A human error approach to aviation accident analysis the human factors analysis and classification system
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| Format: | Buch |
| Sprache: | English |
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Ashgate
2003
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| 100 | 1 | |a Wiegmann, Douglas A. |e Verfasser |4 aut | |
| 245 | 1 | 0 | |a A human error approach to aviation accident analysis |b the human factors analysis and classification system |
| 264 | 1 | |a Aldershot |b Ashgate |c 2003 | |
| 300 | |a XV, 165 S. |b Ill., graph. Darst. | ||
| 336 | |b txt |2 rdacontent | ||
| 337 | |b n |2 rdamedia | ||
| 338 | |b nc |2 rdacarrier | ||
| 500 | |a Literaturverz. S. 157 - 162 | ||
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| 650 | 7 | |a Luchtvaart |2 gtt | |
| 650 | 7 | |a Ongevallen |2 gtt | |
| 650 | 4 | |a Aeronautics |x Human factors | |
| 650 | 4 | |a Aircraft accidents |x Investigation | |
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| 943 | 1 | |a oai:aleph.bib-bvb.de:BVB01-015189653 | |
Datensatz im Suchindex
| _version_ | 1819682905110085632 |
|---|---|
| adam_text | Contents
List of Figures vii
List of Tables x
Acknowledgements xi
Preface xii
1 Errare Humanum Est To Err is Human 1
Aviation Safety Trends 3
Some Reasons for Concern 8
Human Error and Aviation Accidents 10
Engineering Aspects of an Investigation 12
Human Factors Aspects of an Investigation 15
Conclusion 18
2 Human Error Perspectives 20
The Cognitive Perspective 21
The Ergonomic Perspective 26
The Behavioral Perspective 30
The Aeromedical Perspective 32
The Psychosocial Perspective 34
The Organizational Perspective 37
Conclusion 44
3 The Human Factors Analysis and Classification System (HFACS) 45
Reason s Model of Accident Causation 45
Elements of a Productive System 45
Breakdown of a Productive System 47
Strengths and Limitations of Reason s Model 49
Defining the Holes in the Cheese 50
Unsafe Acts of Operators 50
Errors 51
Violations 55
Preconditions for Unsafe Acts 56
Condition of Operators 57
Personnel Factors 60
Environmental Factors 61
v
vi A Human Error Approach to Aviation Accident Analysis
Unsafe Supervision 63
Organizational influences 66
Conclusion 70
4 Aviation Case Studies using HFACS 72
Sometimes Experience does Count 73
Human Factors Analysis using HFACS 75
Summary 82
A World Cup Soccer Game They would Never See 83
Human factors Analysis using HFACS 86
Summary 90
The Volcano Special 91
Human Factors Analysis using HFACS 94
Summary 97
Conclusion 98
5 Exposing the Face of Human Error 99
Quantifying Proficiency within the Fleet 106
Crew Resource Management Training: Success or Failure 111
The Redheaded Stepchild of Aviation 116
Conclusion 121
6 Beyond Gut Feelings... 122
Validity of a Framework 123
Factors Affecting Validity 124
Reliability 124
Comprehensiveness 13 2
Diagnosticity 138
Usability 145
Conclusion 147
7 But What About...? 149
References 757
Index J63
List of Figures
Figure 1.1 The first fatal aviation accident 2
Figure 1.2 Overall and fatal commercial air carrier accidents
worldwide 1961 99 3
Figure 1.3 Accident trends for U.S. general and military
aviation 4
Figure 1.4 U.S. Naval aviation accident rate and intervention
strategies across calendar years 1950 to 2000 5
Figure 1.5 Original straight carrier flight deck and improved
angled carrier flight deck 6
Figure 1.6 Monetary costs of accidents in the U.S. Navy/
Marine Corps from fiscal year 1996 to 2000 8
Figure 1.7 Number of commercial jet accidents, accident rates,
and traffic growth past, present, and future 9
Figure 1.8 Rate of Naval aviation accidents associated with
human error versus those attributable solely to
mechanical or environmental factors 11
Figure 1.9 The engineering investigation and prevention
process 13
Figure 1.10 Human error process loop 17
Figure 2.1 Basic model of information processing 21
Figure 2.2 Decision making model 22
Figure 2.3 A taxonomic framework for assessing aircrew error 24
Figure 2.4 The SHEL model 27
Figure 2.5 Model of accident causation. Successful completion
of the task (top); Unsuccessful completion of the
task (bottom) 29
Figure 2.6 Peterson s motivation, reward, and satisfaction
model 31
Figure 2.7 Epidemiological model of accident causation 33
Figure 2.8 Social factors affecting aircrew error 35
Figure 2.9 The domino theory of accident causation 38
Figure 2.10 The four P s of flight deck operations 41
Figure 3.1 Components of a productive system 46
Figure 3.2 The Swiss cheese model of accident causation 47
Figure 3.3 Categories of unsafe acts committed by aircrews 51
Figure 3.4 Categories of preconditions of unsafe acts 56
vii
viii A Human Error Approach to Aviation Accident Analysis
Figure 3.5 Categories of unsafe supervision 63
Figure 3.6 Organizational factors influencing accidents 66
Figure 3.7 The Human Factors Analysis and Classification
System (HFACS) 71
Figure 4.1 DC 8 with engine number 1 inoperable (marked
with an X ) veers left due to asymmetrical thrust
from number 4 engine 74
Figure 4.2 Steps required to classify causal factors using
HFACS 76
Figure 4.3 Summary of the uncontrolled collision with terrain
of a DC 8 at Kansas City International Airport 83
Figure 4.4 Aircraft descent profile and ground track during the
accident approach 85
Figure 4.5 Sleepiness and performance as a function of time of
day 88
Figure 4.6 Summary of the controlled flight into terrain of the
Learjet one mile short of Dulles International
Airport 91
Figure 4.7 Planned tour route of SAT flights 92
Figure 4.8 Designated, planned, and actual flight path of SAT
Flight 22 93
Figure 4.9 Summary of the in flight collision with Mount
Haleakala, Maui, Hawaii 98
Figure 5.1 Percentage and rate of U.S. Navy/Marine Corps
Class A accidents associated with at least one
violation as defined within HFACS 101
Figure 5.2 The percentage of U.S. Navy/Marine Corps Class A
accidents associated with at least one violation as
defined within HFACS. The mean percentages of
Class A accidents for the U.S. Navy/Marine Corps,
U.S. Army, and U.S. Air Force are plotted with
dashed lines 103
Figure 5.3 The percentage of U.S. Navy/Marine Corps Class A
accidents associated with at least one violation in the
years before and after the intervention strategy was
implemented 105
Figure 5.4 Percentage of accidents associated with skill based
errors. The linear trend is plotted as a dashed line 107
Figure 5.5 Percentage of U.S. military TACAIR and helicopter
accidents occurring between FY 1991 and 2000 that
were associated with skill based errors 109
List of Figures ix
Figure 5.6 Percentage of accidents associated with decision
errors. The linear trend is plotted as a dashed line 111
Figure 5.7 Percentage of accidents associated with crew
resource management failures. The linear trend is
plotted as a dashed line 113
Figure 5.8 Percentage of U.S. scheduled air carrier accidents
associated with crew resource management failures.
The linear trends for the U.S. Navy/Marine Corps
and scheduled air carrier accidents are plotted as
dashed lines 114
Figure 5.9 Percentage of fatal GA accidents associated with
each unsafe act 118
Figure 5.10 Percentage of nonfatal GA accidents associated with
each unsafe act 119
Figure 5.11 Percentage of fatal and nonfatal GA accidents
associated with each unsafe act 120
Figure 6.1 Types of validity with those relevant to error
taxonomies highlighted 123
Figure 6.2 Factors affecting the validity of an error
classification system 125
Figure 6.3 The process of testing and improving the reliability
of an error classification system 126
Figure 6.4 The Taxonomy of Unsafe Operations 127
Figure 6.5 Modifications made to the Taxonomy of Unsafe
Operations. Boxes outlined in dashes represent
category changes. Categories deleted are indicated
with an X 129
Figure 6.6 Additional modifications made to the Taxonomy of
Unsafe Operations. Boxes outlined in dashes
represent category changes. Categories deleted are
indicated with an X 131
Figure 6.7 Percentage of accidents associated with perceptual
errors across military and civilian aviation (1990
98) 143
Figure 6.8 Percentage of accidents associated with skill based
errors across military and civilian aviation (1990
98) 144
Figure 6.9 HFACS as modified by the Canadian Forces (CF
HFACS) 147
List of Tables
Table 2.1 Accident causation within the management system 40
Table 3.1 Selected examples of unsafe acts of operators 52
Table 3.2 Selected examples of preconditions of unsafe acts 58
Table 3.3 Selected examples of unsafe supervision 64
Table 3.4 Selected examples of organizational influences 69
Table 5.1 The number of accidents annually for U.S. commercial,
military, and general aviation 116
Table 6.1 Reliability of the HFACS framework using military
accident data 128
Table 6.2 The person or organization involved with a given
causal factor 135
Table 6.3 What was done or not done by the individual or
organization identified in Table 6.2 136
Table 6.4 Why the what from Table 6.3 was committed 136
Table 6.5 CFIT and non CFIT accidents associated with at
least one instance of a particular causal category 140
Table 6.6 CFIT accidents occurring in clear versus visually
impoverished conditions 141
|
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| author | Wiegmann, Douglas A. Shappell, Scott A. |
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| id | DE-604.BV021974506 |
| illustrated | Illustrated |
| indexdate | 2024-12-23T19:50:25Z |
| institution | BVB |
| isbn | 0754618757 0754618730 |
| language | English |
| oai_aleph_id | oai:aleph.bib-bvb.de:BVB01-015189653 |
| oclc_num | 52090521 |
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| physical | XV, 165 S. Ill., graph. Darst. |
| publishDate | 2003 |
| publishDateSearch | 2003 |
| publishDateSort | 2003 |
| publisher | Ashgate |
| record_format | marc |
| spellingShingle | Wiegmann, Douglas A. Shappell, Scott A. A human error approach to aviation accident analysis the human factors analysis and classification system Fouten gtt Luchtvaart gtt Ongevallen gtt Aeronautics Human factors Aircraft accidents Investigation Flugzeugunfall (DE-588)4017688-5 gnd Klassifikation (DE-588)4030958-7 gnd Menschliches Versagen (DE-588)4126524-5 gnd |
| subject_GND | (DE-588)4017688-5 (DE-588)4030958-7 (DE-588)4126524-5 |
| title | A human error approach to aviation accident analysis the human factors analysis and classification system |
| title_auth | A human error approach to aviation accident analysis the human factors analysis and classification system |
| title_exact_search | A human error approach to aviation accident analysis the human factors analysis and classification system |
| title_full | A human error approach to aviation accident analysis the human factors analysis and classification system |
| title_fullStr | A human error approach to aviation accident analysis the human factors analysis and classification system |
| title_full_unstemmed | A human error approach to aviation accident analysis the human factors analysis and classification system |
| title_short | A human error approach to aviation accident analysis |
| title_sort | a human error approach to aviation accident analysis the human factors analysis and classification system |
| title_sub | the human factors analysis and classification system |
| topic | Fouten gtt Luchtvaart gtt Ongevallen gtt Aeronautics Human factors Aircraft accidents Investigation Flugzeugunfall (DE-588)4017688-5 gnd Klassifikation (DE-588)4030958-7 gnd Menschliches Versagen (DE-588)4126524-5 gnd |
| topic_facet | Fouten Luchtvaart Ongevallen Aeronautics Human factors Aircraft accidents Investigation Flugzeugunfall Klassifikation Menschliches Versagen |
| url | http://bvbr.bib-bvb.de:8991/F?func=service&doc_library=BVB01&local_base=BVB01&doc_number=015189653&sequence=000002&line_number=0001&func_code=DB_RECORDS&service_type=MEDIA |
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