Human error and system safety: Case study of commercial aviation accidents in Mainland China

摘要

This paper tries to find out the relationship of human error and system safety in aviation domain by analysis the importance of human error category associated with 34 commercial aviation accidents with the Chinese Civil Aviation Human Error Analysis System (CN-HFACS). Unsafe acts of operators and the preconditions of unsafe acts account for 76% of all the categories; unsafe acts of operators are mainly basic skill errors, manipulation violations, and emergency handling mistakes; preconditions of unsafe acts are mainly adverse mental states, ineffective labor division and coordination, and physical/mental limitations; most of the unsafe supervision of middle management is inadequate supervision; organization influences are mainly due to mismanagement of crew resource and poor cultural atmosphere; governmental regulation problems are mainly of inadequate inspection and audit. The aviation employers' manipulation level is significantly improved while the violation actions continually increase. Most system safety problems are human error problems.