The Casual Factors of Aviation Accidents Related to Decision Errors in the Cockpit by System Approach

摘要

Aeronautical decision-making is defined by the Federal Aviation Authority (1991) as 'a systematic approach to the mental process used by aircraft pilots to consistently determine the best course of action in response to a given set of circumstances'. This research analyzes 51 accident reports obtained from Aviation Safety Council published between 1999 and 2008. Each accident report was independently analyzed using the Human Factors Analysis and Classification System (HFACS). Statistical relationships linking fallible decisions in upper management were found to directly affect supervisory practices, thereby creating the psychological preconditions for unsafe acts and hence indirectly impairing the performance of pilots' in-flight decision-making. It was observed that 68% of accidents in this sample included a decision error. The results show clearly defined, statistically-described paths with pre-cursors to pilots' decision errors at both the immediately adjacent and also higher levels in the organization. This study provides an understanding, based upon empirical evidence, of how actions and decisions at higher managerial levels in the operation of the commercial aircraft results in decision errors on the flight deck and subsequent accidents. To reduce the accident rate resulting from decision errors in flight operations the 'paths to failure' relating to these organizational and human factors issues must be addressed.