Is There Such a Phenomena as ‘Pilot Error’ in Aviation Accidents

The term Pilot error has been attri stilled to 78%1 of ground forces melodic phrase apoplexys. Despite the technological advances in Rotary Wing (RW) aircraft i. e. , helicopters slashs judged to engineering distress ar decreasing, whilst control error is increasing. Currently, RW virgules are investigated and put kill culture a taxonomy shown to suffer difficulties when coding kind-hearted error and quantifying the while of stillts anterior to an air accident. As serviceman Factors (HF) attributed accidents are increasing, lessons arent being place nor the root arrest is known.Therefore, I propose to introduce Human Factors analysis and Classification dodging (HFACS) an untried taxonomy to the UK army developed as an analytical framework to investigate the role of HF in United States of the States (USA) aviation accidents. HFACS, supports brass instrumental structure, pre-cursors of psychological error and actual error but little explore exists to explain the intra-relations between the levels and comp item-by-itemnts, or the application in the military RW domain. Therefore, I hold still for to conduct post-hoc analysis using HFACS of 30+ air accidents between 1993 to present.Implications of this enquiry are to develop a great recognizeing of how Occupational Psychology (OP) bottom of the inning help voyages understand HF, move on relief valve awareness and reduce HF attributed deathlyities. Introduction On 2 June 1994 an RAF Chinook Mk2 helicopter, ZD 576, dossed on the Mull of Kintyre on a flight from RAF Aldergrove to foregather George, near Inverness. whole on board were killed the two take flights, the two crewmembers and the 25 retrovertengers. This was to shake off been a routine, non-operational flight, to take senior personnel of the security work to a conference.The sortie was planned in advance it was entirely portion for these pilots, Flt Lts Jonathan Tapper and Richard Cook, and for the aircraft, ZD576, to surrender been assigned this mission. An RAF Board of Inquiry (BOI) was convened following the accident and carried out a flesh out probe. BOIs are established to investigate the ca use of serious accidents, primarily, to make safety recommendations but, at the quadrupleth dimension of this crash, to too adjust if human failings were involved.Their stopping point, after an exhaustive investigation was thither was non cardinal single piece of known fact that does not fit the conclusion that this tragic accident was a controlled flight into terrain. The BOI found no order of mechanical failure and multiple witnesses stated that the aircraft come forwarded to be spry at 100ft at 150 knots there was no engine note change, the aircraft didnt appear to be in distress and at the crash film the throttle controls were still in the cruise position (not at essential power if collision with the ground was imminent). 2 So the causation moved to Human Factors (HF). But some qu estions remain unanswered, on that fateful day why did these seas unitaryd and experienced pilots fly their aircraft and passengers into a hillside at 150 knots. If this accident was attributed to HF it now appears to some that the aircrew themselves are more devilish than the aircraft they fly (Mason, 1993 cited in Murray, 1997). The crucial issue consequently is to understand why pilots Flt Lts Jonathan Tapper and Richard Cooks actions made sense to them at the time the fatal accident happened.Relevance of Research So why is this topic relevant to OP research? The British Army branch of aviation is an government c aloneed the Army line of descent Corps (AAC) and in keeping with the trends of the new(prenominal) two services the snuff it look Arm of the Royal Navy and the Royal course Force, it has seen a steep decline in accidents in recent course of studys. However, accidents attributed to Human Factors (HF) have steadily risen and are creditworthy for 90% of only av iation accidents. 3.This research impart depart from the traditional perspective of the label pilot error as the underlying causation of Aviation accidents, whereby current opening and research purport a systemic approach to human factors investigation of Aviation accidents. This approach is derived from concludes Model of Accident Causation, which examines the causal factors of organizational accidents crossways a spectrum of sectors from nuclear power industry (e. g. , Chernobyl), off-shore oil and gas action (e. g. Piper Alpha) to transportation (e. g. Charring Cross) (Reason 1990). This approach recognizes that humans, as comp wholenessnts of socio- expert systems, are involved in designing, manufacturing, maintaining, managing and operating aviation systems including the methods of selecting and priseing potential employees to the aviation industry from Pilots, Cabin crew, Engineers and baggage handlers. Therefore, our ability to identify, understand and manage these pot ential issues en adequate to(p)s us to develop systems that are more error-tolerant, thus reducing risk and the potential for accidents.I intend to be able to provide a more consistent, reliable and detailed analysis of HF causal factors that attribute to aviation accidents inwardly the AAC. On average, the AAC experiences around 6 major accidents per year, although a record year was recorded with only two accidents in 1993. However, in 1992 aviation accidents cost everyplace ?10M4 in taxpayers money. Usually the causation of accidents are classified (human error, technical failure or operational hazard).Whilst there was a reduced suppose of ?1M for 1993, the satisfaction of this financial success was marred by the fact that one of the two accidents resulted in a fatality. However, it is the concept of human error or pilot error that dominates the outcome of most BOIs curiously when there are fatalities. Current taxonomies utilize to classify accident causal groups do not exten d beyond this distinction although more recently organizational factors have been entangled to reflect a more systemic view of accident causation.However, the HF domain is extensive and current taxonomies employed by the AAC do not encapsulate this. By using HFACS (currently adopted by the US Navy, Army, Airforce, and Coast Guard), a human error orientated accident investigation and analysis process I will conduct post-hoc analysis of 30+ category four and five accidents from 1993 to present day. Literature review in advance we start to look at whatsoever reduction in Air Accidents we need to grasp an understanding of category of accident.How m any times when we insure about air accidents, it was pilot error, merely noting HF was responsible doesnt pr point repetition nor identify any critical lessons, positively charged the description is far too generic. The term pilot error doesnt assist us in understanding the processes underlying what fly the coops to a crash, nor does it bump us a means to apply remediation or even identify lessons to prevent re-occurrence. The other issue is that it is very seldom one single factor caused the helicopter to crash. Professor RG Green (1996) uses a smorgasbord method Modes of failure, Aircrew Factors and System failures.Within each of these exist sub-categories. E. g. , in Modes of Failure category lists a number of common errors made by the individual or individuals from selective attention, automatic behaviour, forming inappropriate mental models, affects of pall and perceptual challenges leading to spatial disorientation, particularly common to RW flight. Aircrew factors, refers to telescope factors relevant to individuals decision-making, personality, problem solving, Crew composition, Cockpit Authority Gradient (CAG) and Life stress.Finally, the systems factors relevant to the organization that we serve under, termed enabling conditions such as Ergonomics, Job pressures and organizational Culture. Bodies of Research Now, human error doesnt just happen, usually a range of events will unfold prior to the accident. Human error is a good deal a product of deeper problems they are systematically connected to features of the individuals tools, tasks and the surrounding media (Dekker, 2001).Therefore, in order to provide remediation through the development of strategies it is vital that we understand the various perspectives experienced through flight and how these could answer a pilot these range from cognitive, ergonomic, behavioural, psychosocial, aeromedical, and the agreemental Perspectives (Weigmann and Shappell 2003). Within the environment of human performance error is a unique state of a pilots operational environment that could be change by anyone of, or all of the perspectives.Rasmussen (1982) utilized a cognitive methodology to understanding aircraft accidents. OHare et al. (1994) described the system as consisting of six stages detection of stimulus diagnosis of the sys tem setting the goal selection of strategy adoption of procedure and the action stage. The model was found to be helpful in identifying the human errors involved in aviation accidents and incidents (OHare et al. 1994). One urinate back being that these models using cognition are operator central and do not consider other factors such as the running(a) environment, task properties, or the upervisory and work organization (Wiegmann and Sappell, 2001c). Edwards (1972) developed the HELS system model, which was subsequently called the SHEL model. Citing that humanness do not perform tasks on their own but at bottom the context of a system initially SHEL was a system focussing on the ergonomics and considered the man-machine interface. A tool that notify be use to investigate air accidents through the evaluation of human-machine systems failure. The SHEL model categorizes failure into software, hardware, liveware and environment conditions.However the SHEL model fails to address the functions of management and the cultural aspects of society. Empirical findings dolls Domino Theory (1974) views accidents as a linear sequence of related factors or series of events that lead to an actual mishap. The theory covers the five-step sequence First domain Safety/Loss of control, the second domain, basic causes, identifies the ocellus of causes, such as human, environment or task related. The immediate causes include substandard practices and circumstances. The fourth domain involves contact with hazards.The last domain could be related to personal injury and damage to assets (Bird, 1974 and Heinreich, et al. , 1980). It is much like go dominos each step causes the next to occur. Removing the factors from any of the first 3 dominos could prevent an accident. This view has been expanded upon by Reason (1990). Reasons Swiss cheese model fig 1, includes four levels of human failure organizational factors, brio-threatening supervision, preconditions for unsafe acts and unsafe acts. The HFACS was developed from this model in order to address some of limitations.The starting point for the chain of event is the organization Fallible decisions take place at higher levels, resulting in possible defects waiting for enabling factors (Reason, 1990). Management and safe supervision underpins any air operation through flight operations, planning, maintenance and instruction. However, it is the corporate executives, the decision makers who make available the resources, finances and set budgets. These are then cascaded down through the tiers of management and to the operator.Now this sounds like an efficient and effective organization and according to Reason failures in the organization come about by the breakdown in interactions and holes begin to form in the cheese. Within an organization unsafe acts may be manifested by lack of supervision attributed to organizational cultures operating within a high-pressure environment, insufficient training or poo r communication. The latent conditions at the unsafe supervision level bear on hazard formation and increase the operational risks. Working towards the accident, the third level of the model is preconditions for unsafe acts.Performance of the aircrew can be affected by fatigue, complacency, inadequate design and their psychological and physical state (USNSC, 2001 Shappell and Wiegmann, 2001a Wiegmann and Shappell, 2003). Finally, the unsafe acts of the operator are the direct causal factor of the accident. These actions committed by the aircrew could be either intentional or unintentional (Reason, 1990). The Swiss cheese model sees the aviation environment as a multifaceted system that does not work well when an incorrect decision been taken at higher levels (Wiegmann and Shappell, 2003).The model depicts a thin lining of cheese the veneer symbolizing the defence against Aviation accidents and the dotted holes portray a latent condition or active failure. It is a chain of events t hat usually lead to an accident however as errors are made the holes begin to appear in the cheese, a datum line penetrates the cheese and if all the holes pass through the line, then a catastrophic failure occurs and a crash ensues. These causal attributions of poor management and supervision (organizational perspective) may only be unearthed if equipment is found in poor maintenance (ergonomic).If the organizational culture is one of a pressured environment then this could place unnecessary demands on the aircrew producing fatigue (Aeromedical). Or management could ignore pilots concerns if the CAG was at imbalance (psychosocial perspective). All of these factors could hinder and prevent aircrew from processing and performing efficiently in the cockpit, which could result in pilot error followed later by an Air Accident. However, with Reasons model it doesnt identify what the holes in the cheese depict.For any hinderance strategy to function and prevent reoccurrence the organizat ion must be able to identify the causal factors involved. The important issue in a HF investigation is to understand why pilots actions made sense to them at the time the accident happened (Dekker, 2002). HFACS was specifically developed to define latent and active failures concerned in Reasons Swiss Cheese model so it could be used an accident investigation and analysis tool (Shappel and Weigmann, 1997 1998 1999 2000 2001).The framework was developed and cracking by analyzing hundreds of accident reports containing thousands of human causal factors. Although designed originally for use within the context of the military aviation HFACS has shown to be effective within the civil aviation arena as well (Wiegmann and Shappel, 2001b). Specifically HFACS describes four levels of failure each one corresponds to one of the cheese slices of Reasons model. These are a) unguaranteed acts b) Pre-conditions for Unsafe acts c) Unsafe supervision and d) Organizational influences (Weigmann and S happel, 2001c) MethodologyBy using a combination of qualitative (i. e. the process of recoding causal factors establish on individual and group discussions) and quantitative (causal factor analysis of recoded recitals against HFACS taxonomy) research methodologies to identify further causal groups to be used in classifying accidents and to assess the validity of the HFACS framework as a tool to classify and probe accidents. entropy to be used in this determine will be derived from the write up findings of AAC BOIs conducted between 1990 and 20065. This should equate to approximately 30-35 narratives to be used in the analysis.Authority to access the Board of Inquiry library has been granted by the Armys Flight Safety and Standards Inspectorate, which is the AAC organization responsible for conducting Aviation accident investigations and analysis. Data will only be used that comprises of category 4 accidents (single fatalities and barren damage to aircraft) and category 5 (mult iple fatalities and loss of aircraft). In addition to the narrative description in the report, the following information will also be collected the type of mission in which the accident happened (e. . low-level flying, exercise, HELEARM6) the flight phase (e. g. take-off, in the hover, flight in the operational area, approach, and landing) the rank of the pilot(s) (to circular CAG and see if this is a contributory factor) involved and the type and category of aircraft.This study will concentrate on all Army helicopters including all variants of the Lynx, Gazelle and Squirrel trainer. cryptology frames will be developed and tested for use in the last-place recoding exercise. An Occupational Psychologist from the Human Factors epartment of the MOD will supervise the training and the coders will be a number of RW pilots with a minimum of 1000hours flying time at the time of the research. Each pilot will be provided with a workshop in the use of HFACS framework. This is to ensure par ity and that all coders understand the HFACS categories. After the period of training the raters will be randomly assigned air accidents so that two independent raters can singly code each accident. It is intended to code the inter-rater reliability on a category-by-category basis.The degree of agreement (the inter-rater reliability) initially between the two coders will be achieved by Cohens Kappa (Cohen, 1960Landis and Koch, 1977). SPSS v. 15. 0 will be used to quantify the frequence of causal factors of the 30+ narratives. It is also hoped to compare the inter-rater reliability between all the coders using Fleiss Kappa. Fleisss Kappa assessment method is used to measure the simile agreement of observers and treats them symmetrically (Fleiss, 1981). The level of agreement between the raters is statistically deliberate against what could be achieved through chance.The Kappa level range would be classed as achieving centrist inter reliability if it were between 0. 41-0. 60. Co hens Kappa is based on the statistical meter analysis of the level of agreement between raters in surfeit of (Landis and Koch, 1977). Discussion The research intends to apply an untried methodology not as yet sanctioned by the UKs Ministry of Defence in order to crumple a number of Air Accidents within the AAC between 1993 and present day. 30 plus serious Category 4 and 5 accidents will be re-classified using the taxonomy of HFACS.It is intended where pilot error was the cause, to identify the HF associated and attribute to each accident. It is also hoped that the HFACS taxonomy can accommodate the HF identified during re-coding and consequently provide tangible raise that HFACS could be used by the AAC as a reliable tool. It is hoped a number of comparison analysis can be achieved and are accidents more prevalent when flying in opthalmic meteorological conditions (VMC) or poor visibility instrument meteorological conditions (IMC) therefore two sets of visual conditions VMC a nd daylight or impoverished visual conditions IMC or twilight/nighttime.Wiegmann, D. A. and Shappell, S. A. (2003). What would also be pleaseing was the causation and aircrew behaviours of fatal and non-fatal accidents and are these more prevalent on operations or during training. The agent was in Afghanistan 2006 and over 6-month period there wasnt a single crash let alone fatality. But the AAC records 6 crashes a year so again this is worthy of investigation. The ranks of the pilot is also worthy of interest with regards to achieving a good CAG there may be causal evidence to indicate that an imbalance between ranks could have lead to an aircrash.The Organizational hierarchy will also be researched is it one specific organization that keeps having crashes is there an issue with the pressures placed on the pilots by the organization. The inter-rater reliability will also be calculated by using Fleiss Kappa which will work for more than two raters, it is intended that an acceptab le level of inter rater reliability will be recorded. In addition, the intra-rater reliability as a holistic measurement is hoped to be high in order to support the credibility of the results.An Organization could benefit from gaining a standardized, consistent coding methodology and that data can be used for identifying trends and intervention strategies can then target these trends in accident causation. It is hoped that granularity can be achieved beyond the label pilot error and identify the underlying causation of the accident. If successful and if HFACS is adopted UK military wide, perhaps the real cause of why ZD576 flew into the Mull of Kyntre could be unearthed. If other Military organizations can reap success then HFACS could be a reliable tool to identify causation and could be used in accident investigation.Ethics I will comply fully with the BPS7 ethical principles when conducting research with human participants. All identifiable information relating to individuals di scussed in the narrative findings will be removed in accordance with the data certificate act, for the purposes of analysis and reporting. All participates will be fully appraised of my research, recognize that all the coders are volunteers and give informed consent before the research and to understand how the information will be used.The coders will be reviewing material depiction instances of fatalities therefore it is important that the coders do not come to any psychological harm, over and above the risk of harm in ordinary life (participants will be invited to contact me if participation causes concern at any time or to ask questions). Maintaining a good rapport particularly with the coders is also a desirable. Being an Aeronautical Engineer should also straddle any cultural gaps and maintain a good working relationship.