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Progress in Aerospace Sciences xxx (2017) 1–13

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Progress in Aerospace Sciences


journal homepage: www.elsevier.com/locate/paerosci

A review of human factors causations in commercial air transport accidents


and incidents: From to 2000–2016
Husam Kharoufah a, John Murray a, b, Glenn Baxter c, Graham Wild a, *
a
School of Engineering, RMIT University, Melbourne, Australia
b
School of Engineering, Edith Cowan University, Joondalup, Australia
c
School of Tourism and Hospitality Management, Suan Dusit University, Huahin Prachaup Khiri Khan, Thailand

A R T I C L E I N F O A B S T R A C T

Keywords: Human factors have been defined by the International Civil Aviation Organization (ICAO) as “about people in
Human factors their living and working situations; about their relationship with machines, with procedures and with the envi-
Aviation safety ronment about them; and about their relationships with other people (at work)”. Human factors contribute to
Accident investigation approximately 75% of aircraft accidents and incidents. As such, understanding their influence is essential to
improve safety in the aviation industry. This study examined the different human factors causations in a random
sample of over 200 commercial air transport accidents and incidents from 2000 to 2016. The main objective of
this study was to identify the principal human factor contributions to aviation accidents and incidents. An
exploratory research design was utilised. The qualitative data were recorded in a database, and were coded into
categories about the flights (including date, manufacturer, carrier, state of occurrence, etc). These categories were
then analysed using Chi-Squared tests to determine which were statistically significant in terms of having an
influence on the accidents/incidents. The most significant human factor was found to be situational awareness
followed by non-adherence to procedures. In addition, charter operations proved to have a significantly higher
rate of human factor related occurrence as compared to other type of operations. A significant finding was that
Africa has a high rate of accidents/incidents relative to the amount of traffic and aircraft movements. These
findings reflect some of the more noteworthy incidents that have received significant media attention, including
Air Asia 8501 on the 28th of December 2014, TransAsia Airways 235 on the 4th of February 2015, and Air France
447 on the 1st of June 2009; these accidents resulted in a significant loss of lives where situational awareness and
non-adherence to procedures were significant contributing factors.

1. Introduction 2. How are HFs causes distributed by type of operation in commercial


air transport accidents and incidents attributed to HFs causation over
1.1. Aim the period 2000 to 2016?
3. How are HFs causes distributed by world region (both state of oper-
The purpose of this study is to assess the role of human factors (HFs) ator and state of occurrence) in commercial air transport accidents
in commercial air transport accidents and incidents from 2000 to 2016. and incidents attributed to HFs causation over the period 2000 to
The aim of this assessment is to provide the aviation industry with 2016?
analytical insights to positively impact aviation safety. To provide better
granularity, differences were assessed across 1) world regions, 2) types of
commercial air operation, 3) phases of flight, and 4) type of human error. 1.2. Background
To facilitate this assessment three research questions were identified.
“Human Factors” as an idea is a relatively new subject. The concept
1. What are the most common HFs causes in commercial air transport arose in aviation from work by the UK and North America around the
accidents and incidents over the period from 2000 to 2016? ending of the Second World War [53]. The usage of the term HFs began
informally in literature in British Air Force accident investigation reports

* Corresponding author.
E-mail address: graham.wild@rmit.edu.au (G. Wild).

https://doi.org/10.1016/j.paerosci.2018.03.002
Received 26 November 2017; Received in revised form 2 March 2018; Accepted 6 March 2018
Available online xxxx
0376-0421/Crown Copyright © 2018 Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: H. Kharoufah, et al., A review of human factors causations in commercial air transport accidents and incidents: From
to 2000–2016, Progress in Aerospace Sciences (2017), https://doi.org/10.1016/j.paerosci.2018.03.002
H. Kharoufah et al. Progress in Aerospace Sciences xxx (2017) 1–13

in the 1940s; however, it was first officially used in 1957. The term was decisive for the safety of the aircraft and passengers. The authors state
used to represent the application of scientific knowledge, facts, models, that the process of selecting flight crew and grouping them as per their
and theories derived mostly from various areas of human science such as level of situational awareness consists of 5 vital individual skills which
sociology, psychology, physiology/medicine, engineering, management are: Spatial, attention, memory, perception, and cognitive functions. The
science, and anthropometrics [38]. 5 skills were defined as:
Human error is by no means unique to aviation; it plays a central role
in accidents and financial losses [93]. has defined human error as “any  Spatial: the capability of an individual to interact with the aircraft
member of a set of human actions that exceeds some limits of accept- systems through mental visualization and manipulating objects
ability - it is an out of tolerance action, where the limits of acceptable spatially which are significant for navigational purposes.
performance are defined by the system.” Nowadays, the contribution of  Attention: is the focus on significant details in a demanding environ-
human error in aviation accidents has been a major factor as 66% of ment. The distribution of attention across several, competing sources
hull-loss accidents were associated with flight crew in the period between of information and tasks can be a vital challenge for flight crew during
1992 and 2001 [22]. The impact of human error in general aviation is the different flight phases.
even more significant. For example, 79% of the fatal accidents that  Memory: Memory consists of working memory and long-term memory
occurred in the United States in 2006 were attributed to pilot error [77]. stores. Comprehension and projection of future events that need high
In addition to safety issues, human error can cause huge financial levels of situational awareness must occur in working memory as
losses for the airline industry in the form of tools destroyed, modifica- people try to integrate information from several sources, compare the
tions of flight schedules such as flight delays, and fuel costs. For instance, information obtained to the goals and objectives forecasted, and then
92% of the collisions between aircraft and ground vehicles or structures project future scenarios from known dynamics. While long-term
at airports that were contributed to human error, not including taxiway memory stores, can reduce the load on working memory. According
operations, costs the airline industry globally about 10 billion US dollars to the authors, a deft pilot is differentiated by his ability to know the
annually [79]. As such, it is essential to understand the role of human significance of the details during the flight to know whether the in-
errors in aircraft accidents and incidents. formation should be stored in the long-term memory or not.
 Perception: is the ability of an individual to perceive information in a
2. Literature review short period and to stay aware of infrequent signals to take decisive
actions.
2.1. Flight crew selection  Cognitive functions: is the capability of an individual to deal with
workload and circumvent issues under pressure and extreme envi-
According to [56] for many years, the primary focus of flight crew ronment during the flight.
selection was on the identification of individuals with superior flying
skills and abilities. However [56], explains that, in recent years the These five individual skills should be examined separately in the
aviation community has become increasingly aware that for a flight crew process of flight crew selection to ensure pilots can withstand the
to complete their flight or mission, the flying skills and the ability to work demanding and extreme environment during the flight. Therefore, flight
well in a crew situation during the different phases of the flight are crew should be consistently monitored, trained, and developed to ensure
necessary. Crew resource management (CRM's) skill tests have been their readiness to face all sort of challenges to diminish aircraft accidents
designed to measure problem solving, decision making, and knowledge in the aviation industry [41].
of how individuals perform under pressure with crew members in the
cabin. The authors' findings illustrated that CRM has proved to be more 2.2. Trends in aviation human factors research
effective than traditional methods based on research from scientists
which stated that most aviation accidents are due to miscommunication The term “human factors” has become increasingly popular in the
between crew members in the cockpit. commercial aviation industry as human error has been recognized rather
Another study about flight crew selection presented by Ref. [111]; than technical failure to underlie most aviation accidents and incidents.
focused on testing the individual skills of flight crew in addition to HFs is a very extensive topic in both its knowledge base and scope. HFs
conducting structured interviews to enable human resources to select the involve the collection of information about human abilities, limitations,
best flight crew to fly their aircrafts [111]. conclusions were based on and other characteristics and implementing it to equipment, machine,
substantial research that was completed to find the best method to select jobs, tasks, systems, and environments to generate a safe, comfortable,
pilots. The results illustrated that individuals' tests and structured in- and effective usage by a human. In aviation, the knowledge of how a
terviews is the best method, with the authors discovering a positive human and technology interact in a safe and effective is part of HFs. This
relationship between good interview scores and continued employment knowledge can then be implemented into various areas such as design,
in addition to, a relationship between poor interview scores and flight training, policies, or procedures to enhance human performance [20].
crew being terminated by the company [111]. Much research has been undertaken on the different HFs causes in
Advancement in the aviation sector has led to the discovery of aviation accidents and incidents such as fatigue, situation awareness,
innovative methods, such as profiling [74]. discusses profiling of flight distraction in cockpit, and many other causes. The following sections
crew based on their personalities and mental health. The profiling pro- discussed the most significant HFs in aviation accidents and incidents
cess consists of two methods; select-in and select-out. The select-in such as fatigue, situational awareness, and communication.
method helps in estimating the level of knowledge, skills, and other ca-
pabilities the candidate has for a given job and consists of psychological 2.2.1. Fatigue
testing and measuring the personal traits executed from the analysis of Fatigue is considered one of the most critical factors that has an
the job task. While the select-out method, includes medical techniques impact on the decision making of flight crew members. For instance [25],
and an assessment of psychopathology to observe psychiatric fitness presented a study of major accidents in domestic air carriers from 1978 to
[74]. 1990 produced by the National Transportation Safety Board (NTSB), the
Another study about pilot selection authored by Ref. [41] focused on study estimated that fatigue contributed to between 4 and 7% of civil
the importance of situational awareness of flight crew in the process of aviation mishaps, and data from the US Army Safety Centre suggests
flight crew selection. The authors demonstrated the significance of fatigue is involved in 4% of Army accidents. In addition, statistics from
situational awareness for flight crew to execute the correct action in a the Air Safety Centre blame fatigue for 7.8% of Air Force Class-A mishaps.
short period that can be less than a millisecond which can be very The most significant issue that can be obtained from these data is the

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financial cost of these accidents, as one major civil aviation accident can  Cockpit naps;
exceed $500 million in total financial losses. This was the case in one of  Controlled rest breaks;
the most infamous accidents in aviation history involving flight crew  Caffeine;
fatigue, Korean Air Flight 801 in which 228 people died. Furthermore  Hydration and nutrition; and
[25], presented a survey of flight crew members in both the civilian and  Pharmaceutical options.
military aviation sectors; the international crew surveyed indicated that
sleepiness and lethargy, cognitive slowness, and concentration diffi- These techniques that were recommended by the authors in addition
culties were common causes of flight crew fatigue. International pilots to technological developments can significantly diminish the impact of
regularly attribute fatigue to sleep deprivation and circadian distur- fatigue and enhance safety of in flight operations in even the most
bances related with time-zone transitions. Even though, long-haul pilots difficult circumstances.
are given opportunities to sleep during flights of 12 h or more, research
has proved that sleeping at home is more effective than sleeping in-flight 2.2.2. Situational Awareness
due to noise, turbulence, temperature, and other comfort factors. Do- Another significant HF trend in aviation is situational awareness,
mestic pilots have indicated that their fatigue is due to sleep deprivation which is discussed by Ref. [53]. The author discussed ‘crew situational
and extreme workloads. The survey has indicated many common factors awareness’ which is a unique subject as most in aviation discuss the
for fatigue causation shared by international and domestic flight crew situational awareness for the pilots as individuals. The author believed
such as night flights, jet lag, early wakeups, time pressure, several flight that there should be a greater focus on the crew situational awareness
legs, and successive duty sessions without efficient recovery breaks. rather than focus on the situational awareness of the pilot as an indi-
Another interesting fact indicated by the survey was that 71% of the vidual, as most pilots fly as a member of the flight team. Moreover, the
corporate/executive pilots surveyed reported that they had fallen asleep author discussed the difference between shared and overlapping situa-
during a flight. In fact, 90% of the flight crews surveyed recommended tional awareness [53]. stated that shared situational awareness is when
flight scheduling as a major factor on diminishing fatigue within their all flight crew members have a mutual and a final mutual understanding
operational circumstances [25]. of the flight circumstances. For instance, in the process of an Instrument
[26] also, discussed the effects of fatigue on aviators, from the Landing System (ILS) approach with an individual pilot flying and the
standpoint of flight crew performance where, fatigue plays a significant other pilot observing the instruments, both pilots should have a shared
role in: knowledge. However, in overlapping situational awareness which usu-
ally happens during the normal conduct of the flight, the flight crew will
 Degrading accuracy and timing of flight crew; not have that mutual understanding of the circumstances, in which there
 Diminishing the ability of flight crew to integrate information from are some mutual components between both pilots that ‘overlap’. In
flight instruments; general, flight crew members will be uniquely aware of different aspects
 Narrowing the attention of flight crew and losing the capability to during the flight mission [53]. believed that seeking total shared situa-
efficiently time-share mental resources; tional awareness during the flight is ineffective and inadequate for
 Decreasing the ability of flight crew to do physical activities; members of the flight crew.
 Experiencing perceptual illusions and involuntary lapses into sleep Furthermore [24], observed situational monitoring, information
which may cause task-related details to be missed and failure of flight cross-checking, and activities coordination that are vital skills to set up
crew responses can occur; and situational awareness between flight crew members [98]. had another
 Lowering problem solving and reasoning skills point of view, as he believed that orders from that pilot are significant to
create situational awareness among flight crew members. The author
In general, fatigue greatly affects the capability of flight crew to pay claimed that the pilot's main task during the flight is to receive person
attention to cockpit instruments, radio communications, the coordina- specific information about specific circumstances and translate it to a full
tion of crew, and navigational tasks [26]. image to take actions. Furthermore, the author discussed that the degree
Another interesting study by Ref. [54]; discussed one of the recom- and quality of communication between flight crew members is significant
mended methods to counter fatigue, napping. The author discussed the to enhance the degree of situational awareness assessment.
benefits of strategic naps to flight crews during flights as they can help to
reverse performance deficiency due to sleep loss or disruption, in which 2.2.3. Communication
10 min can be very effective in reducing sleepiness and enhance neuro- The failure of communication and cooperation between flight crew
psychological performance. In addition, strategic naps can be efficient in members during flights has been identified as a main cause of many of
diminishing homeostatic deep drive, which is the gradually augmenting the accidents and incidents in commercial air transport. [49]; presented a
pressure to sleep the longer a person has been awake. The study also study on focus groups of crew members of airlines in which different vital
presented a survey of worldwide commercial airline accidents completed themes were identified. One of the most important themes identified
by Boeing in 2015 that indicated the final approach and landing as the from this study were the barriers to communication during a flight in
most demanding phase of flight. Per the survey, the final approach and which 6 barriers were identified, which were:
landing phases of the flight had the most fatal accidents involving com-
mercial aircraft and indicated the importance of the pilot being fully 2.2.3.1. The protocols of interphone and the locked flight deck door. The
aware of the environment around him. Therefore, to maintain and study has indicated that 81% of cabin crew agreed before discussion and
enhance alertness of flight crew during long-haul flights, commercial then a further 17% agreed after the discussion that a locked cockpit door
airlines should increase the size of flight crews during the flight to allow can be a physical and psychological barrier between crew members. The
pilots to rest in selected bunk facilities, a practice implemented by most study has indicated also the feel of hesitation from the cabin crew to use
air carriers. However, for airlines that do not have additional flight crew the interphone as they were unmindful of the situation in terms of
during a flight, strategic napping can be very effective which can be taken workload in the cockpit. [49]; recommended the installation of video
on the flight deck, although not all airlines allow this practice [54]. cameras by the flight deck door to achieve safety in the cockpit and
Other in-flight fatigue mitigation techniques discussed by Ref. [73] effective communication among crew members.
which can be implemented during the flight to mitigate the impact of
fatigue are: 2.2.3.2. Preflight briefings. Another barrier to communication is the lack
of combined cabin crew and pilot pre-flight briefing; 62% of subjects
 On-board sleep;

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agreed this barrier existed before discussion and a further 11% supported framework, and organization structure required to achieve safety
after discussion. Although it was accepted, briefings were held in two objectives identified by the organization.
different buildings for international crews for all crew members due to  Safety Risk Management – The safety risk management established the
limited space [49]. requirements and quality of new or modified risk controls bases on
the assessment of acceptable risk.
2.2.3.3. Differences in terms and conditions. This aspect is essential to  Safety Assurance – Examines the progressive efficiency of the adopted
effective communication between crew members. Usually, cabin crew risk control techniques. In addition, it supports the identification of
and flight crew stay in different accommodations on transit flights. This new hazards.
results in less effective communication between crew members as they  Safety Promotion – This part of the safety management systems in-
are not able to communicate on the bus or get familiar with each other. In cludes actions to establish a positive safety culture with all de-
general, differences in meals, accommodation, and allowances between partments of the organization such as training and communication.
the two crew groups made communication less effective and adequate
between them [49]. [108]; discussed how HFs in safety management are considered a
competitive advantage. The authors discussed legacy viewpoints, that the
2.2.3.4. Knowledge of basic aircraft terminology. The study has indicated human component in the system should be replaced with reliable tech-
that many cabin crew members do not feel comfortable with the degree nical solutions as human performance is not constant or consistent.
of knowledge they have about the technical aspects of the aircraft in Moreover, the positive view of the human in the system would observe
which many of them face difficulties in describing technical issues that human error in a vital incident as the cause of technical or organizational
occur during a flight. However, the study indicated that this was not an problems such as inefficient interfacing between human and machine or
issue in emergency situations but only in routine conditions [49]. understaffing. Furthermore, the number of serious events in the aviation
industry such as accidents and incidents compared to the amount of air
2.2.3.5. Debriefings after incidents. The process of a debriefing after an traffic yearly is very low [36]. recommends that when an organization
incident is significant for effective communication between crew mem- wants to seek the sources of failure, operational human errors should not
bers. The study showed that cabin crew feel stressed, uncomfortable, and be assumed, but at a higher level away from the organization, since it is
curious wanting to know the causes of incidents. This was an issue for believed that the humans are more than capable of adjusting their per-
18% of the crew members that were involved in the study [49]. formance based on circumstances which leads to success. Furthermore,
[108]; believe that the reason of both success and failure is identical: the
2.2.3.6. Standard operating procedures. Cabin crew members have re- performance of the entire system including the human component can be
ported that they were confused with the standard operating procedures good or poor. The authors believe that the central resource for safety and
(SOPs), in addition to difficulties in understanding the situation in which performance is highly adept, well-trained, and motivated staff.
these procedures should be ignored for safety during the flight [49]. Another significant aspect of safety management systems discussed
by Ref. [105] is the HFs Analysis and Classification System (HFACS) that
2.3. safety management systems- the human component can be adopted by an airline and implemented into its database. HFACS is
one of the most implemented tools to assess the impact of HFs in accident
In the context of aviation, safety is defined by the [67] as “the state in investigation, the system was used to review many military and general
which the possibility of harm to persons or of property damage is reduced aviation accident investigations. The HFACS methodology is imple-
to, and maintained at or below, an acceptable level through a continuing mented in commercial aviation accidents and incidents to enhance safety
process of hazard identification and safety risk management.” in the aviation industry [113].
It is well known that it is impossible for the aviation industry to be The unique aspect about the HFACS methodology is that it is derived
free of hazards and related risk. However, the main objective is to from Professor James Reason's model of human error and Reason's
eliminate aircraft accidents and/or major incidents. Moreover, human distinction between active and latent threats. The main difference be-
tween active threats and latent threats is that active threats are unsafe
activities or human-built systems cannot be assured to be free from
operational faults and their consequences. Consequently, safety risk must acts made by an individual, usually the pilot flying the aircraft while
latent threats are environmental issues contributing to the occurrence of
be progressively diminished as safety is considered a dynamic trait of the
aviation system. It is significant to recognise that the acceptability of an event [91].
[105]; state that HFACS was developed to enhance the completion of
“safety performance” is usually affected by norms and culture. The
aviation system can still be managed to sustain the suitable equilibrium accident investigation which consequently assists 4 levels of framework
connections of causes possibly contributing to accidents, initiating with
between protection and production since safety risks are, to a significant
degree, under control [67]. active and latent threats. However, the Federal Aviation Administration
(FAA) discovered that HFACS assists in supporting many of their objec-
[105]; defined a safety management systems as “a dynamic risk
management system based on quality management system (QMS) prin- tives in their Aviation Safety Action Program (ASAP) which encourages
employees in the organization to voluntarily report safety issues. The
ciples in a structure scaled appropriately to the operational risk, applied
in a safety culture environment.” The safety management system consists HFACS methodology was found out to be very time consuming for pilots
to complete the process of submitting an incident report for ASAP. In fact,
of four significant components which are then divided into 12 elements
which are required for an aviation industry organization to comply with the implementation of the HFACS methodology by the FAA illustrated
that the methodology is very complex for pilots to complete in one report.
the program created by ICAO in its Advisory Circular 120-92A. This
recommendation has been adopted by many organizations around the
world such as United States Federal Aviation Administration (FAA) and 3. Methodology
the Civil Aviation Safety Authority (CASA) [94].
The [47]; state that the four fundamental elements which safety 3.1. Research design
management systems are composed of, are:
Post accident and incident analysis is important for the aviation in-
 Safety Policy – It is vital for the establishment of senior management's dustry to ensure safety is improved from lessons learned the “hard way”.
commitment to gradually enhance safety; defines the procedures, The goal being to ensure the lesson does not have to be repeated. As such,
providing an up-to-date post accident analysis of accidents and incidents
with HF causations is essential, given HFs is the biggest causal factor in

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commercial air transportation [90]. This research problem required a  Category: The type of event, specifically an accident or incident, that
mixed method research design which was a combination of qualitative occurred based on ICAO Annex 13.
and quantitative techniques. The mixed method approach that was  Date of occurrence.
implemented in this research was the exploratory design [80].  State of Occurrence: The country in which the accident/incident
The exploratory design consisted of two phases. The first phase uti- occurred.
lised a qualitative method (document analysis) to collect accidents and  HF causation of incident/accident: The main HF causation that led to
incidents from various databases in addition to reports and documents of the accident/incident. The causes have been adopted from Aviation
accidents/incidents which were analysed to extract the required data. Safety Network which are divided into 8 categories:
The second phase of the research was a quantitative method using cat- o Alcohol & drug usage
egorical data identified in the first phase. This phase of the research o Situational Awareness
focused on testing and generalizing the initial findings using statistics, o Distraction in cockpit
specifically Pearson's Chi-Squared Test. The second phase of the research o Incapacitation
is significant as it displayed trends obtained from the data collected o Fatigue
which was vital to answer the research questions [34]. o Communication
o Non-adherence to procedures
3.2. Data collection o Flight Crew Selection
 Aviation Occurrence: This term is used by Ref. [63] to categorize
In the aviation industry, when investigating an incident or accident aircraft accidents and incidents. The aviation occurrences for the
there are two basic groups of fundamental factors to consider: database were divided into 36 different categories.
 Phase of flight: This term is used by Ref. [66] to categorize the part of
 Causative factors - failure of vital parts of equipment or human errors; flight in which the accident/incident happened. Specifically:
and o Takeoff
 Contributory factors - feature of the job or conditions in which the o Initial climb
task is completed that stimulate failures of human. o En route
o Approach
Causative factors are easier to determine than contributory factors as o Landing
they are related to the sequence of events in an accident or an incident. o Taxi
For instance, when a pilot fails to lower the landing gear the aircraft  Aircraft manufacturer.
crashes on landing. On the other hand, contributory factors are more
difficult to determine as these are only probabilistically associated with Given the importance of data quality, the quality of data was assessed
the outcome of the accidents. For example, loss of situational awareness, based on the following criteria used by Ref. [67] in their safety man-
lack of communication, fatigue, etc., will not always result in an accident agement manual:
or an incident; however, they can augment the possibility of human error
occurrence. Regarding investigation of HFs accidents and incidents, this  Validity: The data collected complied with the established criteria for
research focused mostly on contributory factors rather than causative, their proposed use.
which was a challenge as it is more difficult to determine contributory  Completeness: All relevant data is available.
factors than causative factors [53].  Consistency: The degree to which measurement of a given variable is
In this research, accidents and incidents data were collected from consistent can be regenerated and circumvents errors.
several accidents and incidents databases, specifically:  Accessibility: Data is readily accessible for analysis.
 Timeliness: Data should be suitable to the time period of interest and
 Aviation Safety Network database sponsored by Flight Safety obtainable promptly.
Foundation;  Security: Data is secured from inadvertent or malicious modifications.
 National Transportation Safety Board (NTSB) aviation accident  Accuracy: Data is error-free.
database & synopses;
 Australian Transport Safety Bureau (ATSB) National Aviation 3.3. Data analysis
Occurrence Database;
 Planecrash Info database (planecrashinfo.com); Occurrence data was analysed using Pearson's chi-square test. Spe-
 Aviation Safety Reporting System (ASRS) Database Online; cifically, the chi-square test helped in comparing the relative frequencies
 Bureau of Aircraft Accidents Archives (B3A); of accidents and incidents [80]. Pearson's chi-square is a statistic used to
 FAA Accident and Incident Data System (AIDS); and measure the relationship between two different distributions. For
 The Aviation Herald database. instance, if it was discovered that the distributions were the same, then it
could be inferred that the region or the type of commercial air trans-
The occurrences collected were logged into a database. The database portation etc, do not contribute to HFs related occurrences [50].
consisted of thirteen fields that were adopted from the National Trans- Pearson's chi-square test is ideally suited to analyse categorical data.
portation Safety Board (NTSB) aviation accident database and synopses. The test can assess if the observed frequencies significantly differ from
Specifically: the expected frequencies, and if the observed frequencies are due to
chance or not. In this analysis, as it was vital to have a statistically sig-
 Type of Operation: The type of air carrier involved in the accident/ nificant relationship, a 95% confidence level was used [18]. The statis-
incident which are categorized into 6 types: tical hypotheses for a chi squared test are given as:
o Full Service Network Carrier
o Low Cost Carrier H0: pO,n ¼ pE,n
o Cargo HA: pO,n 6¼ pE,n
o Regional
o Charter where p is the proportions of the n-th category, for the observed, O, and
o Ambulance (or aeromedical) for the expected, E. The null hypothesis (H0) can therefore be expressed
 State of the operator: The country in which the airline operates. as, “the proportions of HFs occurrences are equal to the proportions for

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commercial air transport operations, for the different categories”. more occurrences than for charter aircraft. However, the fact that only 1
Conversely, the alternative hypothesis (HA) is that “the proportions are in 207 was an occurrences involving an air ambulance show that these
not equal”. The chi square statistic, or χ2, is given by Ref. [18], have a high level of safety involving HFs. It is worth noting that only a
small number of aircraft (~67) are responsible for the 77 thousand
X
n
ðOi  Ei Þ2 movements in the RFDA; as such, if the rate of occurrences per aircraft
χ2 ¼ ; (1)
i¼1
Ei were considered the result of air ambulances may be more significant,
highlighting a potential limitation with the data set.
where there are n categories. The number of degrees of freedom, ν, is It is commonly thought by many that LCCs are less safe than other
given as n – 1 for each test. The critical value was then determined from carriers, but this is not the case as LCCs have very good safety records; in
the degrees of freedom using the χ2 table, with a 95% confidence level. fact, many of the major budget carriers have never experienced an ac-
Finally, if χ2 was less than the critical value H0 was accepted, otherwise cident. LCCs operate within a budget by spending less money on
H0 was rejected. customer service while they get their savings from efficient operations;
however, they do not cut corners in regard to maintaining safety stan-
4. Quantitative analyses and discussion dards. For instance, Ryanair and EasyJet, Europe's two largest LCCs, have
never had major accidents or any fatalities during their operations. The
4.1. Type of operation same scenario is in North America, in which JetBlue and Spirit had never
had major occurrences. Moreover, the Jet Airliner Crash Data Evaluation
4.1.1. Analysis Centre in Germany has rated four main LCCs in the world (JetBlue,
The accidents and incidents collected in the database were catego- WestJet, Southwest and Ryanair) as safer than the American Airlines, the
rized into 6 types of operation in commercial air transport. In the absence largest carrier in the world. In regard to the Asian market environment
of specific data by airline business model (number of flights operated on for LCCs, it is not that clear as regulatory standards differ from one
annual basis by type of carrier) it was necessary to develop a proxy to country to another. For instance, Malaysia and Indonesia have serious
undertake the Chi-Squared test analysis. Knowledge and data for the issues in regards of their regulations which explain the reason Indonesia's
Australian Aviation industry was used for this proxy. Data was gathered Lion Air is banned in Europe. However, other countries in Asia like
from Qantas Group (Qantas and JetStar Domestic), Virgin Australia Singapore have highly regarded regulatory agencies which is illustrated
(Virgin Domestic, Tigerair, and Virgin Australia Regional Airlines), by the small number of occurrences in these countries [84]. In other
Regional Express Australia, the Royal Flying Doctor Service, and the world regions, for example, Africa and South America, the LCCs are in
Bureau of Infrastructure, Transport and Regional Economics (BITRE). their relative infancy stage of their market development [87].
The Chi-Squared test was implemented to identify the difference In regard to air cargo carriers, the observed value was significantly
between the two sets of data; observed and expected. The analysis results, greater than the expected value, therefore air cargo operations are more
as shown at the top of Fig. 1, shows that there was a significant difference prone to occurrences involving HF causations, relative to other type of
between the value calculated from the Chi-squared test and the expected carriers such as air ambulance, LCCs, regional airlines, and FSNCs. The
value from the chi-square distribution table for a 95% confidence level. Flight Safety Foundation have noted that the accidents rate of United
Thus, the null hypothesis of no difference between the different types of States all cargo operations are two to five times higher than the accident
operation for HF related accidents and incidents was rejected. rate in passenger and combined passenger/cargo operations. Moreover,
the Air Line Pilots Association (ALPA) claimed that freighter aircraft
4.1.2. Discussion pilots that have night shifts lose an approximately 2 h of sleep per day
As seen in Fig. 1, there are a number of significant differences for the which results in a total sleep deficit of more than 8 h at the end of the
observed relative to the expected. Looking at the “individual chi squared week. Another issue found in the United States by the pilot's union is the
scores”, prior to the summation in (1), then both ambulances and LCC inconsistency in the establishment by airlines of modern safety programs.
present a significantly lower proportion of occurrences involving HF For instance, in 2005, there was only one cargo airline of the 12 airlines
causations. Similarly, cargo and charter present a significantly higher in the flight operational quality assurance (FOQA). Four cargo airlines
proportion of occurrences involving HF causations. were included only out of the 32 aviation safety action programs. Also, of
For air ambulance, if we look at the expected value, which was based 16 line operations safety audits being conducted by air carriers, none was
on the large number of movements annually, we would expect to see by a cargo airline. It can be said that cargo operators in North America
have several issues in regards to their cargo operations [78].
Furthermore, the type of carrier with the most significance difference
between the observed and expected values were charter carriers. There
have been 19 occurrences observed in North America out of the 43
different occurrences which is almost 44%. Charter carriers are consid-
ered the most fatal type of carriers in the United States compared to other
type of carriers in commercial aviation. The issue with charter operations
in North America and particularly the United States that privately-owned
aircrafts are not regulated by U.S law. Another issue determined is that
the Federal Aviation Administration does not frequently inspect charter
operators, and most of the times pilots are the ones who decide when it is
safe to land or the total number of hours they have worked [81]. In
addition, the FAA does not impose age limits for charter pilots like other
commercial carriers in which they must retire at age 64 [89]. Therefore,
charter operators should adhere to stricter safety standards to diminish
the number of fatal accidents.
Surprisingly, regional carriers have a slightly lower observed value
than expected but not that significant; therefore, it can be said that
Fig. 1. Number of HF related accidents and incidents (count) categorized by regional carriers have a good safety record. In regard to FSNCs, the
type of operation in commercial aviation. Note: LCC is Low Cost Carrier, and number of observed occurrences (69) is almost equal to the expected
FSNC is Full Service Network Carrier. value (73) which means that FSNCs did not have a significant impact on

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H. Kharoufah et al. Progress in Aerospace Sciences xxx (2017) 1–13

the result of the Chi-Squared analysis. The FSNC comparison serves as a Europe due to safety concerns. Also, IATA had credited Africa with a rate
metric to validate the proxy used for the expected values. of 9.2 in 2005 for a much-required infrastructure enhancements and
To address the second research question, it can be stated from this technology developments on the region to enhance the safety records [8].
section that charter carriers have the most number of HF-related acci- To address the first half of the third research question, it can be
dents and incidents over the period 2000 to 2014 in commercial aviation. concluded that Africa is the state of operator with the most number of HF-
related occurrences in commercial air transport from the year
2000–2016.
4.2. State of operator
4.3. State of occurrence
4.2.1. Analysis
The HF occurrences were grouped into 7 different regions in the word 4.3.1. Analysis
for state of operator. For this category, a Chi-Squared test was conducted The HF accidents and incidents were categorized into 6 regions ac-
by testing the data collected in comparison with total fleet of aircraft in cording to their state of occurrences (where the occurrence happened, as
2016 from Ref. [23] Current Market Outlook 2017–2036. A Chi-Squared opposed to where the operator is based analysed in Section 4.2). In
test was used to determine if there was a large difference between the regards to this category, a Chi-Squared test was implemented to examine
data collected and the expected values. The value calculated from the the HF related occurrences in each region collected in relative to aircraft
chi-square test, top of Fig. 2, indicated that there was a significant dif- movements in each region that were extracted from the ICAO Facts and
ference with the expected value from the chi-square distribution table for Figures: 2015. Similar to the analysis of the state of operator, the regions
a 95% confidence level. Therefore, the null hypothesis of no difference initially identified were edited to correspond to the ones used by
between the states of operator for HF related occurrences was rejected. Ref. [68]. Therefore, the occurrences that happened in the CIS region
were placed in the Asian region to achieve consistent results. As can be
4.2.2. Discussion seen in Fig. 3, there was a significance difference between the observed
From Fig. 2, we can note that North American operators had a lower and expected value from the chi-square distribution table for a 95%
occurrence rate than the expected rate as with other operators in Asia and confidence level. Thus, the null hypothesis of no difference between the
the Middle East. While operators in Latin America and the Common- states of occurrences for HF related accidents and incidents was rejected.
wealth of Independent States (CIS) had almost equal observed and ex-
pected occurrences rates. However, the only region that had higher 4.3.2. Discussion
observed rates than expected were European and African. Despite this, From Fig. 3 we note that both North and Latin America and the
Europe did not have a significant impact on the chi-square test result, but Middle East observed values are below the expected. Asia Pacific and
African operators had a significant impact on the chi-square test result Europe had almost equal observed and expected rates which meant that
after the chi-square test was repeated by removing the variables of the they do not have a significant impact on the chi-squared value. However,
corresponding regions. The [1] indicated that the below standard African the only region that had a significance difference between its observed
aviation safety records since 2000 can be clearly demonstrated by the and expected values was Africa in which the observed rate was signifi-
small, poorly regulated carriers in which, these pilots are poorly trained cantly greater than the expected rate.
and usually work long hours in a dangerous operating environment. The reasons in which many occurrences happened in Africa are
Many international organizations such as ICAO have identified poor similar to the reasons mentioned in the discussion of the state of operator.
regulatory oversight as the top threat to safety in Africa, followed by poor However, as most of the African airlines excluding a few FSNCs such as
safety management. The African Development Bank Group has stated Ethiopian airlines (a member of Star Alliance), and Kenya Airways, are
that every region in Africa performs worse than the world average in banned from flying into Europe and the limitation of flights into other
most cases by a factor of 2 in every single aspect of safety implementa- regions. Therefore, in relative to the analysis it can be said that most of
tion. Moreover, these deficiencies are highly correlated with accident the flight accidents were regional within Africa in which the main rea-
rates, suggesting that the failure of operator's regulations in demon- sons of these accidents according to [95] were:
strating much of the poor African safety record. The International Air
Transport Association (IATA) stated in its 2006 safety report that with  The prohibition of carriers from maintaining and upgrading their
each million aircrafts taking off in Africa, 4.31 become unusable due to aircraft and infrastructure due to the lack of resources.
accidents compared to the world rate of 0.65. Another indication of
Africa's poor safety records is that 111 African airlines were banned in

Fig. 2. Chi-square test of HF related accidents and incidents categorized by state Fig. 3. Chi-square test of HF related accidents and incidents categorized by state
of operator. Note: CIS is Commonwealth of Independent States. of occurrence.

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 The underdeveloped air traffic control infrastructure contributes to  Unstabilized approach: The unstabilized approach proved to have
poor safety of many carriers. vital role in 20% of all incidents. The violations were:
 Poor airport infrastructure that led to fears from international orga- o 58% too high
nizations about the safety of air traffic in this region. o 57% too fast
o 27% due to lateral offset
This answers the second half of the third research question; that is, o 17% too low
Africa is the state of occurrence with the most number of HF-related o 21% due to incorrect configuration
accidents and incidents in commercial air transport from the year  Deviation from ATC clearances: The error ensues almost always un-
2000–2014. consciously, which shows the level of pressure in the cockpit. The
type of error contributed to 19% of all occurrences. Out of these
4.4. HF causation incidents:
o 45% contributed to flying at an uncleared flight level
4.4.1. Analysis o 22% is attributed to course deviation
The HF occurrences were grouped into 8 different HF causations. The o 21% is attributed to deviation from a standard terminal arrival
Chi-Squared test was undertaken to test the association between the route (STAR) and Standard instrument departure (SID)
observed and expected values. Here, no specific expected distribution o 10% is attributed to takeoff or landing without clearance
was expected, and hence what needed to be determined was if the pro-  Basic flying: The study proved that there are deficiencies with flight
portions of HF occurrences were uniform or not. The value calculated crew members flying capabilities in which this type of error
from the chi-square test, Fig. 4, indicates that there was a significant contributed to 19% of all incidents. Out of these incidents:
difference with the expected value from the chi-square distribution table o 60% happened while target parameters were corrected
for a 95% confidence level. Therefore, the null hypothesis of no differ- o 33% happened in the landing phase
ence between the HF causations for HF related occurrences was rejected. o 21% happened in the taxiing phase
o 10% happened during go-around
4.4.2. Discussion  Equipment operation: The study proved that crew members are well
From Fig. 4, it is noted that situational awareness (SA) was the most familiar with the aircraft and its functions; it is all a matter of self-
significant HF causation in the sample. The increase rate of occurrences discipline to solve this issue. This error accounts to 18% of all in-
contributed to situational awareness can be due to the difficulty in cidents. Out of these incidents:
achieving accurate situational awareness [86]. state that to achieve ac- o 30% is attributed to wrong inputs
curate situational awareness at least eight individual skills are required, o 20% is attributed to mistakenly omitted component actuation
to establish a minimum skill set. After achieving situational awareness, o 14% is due to stimulating the wrong switch
other critical skills such as effective threat and error management, o 14% is attributed to actuating the incorrect mode.
making decisions concerned of risk and managing the aircraft's systems,
stimulate an additional level above situational awareness. Consequently, Unsurprisingly, the consumption of alcohol and drugs in regard to HF
this controls the situation which is vital to maintain ideal and safe flight related occurrences showed a significantly lower observed value than
path management. what was expected. The low rate of HF occurrences involving the con-
Another common HF causation in sample was the non-adherence to sumption of alcohol and drugs was mainly due to the strict laws and
procedures by flight crew members. The high number of occurrences regulations in regards to this issue. For example, the Civil Aviation Safety
associated with this type of HF causation, can be clearly seen in the ATSB Authority (CASA) in Australia developed the Drug and Alcohol Man-
database as it recorded 197 different occurrences only in 2014 [10] [37]. agement Plans (DAMP) program under CASR Part 99 in 2009. The part
intensively studied Lufthansa incidents from 1997 to 1999 in which 2070 99 established a legislative framework for the developments of DAMP in
pilots participated. The study found that flight crews were aware about addition to a no-notice alcohol and other drug (AOD) testing adminis-
the importance of Standard Operating procedures (SOPs), nevertheless tration for all individual involved in safety sensitive aviation activities.
the procedures were breached several times, either knowingly or un- The purpose of the DAMP program is to guarantee that all individual
knowingly. The study has grouped non-adherence to procedures that under the effect of AOD while undertaking any sensitive aviation activ-
contributed to 77% of the incidents to four categories which were: ities are determined and tested [32]. Since DAMP related violations are
so uncommon, especially in commercial air transport, it is not surprising
to note that when it does happen it is highly publicised, like the recent
incident in Canada, which ultimately resulted in a jail term [100].
Other HF causations almost had equal or slightly different observed
and expected values with no significant impact on the result of the Chi-
squared test. This section contributes significantly to answering the
first research question, such that situational awareness and non-
adherence to procedures are the two most significant HF causations.

4.5. Aviation occurrence category

4.5.1. Analysis
The HF occurrences collected in the database were placed in 18
different aviation occurrence categories. The comparative data was taken
from the ICAO iSTARS API Data Service [70]; that is, the expected value
was all ACCIDENTS reported by ICAO, including HF and non-HF occur-
rences. The reduction in categories was necessary as a limitation of the
Chi Squared test is that no more than 80% of the categories can contain
an expected value less than 5 [18]. As such, all the less significant cate-
Fig. 4. Chi-square test of HF related accidents and incidents categorized by HF gories were omitted (for example, turbulence and wildlife, which are
causation. Note: SA is Situational Awareness. external factors to the aircraft). Although significant in size, the unknown

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H. Kharoufah et al. Progress in Aerospace Sciences xxx (2017) 1–13

category was also omitted. As displayed in Fig. 5, the chi-square value 4.6. Phase of flight
calculated was significantly greater than the critical value so it can be
said that there was a significant difference between the between the 4.6.1. Analysis
observed and expected values for a 95% confidence level. This led to It is vital to know the phase of flight in which HF occurrences happen.
reject the null hypothesis of no difference between the aviation occur- Therefore, the occurrences collected in the database were categorized
rences associated with HF accidents and incidents. into the main 6 phases of flight. To implement the Chi-Squared test, the
phases of flight used in Ref. [23] Statistical Summary of Commercial Jet
4.5.2. Discussion Airplane Accidents from 1959-2016 were aligned to match the phases used
Fig. 5 shows that the loss of control-inflight (LOC-I) and controlled in the database which were taken from Ref. [66]. The Chi-Squared test
flight into terrain (CFIT) were the most statistically significant aviation conducted proved that there is a significance difference between the
occurrence categories for the HF occurrences from 2000 to 2016. That is, chi-squared value and the expected value from the chi-square distribu-
their observed values were significantly larger than the expected values tion table for a 95% confidence level. Accordingly, the null hypothesis of
[3]. indicate the two main accident categories that accounted for the no difference between the different phases of flight in association with
majority of aviation accidents were loss of control-inflight (LOC-I) and HF related accidents and incidents was rejected.
controlled flight into terrain (CFIT). The statistical analysis report
generated by Airbus shows that LOC-I was responsible for the most 4.6.2. Discussion
number of fatal occurrences from the period 1995–2014 while it was Fig. 6 shows that the phase of flight that had a significantly greater
considered the third main source of hull losses during the same period. observed value than expected was en route. This meant that the en route
Regarding CFIT, it was considered the second main sources of fatal ac- was the phase of flight in which most HFs occurrences happened more
cidents while it is the third main source of hull losses in aviation. The than expected [110]. states that the most fatal aviation phase is when the
individual score for overshoot or undershoot is also statistically signifi- aircraft descend from its cruising altitude in establishing its approach to
cant, indicating that HF occurrences result is a greater number of these its destination. This phase of the flight is considered part of the en route
then other contributing factors. The lack of HF occurrences that result in
system component failures is significantly less than expected, which is
not surprising. That is, a significant degree of automation has removed
many of the direct ways in which human error by the pilot can directly
result in a system or component failure. In legacy aircraft where a flight
engineer was responsible for starting and maintaining engine settings,
damaging an engine could be easily achieved with a lack of situational
awareness. Of more interest are runway excursions and abnormal runway
contact, which are much less than expected; it would also be plausible to
hypothesis that these would be closely related to HF causations. It should
also be noted that for comparison, all ICAO occurrences was also
considered for the expected distribution; however, the only category that
was significantly different statistically, was SCF, which was even more
common for all ICAO occurrences, and the resultant chi squared value
was 876.
The conclusion of this section also adds to the answer of the first
research question, indicating that HF causations are strongly linked to a
spike in loss of control in flight occurrences.
Fig. 6. Chi-square test of HF related accidents and incidents categorized by
phase of flight.

Fig. 5. Chi-square test of HF related accidents and incidents categorized by aviation occurrence category.

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H. Kharoufah et al. Progress in Aerospace Sciences xxx (2017) 1–13

phase which combines climb, cruise, and descent as mentioned in the the issue is not only with Ilyushin, as according to the chi-squared test
ICAO phase of flight taxonomy. As reported by Boeing, 59% of the fatal conducted as seen in Fig. 7, all aircraft manufacturers that are established
accidents that occurred between 2007 and 2016 occurred during descent, in the Commonwealth of Independent States (CIS) and especially
approach, and landing. However, accidents that occur during the cruising Ukrainian and Russian aircraft manufacturers such as Antonov and
part of the en route phase tend to be very catastrophic. For instance, the Tupolev have proved that they have relatively poor safety records [101].
42 occurrences documented in the Boeing study claimed 2226 lives, indicates that the Russian and Ukrainian aircraft manufacturers have
which accounted for 58% for all commercial airline fatalities. recorded 56 fatal crashes. Antonovs are still used in 80 countries around
Unsurprisingly, the phase of flight which showed significantly less the world [51], the Ilyushins are mostly used for air cargo operations in
observed values than expected was aircraft taxing phase because this type which Cubana airlines have 4 of the 11 that are still in operation [5],
of occurrences generally happen at a very low speed. In the [23] study of while for the Tupolevs, especially the Tu-54 are mostly used in the CIS
commercial aviation that covered most aircraft manufacturers and re- region, by the national carrier of North Korea, Air Koryo and a charter
gions, it was stated that 10% of all fatal aviation accidents over the last carrier in Egypt, Cairo Aviation [33].
decade happened when aircraft were taxing, unloading or loading pas- In an article written in Forbes magazine by Ref. [82]; the reason for
sengers and baggage, being towed or parked. In fact, only one passenger the Russian and Ukrainian aircraft manufacturers' poor safety records as
died during a taxing accident in a decade [110]. explained by the author is the famous hyperinflation in Russia in the
Both takeoff and initial climb were the next most significant phases, 1990s which caused the aviation industry to collapse. Accordingly, the
much more significant than approach and landing. That is, takeoff and production of aircrafts dropped to dozens instead of increasing by hun-
initial climb have slightly high proportions for HF occurrences relative to dreds, this has made Russian and Ukrainian aircrafts rare which made it
all occurrence from 2007 to 2016. This contributes to answering the first difficult and costly to service these aircrafts. Moreover, other aircraft
research question, where HF causations result in a larger proportion of manufacturers like Boeing have integrated an extensive worldwide
occurrences while en route, followed by takeoff and initial climb. network to rush parts to grounded aircraft, finding a part for a broken
Antonov or Ilyushin could take several weeks and sometimes it is
impossible to find some of the aircrafts' parts. This did not only result in
4.7. Aircraft manufacturer losses for Russian operators flying old Russian aircrafts but also issues for
these manufacturers, who, in the beginning of 2000s resorted to be
4.7.1. Analysis known as “aviacannibalism”: the breakdown of aircrafts for parts to
The HF related occurrences collected in the database were grouped by service other aircrafts.
aircraft manufacturer. The expected aircraft fleet data was taken from Other major aircraft manufacturers such as Boeing, Airbus, and
airfleets.net and ch-aviation.com databases to undertake the Chi-Squared Embraer proved to have unsurprisingly very good safety records as
test for this category. As it can be seen in Fig. 7, the chi-squared value observed values were less than what was expected. Conventionally,
calculated is significantly greater than the expected value from the chi- Airbus and Boeing tend to avoid safety comparisons when selling their
square distribution table for a 95% confidence level. Accordingly, it aircrafts to operators [109]. It can be said that manufacturers with more
can be said that the null hypothesis of no difference between aircraft aircraft in operation tend to have better safety records than the ones with
manufacturers in relation with HF related accidents and incidents was fewer aircrafts.
rejected.
5. Qualitative analyses and discussion
4.7.2. Discussion
As shown in Fig. 7, many aircraft manufacturers have proved to have A qualitative analysis of three recent airline accidents indicates the
poor safety records. However, the aircraft manufacturer with a signifi- importance of situational awareness in the operational setting and how
cantly poor safety record that had a significant impact on the result of the the degradation of situational awareness amongst crew is a significant
analysis was the Russian manufacturer, Ilyushin in which 3 occurrences contributory factor in an accident. As with an earlier study [72] most
were observed out of the 11 aircraft in operation. However, it seems that

Fig. 7. Chi-square test of HF related accidents and incidents categorized by aircraft manufacturer.

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situational awareness errors within the reviewed accidents were at an ATR72 as they took off from Taipei's Songshan Airport in February
Endsley's [39] perception (Level 1) or understanding (Level 2) levels of 2015.
situational awareness. Also, noted as occurring in the accidents is the As the aircraft climbed through 1200 feet after take-off the propeller
different levels of situational awareness developed by different members of number 2 engine shut down and feathered and a warning that the
of the crew which has been identified by Ref. [103]. number 2 engine had flamed out was displayed in the cockpit.
The crew's response began with the Pilot Flying stating that he would
5.1. Air France 447 retard the number 1 engine throttle, which was the still working engine.
The Pilot Not Flying asked to firstly cross-check but the number 1 engine
On the 1st of June 2009, an A330 operated by Air France while on throttle was already being retarded. As the crew communicated about the
cruise from Rio de Janerio to Paris stalled and crashed killing all 228 required checks they identified that the number 2 engine had failed when
people aboard. The triggering event was the freezing over of the pitot the monitoring pilot announced, “okay now number 2 engine flameout
tubes resulting in inconsistent airspeed measurements. The active error confirmed” [12–14]. (P. 12). Despite this the number 1 engine throttle
was the loss of situational awareness amongst the crew leading to the remained in a retarded position. From the information being provided to
aircraft departing from the flight envelope [106]. the pilots they did not correctly perceive which engine had failed.
The loss of situational awareness arose when the auto pilot and auto With a continuing climb attitude the stall warning sounded. The
throttle disengaged due to inconsistent airspeed measurements arising response of the pilot monitoring was to call, “okay push, push back”
from blocked pitot tubes, surprising the crew with control of the aircraft [12–14] (p. 13) a very confusing command in the cockpit. If the intention
changing from normal law to alternate2B law [16]. was to lower the angle of attack of the aircraft – a correct response to a
The response of the pilots on the flight deck (the captain had earlier stall warning – the control column would normally be pushed forward as
left the flight deck for a rest period) was to take control. The aircraft against it being pulled back if the intention was to have the aircraft climb.
rolled to the right because of turbulence and the pilot flying attempted to There was then a call from the Pilot Not Flying for a throttle to be
correct with a left sidestick input that also had a nose-up input. The stall advanced. The number 2 (the dead engine) was advanced and the
warning sounded twice briefly. number 1 throttle (the operating engine) fully retarded to the idle posi-
The Pilot Not Flying began to perceive (Level 1) the status of the tion. A bank to the left was experienced by the aircraft.
changed operating environment when he announced that speeds had The Pilot Not Flying now identified that they had “lost both sides” and
been lost and that alternate law protections were now in place. However, the Pilot Flying's response was to call for a restart of the engine (called for
“erroneous airspeed indications and ECAM (Electronic centralised eight times). The report does not state if the Pilot Flying stated which
aircraft monitor) messages did not help with the diagnosis” and the pilots engine he wanted re-started as it would appear that he still had not
did not fully perceive what was happening nor ascend to Level 2 of correctly identified which engine had originally failed. However, the
situational awareness through integration of the various pieces of in- number 1 throttle was partially moved forward. Seven seconds later the
formation regarding the status of the flight allowing the pilots to arrive at PF acknowledges his lack of awareness of what was happening with his
an understanding of what was happening. aircraft when he states; “wow pulled back the wrong side throttle”
The lack of Level 1 SA can be noted in both pilots failing to [12–14] (p. 13).
acknowledge the stall warning and the lack of Level 2 situational The partial movement of the number 1 throttle lead to a large amount
awareness is seen in the crew not identifying the aircraft had reached a of drag being generated on the left side of the aircraft without an increase
stalled condition, [17]. in generation of thrust. The asymmetric drag lead to the aircraft yawing
However, it would appear the Pilot Not Flying developed a fuller and rolling to the left.
awareness of the situation when he told the Pilot Flying the aircraft was Seven seconds after acknowledgement of their incorrect diagnosis
climbing “and asked the Pilot Flying several times to descend” [16]; (p. and actions the EGPWS sounded, the aircraft increased its roll to the left
22). The report summarises these callouts as “imprecise flight path cor- (approximately 80 ), contacted a road bridge and a car on the bridge and
rections. They were, however, essential and sufficient for short-term hit the river in an inverted position. Forty-three crew members and
management of the situation.” (p. 199). passengers were killed and the remaining passengers survived with
In response to the PNF the PF attempted nose-down inputs but the serious injuries.
aircraft continued to climb. The stall warning again sounded, this time
for 54 s. The aircraft also experienced strong airframe buffeting. The PF 5.3. Indonesia Air Asia QZ8501
increased throttle setting to TO/GA (take-off/go around) and maintained
nose-up input. The report identifies that the aircraft reacted correctly to During a routine flight from Surabaya, Indonesia, to Singapore on 28
the inputs from the pilot controls. The aircraft remained in a stalled December 2014 poor pilot responses to a developing situation caused by
condition until the end of the flight when it collided with the ocean. equipment failure led to QZ8501 an A320 aircraft entering a stall the
Enhancing the situational awareness of a crew is finding the “right pilots did not recover from and the flight ended with it crashing into the
adequacy between the cognitive capacities of pilots and the signals that ocean killing all 162 people aboard the flight.
are provided to them to understand and act on” [106]; (p. 8). In the case Weather near the aircraft was originally thought to have played a role
of AF447 the blocked pitot tubes meant there was confusion about the in the accident but although the pilots had requested a deviation to the
inconsistency of the airspeed on different displays including the inte- route because of weather build-up ahead in fact weather did not nega-
grated standby instrument system (ISIS) which in part contributed to the tively affect the flight or play a role in the accident, [75].
pilots not perceiving the changing elements regarding the status of the During cruise, there were, over a period of 12 min, 3 warnings dis-
flight hindering the development of their Level 1 and Level 2 situational played in the cockpit indicating a rudder travel limiter unit failure. For
awareness. these warnings, the PIC reset the Flight Augmentation Computer (FAC)
push buttons to OFF and then ON as advised by the ECAM, which
5.2. TransAsia airways 235 appeared to solve the problem.
There were following warnings which were regarding the FAC. They
For [40]; when a crew is confronted with equipment failure the level were responded to by the pilots in a manner which did not adhere to
2 situational awareness required by the crew is the understanding of the procedures when the FAC circuit breaker was reset by the crew. The
impact of the failure on the performance of the aircraft and the level 3 is result was the disengagement of the autopilot and auto thrust and a
knowing the projected path of the aircraft after the failure (p. 13). This reversion to alternate law from normal law [75] (p. 112). Thus, the pilots
was the situational awareness required to be developed by two pilots of now had to manually fly the aircraft.

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In developing an awareness of a situation, the crew may draw upon databases. The research covered several areas associated with HFs in
the contents of the long term memory to recognise and make sense of the aviation to provide the public with an extensive literature that expands
current situation. Past experiences form stored prototypical situations or the knowledge of readers about the impact of HFs in aviation. Therefore,
schema allows for “pattern matching between the current situation and this research investigated in hundreds of HFs associated accidents and
schema (and) people can instantly recognise classes of situations” [39]; incidents in the commercial sector of the aviation industry to answer the
(p. 98). Three days earlier the captain had, when on the ground, expe- research questions.
rienced a similar warning to that which he received in flight. He watched The answers of the research questions were: What were the most
the engineers reset the FAC circuit breaker which appeared to solve the common HFs causes in commercial air transport accidents and incidents
problem. This prior experience may have been used by the pilot in over the period from 2000 to 2016? Situational awareness was the most
command during the flight to develop his situational awareness of the common HF causation followed by non-adherence to procedures in
developing situation despite the resetting the FAC circuit breaker in flight commercial air transport accidents and incidents over the period from
not being a permitted action. 2000 to 2016. These were associated with greater loss of control in-flight
During the disengagement of the autopilot the rudder deflected 2 . occurrences, and to an increase in occurrences en route. What type of
The pilots failed to input any manual control movements for 9 s after the commercial air transport operation has more HF-related accidents and
autopilot disengaged with a resulting roll to the left of 54 . The Pilot incidents over the period 2000 to 2016? Charter carriers are the type of
Flying responded with a roll command to the right to maximum deflec- commercial air transport operation that has the most HF-related acci-
tion [75] (p. 108) and a nose-up input. Roll control of the Airbus at angles dents and incidents over the period 2000 to 2016. Were there any dif-
of bank of less than 33 did not need pitch correction but when the angle ferences by world region (both state of operator and state of occurrence)
of bank was greater than 33 nose-up input was required to maintain in the commercial air transport accidents and incidents attributed to HF
level flight. The maximum deflection roll command caused the aircraft causation over the period 2000 to 2016? Africa is the region (both state
the roll from 54 left to 9 left in 2 s. The rapid roll led the pilot to reverse of operator and state of occurrence) with the most number of HF related
the roll back to the left and the aircraft rolled back to 53 left. The Pilot accidents and incidents compared over the period 2000 to 2016.
Flying then rolled the aircraft back to near wings level at a gentler rate of This study has a vital role in enhancing safety in the aviation industry
roll. as it provided aviation safety specialists and the public with an extensive
The pitch-up inputs remained however, and with an increasing angle investigation about the different HF causations in commercial aviation
of attack Angle of Attack (AoA) caused by the pitch up command the stall which will inspire aviation specialists in discovering strategies to miti-
warning sounded as the aircraft went past 8 (AoA). The pilot corrected gate the impact of human errors in aviation accidents and incidents as
with a nose pitch down command which lowered the AoA and silenced well as, promote the awareness of the public about the significance of HFs
the stall warning. However, a short period after the stall warning stopped in aviation.
the nose was pitched up to 12 AoA and the aircraft resumed climbing at When considering the worst-case scenario of these findings, a CIS
12,000 feet per minute. In response to the increasing AoA the captain built aircraft, operating in an African country, on charter or for cargo, and
confusingly called, “pull down …. pull down” [75] (p. 109). It is a normal during takeoff, climb out, or en route, the recent accident in the Ivory
command to” pull back” to pitch the aircraft up and if the nose of the Coast accident on the 14th of October 2017 is not surprising [99], and is
aircraft is to be pitched down the call would be to “push forward”. (The similar to the accident in South Sudan on the 4th of November 2015
Indonesian report contains a diagram illustrating the movement of the where 36 people were killed [58].
side stick for pitch control. To pitch the nose up the description is
“sidestick pulled” and to lower the nose attitude the description is References
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