manual, Doc 9859-AN/474. Third Edition, Montreal: ICAO.
  10. ICAO (2005). Threat and Error Management (TEM). Preliminary Edition, Montreal: ICAO.
  11. ICAO (1993). Human Factors Digest No. 7: Investigation of Human Factors in Accidents and Incidents. Circular 240-AN/144, Montreal: ICAO.
  12. Johnson, W. B., Maddox, M. E. (2007). A Model to Explain Human Factors in Aviation Maintenance. Avionics News, April 2007, pp. 38-41.
  13. Kern, T. T. (1998) Flight Discipline. New York: McGrow Hill.
  14. Latorella, K. A., Prabhu, P. V. (2000). A review of human error in aviation maintenance and inspection. International Journal of Industrial Ergonomics, 26, pp. 133-161.
  15. Latorella, K. A., Drury, C. G. (1992). A framework for human reliability in aircraft inspection. In: Proceedings of the 7th FAA Meeting on Human Factors Issues in Aircraft Maintenance and Inspection. FAA, Washington, DC
  16. Li, G. et al. (2001). Factors associated with pilot error in aviation crashes. Aviation, Space and Environmental Medicine, 72 (1), pp. 52-58.
  17. Maurino, D. (2005). Threat and Error Management (TEM), Canadian Aviation Safety Seminar (CASS), Vancouver, BC, 18-20 April 2005, pp. 1-7.
  18. Naranji E., Sarkani, S., Mazzuchi, T. (2015). Reducing Human/Pilot Errors in Aviation Using Augmented Cognition and Automation Systems in Aircraft Cockpit. In: Transactions on Human-Computer Interaction, 7 (2), pp. 71-96.
  19. Norman, D. A. (1981). Categorization of Action Slips. The Psychological Review, 88, 1, pp. 1-15.
  20. Rankin, W. L. (2000). The Maintenance Error Decision Aid (MEDA) Process. In: Proceedings of IAEA 2000/HFES 2000 Congress, pp. 795-798.
  21. Rasmussen, J. (1981). Skills, Rules and Knowledge: Signals, Signs and Symbols, and Other Distinctions in Human Performance Models. IEEE Transactions on Systems, Man and Cybernetics, 13 (3), pp. 257-266.
  22. Reason, J. (2016). Organizational Accidents Revisited. New York: CRC Francis Group.
  23. Reason, J. (2005). Safety in the operating theatre – Part 2: Human error and organisational failure, Qual Saf Health Care, 14, pp. 56-61.
  24. Reason, J. Maddox, M. E. (1995). Human error. In: Human Factors Guide for Aviation Maintenance. U.S. Department of Transportation, Washington, DC, Chapter 14, pp. 1-48.
  25. Reason J. (1990). Human Error. New York: Cambridge University Press.
  26. Strauch, B. (2002) Investigating Human Error: Incidents, Accidents and Complex Systems. Aldershot: Ashgate Publishing Ltd.
  27. Web resources
  28. EVAIR – retrieved from https://www.eurocontrol.int/service/eurocontrol-voluntary-atm-incident-reporting
  29. OGFA Briefing Note – Error Management (OGHFA BN) | SKYbrary Aviation Safety – retrieved from https://skybrary.aero/articles/error-management-oghfa-bn
  30. Human Error in Aviation: An Introduction – retrieved from https://aviationknowledge.wikidot.com/aviation:human-error-in-aviation
  31. HFACS – retrieved from https://skybrary.aero/articles/human-factors-analysis-and-classification-system-hfacs
  32. Human Factors ‘Dirty Dozen’ – retrieved from https://skybrary.aero/articles/human-factors-dirty-dozen
  33. TOKAI – retrieved from https://www.eurocontrol.int/tool/toolkit-air-traffic-management-occurrence-investigation