Exploring human error in military aviation flight safety events using post-incident classification systems

摘要

Introduction: Human error classification systems theoretically allow researchers to analyze postaccident data in an objective and consistent manner. The Human Factors Analysis and Classifi cation System (HFACS) framework is one such practical analysis tool that has been widely used to classify human error in aviation. The Cognitive Error Taxonomy (CET) is another. It has been postulated that the focus on interrelationships within HFACS can facilitate the identifi cation of the underlying causes of pilot error. The CET provides increased granularity at the level of unsafe acts. The aim was to analyze the infl uence of factors at higher organizational levels on the unsafe acts of front-line operators and to compare the errors of fi xed-wing and rotary-wing operations. Method: This study analyzed 288 aircraft incidents involving human error from an Australasian military organization occurring between 2001 and 2008. Results: Action errors accounted for almost twice (44%) the proportion of rotary wing compared to fi xed wing (23%) incidents. Both classifi catory systems showed signifi cant relationships between precursor factors such as the physical environment, mental and physiological states, crew resource management, training and personal readiness, and skill-based, but not decision-based, acts. The CET analysis showed different predisposing factors for different aspects of skill-based behaviors. Discussion: Skill-based errors in military operations are more prevalent in rotary wing incidents and are related to higher level supervisory processes in the organization. The Cognitive Error Taxonomy provides increased granularity to HFACS analyses of unsafe acts.