Journal of Air Transport Management 84 (2020) 101784

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Journal of Air Transport Management

journal homepage: http://www.elsevier.com/locate/jairtraman

The effect of management practices on aircraft incidents

€nmez *, Suat Uslu
Kadir Do
Eskişehir Technical University, Air Traffic Control Department, Turkey

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

Keywords: Many models have been put forward in order to examine the human factors in aircraft accidents and incidents.
Aircraft incidents Human Factors Analysis and Classification System (HFACS) which is the most widely used in literature is one of
Proactive approach these models. HFACS is based on Reason’s Swiss Cheese Model. The biggest disadvantage of the Reason’s model
Human factors
is its post-accident applicability. Mostly HFACS aviation applications are usually based on accident data. This is a
Management
HFACS
reagent (result-focused) approach. In this study, however, HFACS which is an improved version of Reason’s
model, was applied to aircraft incidents that did not result in an accident. This is a proactive approach. Thus,
with this approach, the biggest disadvantage of Reason’s model is turned into an advantage. In addition, a
realistic application of this approach has been demonstrated in this study, focusing on aircraft incidents that took
place between 2000 and 2018. The year 2000 forms a milestone in the manufacture of more technically
advanced aircraft models which significantly reduced occurrence of technical errors in aircrafts, hence the choice
of 2000 as base year. A total of 328 aircraft incident reports from the National Transportation Safety Board
(NTSB) database were studied and among these reports cockpit crew related incidents were analyzed using
HFACS. As a result of the analyzes, the root causes of incidents have been identified. In addition, unlike tradi­
tional HFACS analysis, the relationship between errors occurred at management levels of HFACS and the unsafe
acts of the cockpit crew in aircraft incidents was statistically revealed.

1. Introduction
During the analysis of an aircraft accident or incident, if the cause is a
technical factor, it can be detected based on the data obtained from
flight data recorder, voice recorder or from other sources with certain
tests (fatigue test etc.). These causes can be entered into the accident or
incident database in a well-defined way. For example; pilot tube mal­
function or engine failure. This facilitates the work of aviation author­
ities to ensure that post-accident database analyzes are carried out in a
methodical way. However, if the accident or incident was caused by
human factors, it will be more difficult to find out the exact cause, in this
case, the analysis of the accident or incident will be more intuitive rather
than data-based. Moreover, it would have been impossible to make
advanced tests as in the case of mechanical failures. In addition, the
expressions entered into the accident database will not be well defined.
As a result, this will not provide useful, convenient, data for aviation
authorities when performing subsequent data analysis (Shappell and
Wiegmann, 2003). For all the above reasons, a comprehensive frame­
work is needed to analyze human factors. If all analyzes are carried out
using an advanced framework, the expressions entered in the database
will be well defined and useful. The Human Factor Analysis and Clas­
sification System (HFACS) was developed by Shappell and Wiegmann to
meet this need (Wiegmann and Shappell, 2001b).
1.1. Research problem and specificity of study
According to the International Civil Aviation Organization (ICAO),
the only way to prevent accidents is to analyze previous accidents and
incidents (ICAO, 2010). If the aviation industry and other authorities
want to reduce accident or incident rates in future, they should focus on
human factors as a plausible cause. However, increasing the amount of
money and the resources invested in investigating human factors will
not be the solution, indeed the necessary resources are already being
allocated in this regard. What needs to be done, however, is to make a
comprehensive analysis of human factors that cause accidents or in­
cidents by systematically focusing on existing accident and incident data
(Wiegmann and Shappell, 2001b).
As a result, it is necessary to use a model that is efficient and widely
used in literature in these analyzes. It has been emphasized that HFACS
is the most efficient and useful model in accident analysis (Scarborough

* Corresponding author.
E-mail address: kadirdonmez@eskisehir.edu.tr (K. D€
onmez).

https://doi.org/10.1016/j.jairtraman.2020.101784
Received 25 October 2018; Received in revised form 10 February 2020; Accepted 11 February 2020
Available online 24 February 2020
0969-6997/© 2020 Elsevier Ltd. All rights reserved.
K. D€
onmez and S. Uslu Journal of Air Transport Management 84 (2020) 101784

et al., 2005). The applications of HFACS in aviation and other sectors are
shown in Table 1;
As we have stated in Table 1, HFACS aviation applications are usu­
ally based on accident data. This is a reagent (result-focused) approach.
Today, however, the safety management system is defined as an activity
that attempts to analyze and mitigate risks before accidents happen
(SHGM, 2012). As can be understood from this description, safety in­
vestigations must be carried out with a proactive and predictive
approach. HFACS is the improved form of Reason’s model, the greatest
deficiency of which is its post-accident applicability. This disadvantage
can be turned into an advantage by applying HFACS to aircraft incidents
rather than accident. A study of HFACS applied to aircraft incidents will
be more innovative in terms of approaches to safety.
In addition, Airbus reported that the total commercial flight traffic
between 2000 and 2015 was double the traffic in previous years. Also, it
emphasized that the aircraft used after 2000 were highly technologically
advanced planes that reduced the rate of accidents resulting from CFIT
(Controlled Flight into Terrain) and LOC (Loss of Control) by 70–80%
(Airbus, 2017). Therefore, between these dates, the problems caused by
the aircraft were minimized and the importance of investigating the
human factors between these dates has increased.
When all the above-mentioned conditions are considered, it is
necessary to carry out HFACS analysis for aircraft incidents which
occurred after 2000 to achieve a more realistic approach. This will be
important in order to realize the dangers that human beings experience
together and to fulfill the necessities of today’s safety approaches. Thus,
it can be said that the year 2000 is the milestone for accident in­
vestigations. Do €nmez, 2018 provides a detailed analysis of human fac­
tors in aircraft incidents which occurred 2000–2016. Our current study
is based on this master thesis study (Do €nmez, 2018).
The purpose of this study was determined as reveal the management
effect in the incidents by describing the associations between HFACS
causal factors from organizational influences to the condition of flight
operators observed in the incidents, considering the above-mentioned
shortcomings and requirements. Therefore, HFACS applied to aircraft
incidents which occurred between 2000 and 2018.
and data analysis tool for the US Navy. Since its first design, HFACS has
been applied to more than 1000 military aviation accidents. HFACS,
increases the quality and quantity of the data collection process while
increasing the efficiency of data-driven research strategies (Wiegmann
and Shappell, 2001b). HFACS consists of 4 levels and 19 causal sub­
categories. Level 1 is the unsafe acts that cause accidents directly. Level
2 is the preconditions for the unsafe acts that make up the underlying
causes of accidents. Level 3 is unsafe supervision, which contains most of
the hidden errors. Level 4 is the organizational influences that are
typically ignored by accident analysts. HFACS framework is shown in
Fig. 1;
Levels of HFACS and causal factors are described below. The first of
these levels is unsafe acts which are most closely associated with
incidents.
2.1.1. Unsafe acts
The first level to analyze is the bottommost level – unsafe acts. Un­
safe acts are divided into two groups; errors and violations. While errors
are defined as unsafe acts that occur within rules, violations are defined
as deliberate ignorance of the rules (Shappell and Wiegmann, 2000).
Errors are examined in three causal subcategories:
� Decision errors
� Skill based errors
� Perceptual errors
Decision errors are the most common error types. In this type of error,
the planned process progresses as desired but the plan is made incor­
rectly at first. Contrary to decision errors, skill-based errors occur in sit­
uations that do not require any thought. For example; movements such
as steering control or gear shifting when using a car are automated be­
haviors. Perceptual errors are as important as the other two error groups.
This type of error occurs when perceptual input decreases or when un­
usual environmental factors (such as nighttime conditions, bad weather
conditions etc.) decrease perception.
Violations are examined in two causal subcategories:

2. Analytical framework � Routine violations

2.1. Human factor analysis and Classification System (HFACS)
The origin of HFACS is based on Reason’s Swiss Cheese Model.
HFACS was originally designed as an accident and incident investigation
Table 1
Applications of HFACS.
Scope
Commercial aviation
accidents
General aviation
accidents
Military aviation
accidents
Maintenance-related
accidents
Helicopter accidents
Air traffic control related
accidents
Unmanned aerial vehicle
accident
Railway accidents
Maritime accidents
Health and Medicine
Mining accidents
Studies
(Wiegmann and Shappell, 2001b), (Wiegmann and
Shappell, 2001a), (Wiegmann and Shappell, 2001c),
(Shappell et al., 2006), (Shappell et al., 2007), (W. Li
et al., 2008), (ATSB, 2007), (Ting and Dai, 2011)
(Shappell and Wiegmann, 2003), (Wiegmann et al.,
2005), (Lenn� e et al., 2008), (Daramola, 2014)
(Shappell and Wiegmann, 2004), (Li and Harris, 2005),
(Li and Harris, 2006b), (Li and Harris, 2006a), (Olsen
and Shorrock, 2010), (O Connor and Walker, 2011)
(Thaden et al., 2007), (Rashid, 2010), (Rashid et al.,
2010)
Liu et al. (2013)
(Pape et al., 2001), (Broach and Dollar, 2002), (
Scarborough et al., 2005)
Yesilbas and Cotter (2014)
(Reinach and Viale, 2006), (Zhan et al., 2017), (Baysari
et al., 2008), (Baysari et al., 2009)
(Hinrichs et al., 2011), (Akyuz and Celik, 2014), (Celik
and Cebi, 2009), (Bilbro, 2013)
(Cintron, 2015), (Diller et al., 2014)
Patterson and Shappell (2010)
� Exceptional violations
Routine violations are habitual behaviors which usually allowed by
the system or administrations. A typical example of this situation, which
is also referred to as stretching the rules, is driving at a speed of 55 km on
a road with a speed limit of 50 km. Moving over the speed limit 5 km
may be a condition permitted by law.
Exceptional violations can be described as situations that are in con­
flict with the authorities. The most typical example for these violations is
driving at a speed of 120 km on a road with a speed limit of 50 km.
Neither authority nor laws allow this. A police officer who sees this
situation will certainly impose a penalty on the person (Wiegmann and
Shappell, 2001a).
2.1.2. Preconditions for unsafe acts
This category is the second level of HFACS. Focusing on only the
unsafe acts is like focusing on body heat instead of the underlying causes
of a patient with fever (Wiegmann and Shappell, 2001a). To analyze the
preconditions for unsafe acts, researchers need to conduct further
research. Preconditions for unsafe acts are examined in three classes
within HFACS.
Environmental factors are examined in two causal subcategories;
� Physical environment
� Technological environment.
Physical environment, which significantly affects the performance of
the cockpit crew, has numerous limitations on team performance.

2
K. D€
onmez and S. Uslu
Fig. 1. HFACS framework (Shappell and Wiegmann, 2003).
Factors such as temperature, noise, vibration, external forces, light, etc.
are examined in this class. The technological environment factor has
entered aviation literature with the rapid development of technology in
recent years. This factor includes the design, display characteristics and
automation of any hardware and controls that may affect the perfor­
mance of the cockpit crew (Villela, 2011).
Condition of operators includes three causal subcategories:
� Adverse mental states
� Adverse physiological conditions
� Physical and mental limitations
Adverse mental states include harmful attitudes that may adversely
affect decisions such as a loss of situational awareness, mental fatigue,
circadian rhythm disorder, excessive self-confidence, complacency or
poor motivation. Adverse physiological conditions this category includes
physiological factors that are important for aviation, such as spatial
disorientation, poisoning, visual anomalies, insomnia, and medical or
chemical abnormalities affecting performance (Wiegmann and Shappell,
2001a). Physical and mental limitations include the conditions that exceed
the limit of the individual in the control of the aircraft. For example;
people’s visual perception drops significantly at night. When perception
decreases while driving a car in the dark at night, additional measures
can be taken such as slowing down. In aviation, slowing down is not an
option. In such cases, more attention to basic flight instruments will be a
measure that increases safety. However, if necessary precautions are not
taken, the results can be catastrophic as pilots will have difficulty seeing
other aircrafts or obstacles (Shappell and Wiegmann, 2000).
Personal factors are examined in two causal subcategories;
� Crew resource management
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Journal of Air Transport Management 84 (2020) 101784
� Personal readiness
Crew resource management category includes deficiencies in the
crew’s cockpit and non-cockpit (with air traffic controllers or ground
personnel etc.) communications. This category also includes situations
where the crew cannot work together in harmony. Personal readiness
category includes violations of rest periods, violations of alcohol re­
strictions, self-medication, dieting etc. (Wiegmann and Shappell,
2001a).
2.1.3. Unsafe supervision
It is clear that the cockpit crew is responsible for their own actions.
However, there are many examples in which managers’ errors and
hidden errors trigger the unsafe acts of the crew. Hidden errors are
mostly caused by the management level.
Unsafe supervision includes four causal subcategories;
� Inadequate supervision
� Planned inappropriate operations
� Failed to correct problem
� Supervisory violations
Inadequate supervision category contains errors in the chain of
administrative command affecting the attitudes and actions of the su­
pervisors. Managers should demonstrate appropriate and necessary at­
titudes towards the individual, such as providing adequate training,
providing professional guidance, and conducting organizational lead­
ership. Planned inappropriate operations; Often, operational tempo or
work calendars are planned which adversely affect an individual’s
performance due to financial concern. Inappropriate crew matching,
non-allocation of appropriate rest times for the crew, and failure to
K. D€
onmez and S. Uslu Journal of Air Transport Management 84 (2020) 101784

manage risk in specific tasks are examined under this causal factor.
Failed to correct problem category includes such situations where,
although the problems for the individual, the hardware or the relevant
safety areas are known by the managers, the operations continue
without corrective action. Supervisory violations category includes situ­
ations such as the deliberate violation of rules or regulations by man­
agers. For example; allowing personnel without a valid license or
certificate to fly can be the beginning of a chain of events that will lead
to disasters (Wiegmann and Shappell, 2001a).
2.1.4. Organizational influences
Incorrect decisions by higher-level management can directly affect
the practices at mid management level, or even the conditions or
movements of the cockpit team. Unfortunately, organizational in­
fluences are often overlooked by even the best accident investigators
and are not reported.
Organizational influences are examined in three causal
subcategories:
� Resource management
� Organizational climate
� Organizational process
Resource management category includes the management, allocation
and maintenance of organizational resources. The resource management
category also includes topics such as human resource management
(elimination, training, staffing), budget management and hardware
design. Organizational climate category is generally defined as how the
organization behaves towards individuals. It can also be expressed as
any kind of change in the organization that affects the performance of
the individual. It includes formal accountability, order of the command
chain, assignment of authorities and responsibilities, communication
channels etc. Organizational process category covers topics such as the
formal processes (operational tempo, time pressure, work calendars),
methods (performance standards, objectives, instructions on methods)
and oversight within the organization (organizational work, risk man­
agement, safety program implementation and preparation). Each of the
deficiencies in management and the decisions by the upper levels can
negatively affect the performance of the cockpit crew and system safety
indirectly (Wiegmann and Shappell, 2001a).
3.2. Data coding and analysis
The version of HFACS framework introduced in Shappell and
Wiegmann (2003) was used in this study as a classification framework
(see Fig. 1) (Shappell and Wiegmann, 2003). Among the 328 aircraft
incident reports obtained from the NTSB database, coding has been
applied to the 74 aircraft incident reports related to the cockpit crew.
3.2.1. Reliability analysis
Coding was achieved by two experienced academicians according to
the presence or absence of each HFACS category. If any causal factor was
observed in any incident, it was encoded as “1” and if not observed as
“0”. After the coding was completed, the independent ratings were
compared. The inter-rater reliability was determined as a simple per­
centage. As a result, overall compliance between the coders was
measured as 94.14%. In cases where disputes existed, consensus was
achieved by bringing together relevant experts and results were
included in the database. Compatibility between coders was measured
by a simple percentage and kappa coefficients. Table 2 shows the results
of the inter-rater reliability tests;
The Kappa coefficient is a rate calculated from symmetric cross ta­
bles with a row ¼ column. The Kappa coefficient determines the inter-
rater reliability coefficient between two observers who evaluate a situ­
ation or event at the same time. The Kappa coefficient varies from 1 to
þ1. A value of 0 indicates inconsistency, and a value of þ1 indicates
positive full compliance.
If Kappa coefficient (κ);
� -1 ¼ perfect disagreement
� 0 � κ � 0.20 ¼ there is no compatibility
� 0.20 � κ � 0.40 ¼ there is weak compatibility.
� 0.40 � κ � 0.60 ¼ there is moderate (adequate) compatibility.
� 0.60 � κ � 0.80 ¼ there is a very good (high) level of compatibility.
� 0.80 � κ � 1.00 ¼ There is excellent compliance (Ozdamar,
€ 2004).
Table 2
Inter-rater reliability tests results.
HFACS category Cohen’s Kappa Simple percentage
coefficient (κ) compliance rate (%)

Level 4 – Organizational Influences

3. Method
Organizational process .877 94.5
Organizational climate .269 93.2
3.1. Inclusion criteria Resource management .684 90.5

Level 3 – Unsafe Supervision

Reports of 328 aircraft incidents in the USA between 2000 and 2018
Supervisory violations .774 93.2
were obtained from the NTSB database according to the following
Failed to correct problem .734 89.1
criteria; Planned inappropriate .863 94.5
operations
� Time interval: 2000–2018 Inadequate supervision .949 98.6
� Type of research: Aviation incidents Level 2 – Preconditions for Unsafe Acts
� Aircraft category: Airplane
Technological .867 94.5
� Operation: Air carriers (part-121) environment
� Flight type: Scheduled flights Physical environment .890 94.5
� Report type: Final reports Personal readiness .490 98.6
Crew resource .844 93,2
management
Part 121 is one of the Federal Aviation Administration (FAA) regu­ Physical and mental .904 95.9
lations relative to airworthiness certification which includes operating limitations
requirements: Domestic, flag and supplemental operations. To reach Adverse physiological .572 94.5
detailed information about FAA regulations (FAA, 2020). Part 121 conditions
Adverse mental states .827 93.2
scheduled flights consists of commercial passenger flights of major
airline companies, therefore it has been selected in order to better Level 1- Unsafe Acts
observe the influence of management and organizational factors. Also, Violations .891 94.5
the most accurate and complete information about the incident is ob­ Perception errors .852 93.2
tained from the final reports. Skill based errors .786 93.2
Decision errors .889 94.5

4
K. D€
onmez and S. Uslu
Kılıç (2015) emphasized that the kappa value in the kappa test was
influenced by the number of classes. Also, he stated that the smaller the
number of categories (the best case being two categorical variables), the
larger the kappa value that can be calculated (Kılıç, 2015). However,
low observed frequencies can distort the kappa value ( Li et al., 2008).
For example, two variables with 95% compliance by percentage may be
inconsistent in the kappa test. For this reason, the compliance between
the variables coded by the two coders is given both as the kappa test
results and as a percentage in Table 2. When we look at Table 2, it is seen
that the kappa coefficient is adequate, good or excellent in almost all
categories except the organizational climate category, the kappa coef­
ficient was found to be 0.269, although the percent compliance was
93.2% in this category. This is because the frequency of the organiza­
tional climate class is very low (only 1). If the inter-rater reliability tests
result between the coders is evaluated; the rates of compliance were
quite high compared to literature.
In their study, Li et al. (2008) emphasized that, for the rate of
compliance between coders, between 63% and 95% is acceptable ( Li
et al., 2008). Shappell and Wiegmann (2003) found 85% overall
agreement between coders in their study and interpreted this as an
excellent level (Shappell and Wiegmann, 2003). Li and Harris (2005)
found compliance rates between coders of between 72% and 96%, and
described this as acceptable ( Li and Harris, 2005).
3.2.2. Relationship analysis
HFACS framework allows for relationship analyses thanks to its
structure. It is possible to examine how all levels of HFACS affect each
other, from the top-level organizational influences to the unsafe acts,
which is the lowest level. The database obtained from coding was
transferred to the SPSS (Statistical Package for the Social Science) pro­
gram and the relationship between HFACS levels was determined by the
Chi-square independence test, phi correlation coefficient and the odds
ratio.
3.2.2.1. Chi square independence test. Non-parametric tests are used for
statistical analyzes if the data does not show a certain distribution fit and
if it is a nominal or ordered scale. Whether the X and Y variables with 2
or more classes are dependent on each other is tested by a chi-square
independence test. The chi square independence test is applied to
cross tables in the form of 2*2 or r*c. The hypotheses tested in the in­
dependence test are “there is no association” or “there is an association”
(Ozdamar,
€ 2004). Chi-square is calculated as:
X ðO EÞ2
χ 2i j ¼
E factors. In total, 66.8% of incidents were caused by human factors. Since
Where:
O ¼ Observed value
E ¼ Expected value
χ 2 ¼ The cell Chi-square value
P 2
χ ¼ Formula instruction to sum all the cell Chi square values
χ 2 i j ¼ i-j is the correct notation to represent all the cells, from the
first cell (i) to the last cell (j) (Mchugh, 2013).
The chi-square independence analysis in the 2*2 cross tables is made
with three different approaches according to the size of the theoretical
values in the table cells;
� Pearson chi-square test; if the theoretical values in the cells are all
equal to or greater than 25.
� Yates’ chi-square test; if any of the theoretical frequencies in the cells
are between 5 and 25.
� Fisher exact test; if any of the theoretical frequencies in the cells are
less than 5 (Ozdamar,
€ 2004).
5
Journal of Air Transport Management 84 (2020) 101784
Riffenburgh briefly summarizes the difference of these three tests as
follows; Yates chi-square test which is also called Yates correction is a
different form of chi square statistics calculated as [(∣observed value-
expected value∣-0.5)2/expected value]. The coefficient 0.5 is to adjust
for the counts being restricted to integers. It was preferred tables with
small cell counts. Fisher’s exact test provides a better solution to dealing
with small cell counts. For larger cell counts, Yates’ correction alters the
result negligibly and may be ignored (Riffenburgh, 2006). According to
Beukelman and Brunner, Yates correction is used to compensate for
deviations from the theoretical (smooth) probability distribution and
the Fisher exact test is used when the expected frequency of one or more
cells is less than 5. This test is commonly used in studies in which one or
more events are rare (Beukelman and Brunner, 2016). Manual calcula­
tion of the fisher test is quite difficult. But it can be easily calculated by
computer.
3.2.2.2. Phi (Φ) coefficient. It is the recommended correlation coeffi­
cient for 2 class 2*2 tables. The significance of the relationship between
the two variables is given by a chi-square test and the information about
the level of the relationship is given by the phi correlation coefficient
(Kilmen, 2015). The Phi coefficient varies from 0 to þ1, a value of
0 indicating that two variables are independent and a value of þ1 in­
dicates a complete association between the two variables (Ozdamar,€
2004). Cohen (1988) emphasized that if the value of the Phi coefficient
is equal to 0.1, it indicates a low level of relationship, if it equals 0.3 it
indicates moderate and 0.5 indicates a high level of relationship (Cohen,
1988).
3.2.2.3. Odds ratio. The odds ratio is the risk statistic calculated in the
2*2 cross table based on case control studies (Ozdamar,
€ 2004). The odds
value is the ratio of the likelihood of occurrence of an examined event to
the likelihood of its non-occurrence. The ratio of odds values belonging
to two different events is called the ‘odds ratio’. Since the odds ratio is
the ratio of the probability of an event occurring to not occurring, it
indicates how many times the Y variable is likely to be observed with the
effect of the X variable (Girginer and Cankuş, 2008).
4. Results
In this section, firstly, the descriptive analysis results of the examined
incident reports are given. HFACS analysis results and relationship
analysis results followed this part. As a result of examining 328 reports,
the following Table 3 was obtained;
As it seen in Table 3, from cockpit crew to managers are human
multiple factors can be observed in the incidents at the same time, it
cannot be expected that the sum of the percentages is equal to 100%.
With this ratio, human factors have been the primary cause of incidents,
leaving environmental and equipment factors behind.
The five most frequent aircraft types in the 328 aircraft incidents
were; B737 (19.4%), Bombardier CL600 (8.9%), B757 (7.4%), A320
(6.7%), EMB145 (4.9%), other (52.4%). Note that different aircraft
Table 3
Main causes of incidents.
The factors that caused the incidents Frequency (n) Percent (%)
Cockpit crew 74 22.6
Air traffic controller 54 16.5
Ground crew 34 10.4
Maintenance personnel 76 23.2
Managers 90 27,4
Total human factors 219 66,8
Equipment, materials 183 55,8
Environmental impacts 79 24,1
K. D€
onmez and S. Uslu
types are used more frequently than others, as such the frequency in
these incidents does not mean that the aircraft type is problematic.
A total of 177 people were injured slightly in the 328 aircraft in­
cidents investigated. 216 (65.8%) incidents occurred during the day and
83 (25.3%) incidents occurred during the night. For 29 (8.8%) incidents,
the time of occurrence was not recorded on the NTSB.
Cockpit crew related incidents were mostly observed at the landing
phase of the flights with 32.4%. In addition, air traffic controller related
incidents were mostly observed at the takeoff phase of the flights with
35%.
4.1. HFACS analysis results
HFACS analysis was performed on 74 cockpit crew related aircraft
incidents from 328 aircraft incidents. From the coding, 532 causal fac­
tors were identified. The results obtained from the analysis of the 4
levels of HFACS are shown in Fig. 2;
227 unsafe acts, 182 preconditions for unsafe acts, 71 unsafe su­
pervisions and 52 organizational influences factors were observed in
cockpit crew-related aircraft incidents. The frequency of HFACS causal
categories in HFACS levels is shown in Fig. 3;
It can be seen from Fig. 3, unsafe acts consist of skill-based errors
(90), decision errors (62), violations (47) and perceptual errors (28)
respectively. This ranking observed that in unsafe acts in HFACS was
similar to other studies in literature in terms of proportions accounted
for; (Wiegmann and Shappell, 2001c), (Wiegmann and Shappell,
2001a), (Shappell et al., 2007), (Shappell et al., 2006), (Ting and Dai,
2011). In precondition for unsafe acts level, the highest ratio belongs to
personal factors (79). The highest ratio in level 3 and level 4 belongs to
failed to correct problem (22) and organizational process (35) causal
category respectively. The percentages of the most common HFACS
factors observed in the incidents are given in Table 4;
As seen in Table 4, in level 1 for decision error, skill-based error,
perceptual error and violations the most common factors were inad­
vertent use of flight controls (61%), poor decision (34%), visual illusion
(28%) and failed to properly prepare for the flight (19%) respectively.
(Note that percentages do not add up to 100% because each incident is
typically associated with multiple causal factors across several causal
categories).
In level 2, for condition of operators, personnel factors and envi­
ronmental impacts causal categories the most common factors were
failed to communicate/coordinate (54%), physical environment (41%),
technological environment (28%) and visual limitation (26%)
respectively.
In level 3, for inadequate supervision, planned inappropriate oper­
ations, failed to correct problem and supervisory violations causal cat­
egories the most common factors were failed to provide correct data
(18%), failed to identify an at-risk aviator (16%) and authorized un­
necessary hazard (16%) failed to provide oversight (9%) respectively.
As it seen in Table 4, the most frequently observed factor in level 4 in
organizational process causal category was the oversight with 27%. This
Fig. 2. HFACS levels’ rates.
6
Journal of Air Transport Management 84 (2020) 101784
factor was followed by procedures, at 17%. The equipment/facility re­
sources factor was observed in 12% of aircraft incidents and it was the
most frequently observed factor in resource management causal cate­
gory. Human resources factor followed this with 9%.
4.1.1. Relationship analysis results
18 HFACS causal categories were coded as present or absent (1-0) for
each of the 74 aircraft incidents. Then the relationship between the
categories was examined individually as 2 * 2 tables. As a result, sig­
nificance values and coefficients obtained from chi square independence
test, phi correlation coefficient and odds ratio are given in Table 5;
Analysis of the strength of association between categories in the
higher and lower levels of HFACS framework was shown in Table 5. The
level 4 organizational influences versus level 3 unsafe supervision found
that there were seven pairs of significant associations. Also two pairs of
categories have significant association between level 3 and level 2.
Analysis of the strength of association between categories at level 2
preconditions for unsafe acts versus level 1 unsafe acts of operators
showed three pairs of significant associations.
In the level 4 categories resource management was significantly
associated with three categories of unsafe supervision: inadequate su­
pervision (df ¼ 1, p � 0.001), failure to correct a known problem (df ¼ 1,
p � 0.01) and supervisory violations (df ¼ 1, p � 0.05). Organizational
process was significantly associated with four categories of unsafe su­
pervision: inadequate supervision (df ¼ 1, p � 0.001), planned inap­
propriate operations (x2 ¼ 34.248, df ¼ 1, p � 0.001), failure to correct a
known problem (x2 ¼ 36.888, df ¼ 1, p � 0.001) and supervisory vio­
lations (x2 ¼ 15.024, df ¼ 1, p � 0.001).
In the level-3 categories, supervisory violations were significantly
associated with one category of level 2: technological environment (df
¼ 1, p � 0.01). Planned inappropriate operations was significantly
associated with one category of level 2: crew resource management (x2
¼ 5.834, df ¼ 1, p � 0.05).
In the level-2 categories, technological environment was signifi­
cantly associated with one category of level 1: perceptual errors (x2 ¼
6.161, df ¼ 1, p � 0.05). Physical environment was significantly asso­
ciated with one category of level 1: perceptual errors (x2 ¼ 25.416, df ¼
1, p � 0.001). Physical/mental limitations were significantly associated
with one category of level 1: perceptual errors (x2 ¼ 32.924, df ¼ 1, p �
0.001).
When the correlation coefficients were examined, the statistically
highest significant positive correlation was observed in level 4 and level
3 between the organizational process and failed to correct known
problem (Φ ¼ 0.737, p � 0.001). In level 3 and level 2 there was a
moderate correlation between couples with a statistically significant
relationship between them. The statistically highest significant positive
correlation was observed in level 2 and level 1 between physical/mental
limitations and perceptual errors (Φ ¼ 0.698, p � 0.001).
Odds ratios were interpreted only in the context of human factors.
That is the likelihood of the occurrence of a human factor in the presence
of another human factor was interpreted. In this analysis, the effect of
management practices on incidents were tried to be revealed based on
the associations between the causal factors in incidents.
Odds ratio analysis can contribute to an easier understanding of the
relationships between the causes obtained in analysis of Chi-square.
With this analysis how many times the probability of occurrence of
one cause increased in the presence of the other can easily be observed.
Also, it can provide an insight into what kinds of interactions happen
until incident takes place.
When odds ratios were examined, it can be said that the occurrence
of physical and mental limitations increases the probability of percep­
tual errors by about 40 times. The highest odds ratio in the table was
determined between these two pairs. The odds ratios between the other
couples can be similarly interpreted. But it can be logically said that the
probability of perceptual errors will increase when there is a physical
restraint. In this respect, the odds ratio is more important for the other
K. D€
onmez and S. Uslu
Fig. 3. HFACS causal categories’ rates.
Table 4
Most common causal factors.
HFACS Most Common Causal Factors
Levels
Unsafe Acts Improper procedure
Inappropriate maneuver
Poor decision
Breakdown in visual scan
Inadvertent use of flight controls
Visual illusion
Failed to adhere to brief
Failed to properly prepare for the flight
Preconditions for Distraction
Unsafe Acts Visual limitation
Failed to communicate/coordinate
Failed to conduct adequate brief
Failed to use all available resources
Misinterpretation of traffic calls
Physical environment
Technological environment
Unsafe Supervision Failed to provide oversight
Failed to provide correct data
Failed to identify an at-risk aviator
Authorized unnecessary hazard
Organizational Human resources; selection, staffing/
Influences manning, training
Equipment/facility resources; poor design,
purchasing of unsuitable equipment
Procedures; Standards, documentation,
clearly defined objectives, instructions
Oversight; Risk management, safety
programs
pairs that are not logically embedded. Planned inappropriate operations
and crew resource management pairs can be given as an example. The
probability of encountering a problem in crew resource management in
the presence of planned inappropriate operations is about 11 times
higher. Disagreements can be observed between the crew if
Journal of Air Transport Management 84 (2020) 101784
management does not plan the work and crew matching properly. This
pair is not directly embedded like the physical and mental limitations
and perceptual errors pair.
Percentage When the relationships between HFACS organizational and super­
(%)
vision levels and unsafe acts of operators were examined, Table 6 is
24 obtained;
11 There was one pair of significant associations in level-4 versus level-
34
14
1; organizational process and violations of operators (x2 ¼ 6.343, sd ¼ 1,
61 p � 0.05). Also, there was one pair of significant associations in level-3
28 versus level-1; supervisory violations and violations of operators (x2 ¼
12 4.205, df ¼ 1, p � 0.05). Intermediate and low positive correlations were
19
found between these pairs, respectively. There was a statistically sig­
12 nificant relationship between supervisory violations and violations of
26 operators, but the coefficient of this significance is close irrelevance as
54
15
the correlation between them is very low. Therefore, it can be said that
15 there may be other factors that affect the relationship between these two
12 factors rather than a direct relationship. When odds ratios are examined,
41 it can be said that the occurrence of supervisory violations or problem of
28
organizational process increase the probability of a violation of opera­
9 tors by about 3–4 times.
18
16
16
5. Discussion and conclusion
9
The results of the analysis into the unsafe acts by cockpit crew that
12 lead to incidents between the years 2000 and 2018 were ranked ac­
cording to the frequency of the type of act. In line with other findings in
17 literature, skill-based errors were highest, followed by decision errors,
violations and then perceptual errors.
27
The most observed factor in skill-based errors is the inadvertent use
of flight controls with 61%. DOD (Department of Defense) defined this
factor as the excessive or inadequate control of the aircraft or systems
causing an inappropriate response that is not in accordance with the
rules by the individual (DOD, 2005b). No statistically significant rela­
tionship was found between the skill-based error and other causal cat­
egories of HFACS.
The most frequently observed factor in decision errors is poor
7
K. D€
onmez and S. Uslu Journal of Air Transport Management 84 (2020) 101784

Table 5 Table 6
Relationship analysis results. Relationship analysis results - management effect.
HFACS Levels Chi Square Test Phi (Φ) Odds HFACS Levels Chi Square Test Phi (Φ) Odds
Ratio Ratio

Chi p-Value Phi P- Value Chi p- Phi p- p-

Square coefficient Value Square Value coefficient Value Value
Value Value

Level 4 – Level 3 Level 4 – Level 1

Organizational Process 6.343 .012* .320 .006** 3.867
Resource – .000*** .538 .000*** 20.300
x Violations of
Management x
operators
Inadequate
Level 3 – Level 1
Supervision
Supervisory Violations 4.205 .040* .274 .018* 4.800
Resource – .002** .393 .001** 8.333
x Violations of
Management x
operators
Failed to Correct a
Known Problem *P � 0.05 **p � 0.01 ***p � 0.001.
Resource – .030* .279 .017* 4.821 Note 1: Degrees of freedom ¼ 1 for the entire table.
Management x Note 2: All other comparisons were non-significant.
Supervisory
Note 3: The Fisher Exact test was used when the expected value was below 5.
Violations
Organizational – .000*** .429 .000*** 21.500
This test only gives significance (P) value.
Process x Note 4: If one of the cells in the 2*2 tables is 0, the odds ratio cannot be
Inadequate calculated. The confidence interval for calculating the odds ratio is 95%.
Supervision
Organizational 34.248 .000*** .712 .000*** –
accidents had occurred. Some pilots may instantly lose their ability to
Process x Planned
Inappropriate make decisions under factors such as fatigue and stress. In some, a more
Operations widespread and persistent lack of the ability of judgement was observed
Organizational 36.888 .000*** .737 .000*** – as a consequence of the social environment and excessive personalities.
Process x Failed to However, according to Krause, a pilot can re-learn or regain these
Correct a Known
Problem
abilities (decision making) regardless of how or why he lost his abilities.
Organizational 15.024 .000*** .487 .000*** 28.667 There are two basic principles of good judgment and decision making.
Process x These are the perception and ability to distinguish between right and
Supervisory wrong solutions. Examining the identification of perception and
Violations
discrimination reveals many layers of mental ability leading to a good
Level 3 – Level 2 judgment. You have to perceive (be aware, observe, detect, understand)
Supervisory – .004** .359 .002** 6.533 and distinguish between the right and wrong alternatives for the solu­
Violations x tion (recognize, see clearly, and understand the differences). There are
Technological four basic skills needed to develop correct perception; a vigilant sense of
environment
awareness, observation, detection and understanding. Even if the pilots
Planned 5.834 .016* .315 .007** 11.118
Inappropriate are competent in terms of judging, some factors considerably affect their
Operations x Crew judgements. Cognitive, moral, emotional, physiological, social, per­
resource sonal, and attitude factors directly influence the judging process. Any of
management these factors can lead to a failed judgment. However, it is possible for
Level 2 – Level 1 pilots to know the existence of these negative factors and to learn how to
Technological 6.161 .013* .320 .006** 0.139 change these conditions (Krause, 2003).
environment x The most frequently observed factor in violations is the failed to
Perceptual Errors properly prepare for the flight factor. This factor is included in routine
Physical Environment 25.416 .000*** .615 .000*** 20.900 violations. One thing to note here is that this factor is not to be confused
x Perceptual Errors
Physical/Mental 32.924 .000*** .698 .000*** 40.714
with the personal readiness causal factor under the heading of pre­
Limitations x conditions for unsafe acts. The personal readiness factor includes pre-
Perceptual Errors flight drug use, alcohol consumption, sleep patterns, etc. The failed to
*P � 0.05 **p � 0.01 ***p � 0.001. properly prepare for the flight factor includes situations such as
Note 1: Degrees of freedom ¼ 1 for the entire table. incompletion or violation of the procedural controls immediately prior
Note 2: All other comparisons were non-significant. to the flight.
Note 3: The Fisher Exact test was used when the expected value was below 5. The most frequently observed factor under the heading of perceptual
This test only gives significance (P) value. errors was the visual illusion factor. Perceptual errors can be described
Note 4: If one of the cells in the 2*2 tables is 0, the odds ratio cannot be as the difference between the world that the individual perceives and the
calculated. The confidence interval for calculating the odds ratio is 95%. real world. Misjudgment of distance, and the wrong decisions made after
the visual illusion can be given as an example for this error group. The
decision factor. DOD defined this factor as an individual not sufficiently root of perceptual errors are sensory inputs (Berry, 2010). DOD
or successfully assessing the risks associated with a particular action described perception errors as a factor that caused human error,
plan and the individual causes an unsafe act after making an inappro­ resulting in the misinterpretation of an object, threat or condition. These
priate decision as a result of this incorrect assessment (DOD, 2005b). misinterpretations are seen as visual and auditory delusions, or cogni­
Krause (2003) emphasizes that good judgment and decision-making are tive and attention deficits (DOD, 2005a).
mental abilities that each pilot can learn. In addition, Krause stated that
there was irrefutable evidence from academic studies, into safety sur­ 5.1. The key factor ‘crew resource management’
veys and accident reports, that showed that there had been deficiencies
in the decision-making abilities of pilots during flights in which When preconditions for unsafe acts were examined, the most

8
K. D€
onmez and S. Uslu
common factor was the failed to communicate and coordinate which is
under the category of CRM. This factor was observed in 54% of all in­
cidents and thus the CRM causal factor, with the other sub factors that it
includes, can be identified as a key factor in incidents.
According to Krause (2003), crew resource management is a com­
bination of a pilot’s judging and decision-making abilities, personal
behavior and attitudes towards others within group dynamics. Inter­
personal attitudes in crew resource management will ultimately inter­
fere with a pilots’ technical skills and aviation knowledge. The failure of
any component of crew resource management will adversely affect a
crew’s flight performance and flight safety. It should not be forgotten
that a team is as strong as the weakest member, but it is unacceptable for
a cockpit crew to include any weakness. Krause (2003) described the
widespread purpose of crew resource management training as
improving the decision-making process by increasing the performance
of the cockpit team in communication, teamwork and leadership. He
described the following as key factors for quality communication in the
context of crew resource management;
� Interrogation: A systematic investigation of information.
� Defense: confidence in expressing situations and feelings.
� Active listening: to actively contribute to the collection of informa­
tion and to accept or reject the ideas presented.
� Conflict resolution: Deciding on the causes of the conflict and making
the appropriate action plan correctly.
� Criticism: To assess the overall situation correctly through personal
performance and feedback (Krause, 2003).
Coordination and communication has become a very important issue
in aviation in recent years and there are now many studies on this
subject. Some examples from literature are given below for a better
understanding of the importance of the CRM factor.
Do€nmez and Uslu (2016) investigated communication-related acci­
dents in aviation. These accidents were studied under three classes based
on linguistic problems, expectations and cultural differences. As a result,
they found that education, standardization, and management issues
should be emphasized in order to eliminate communication problems
(Do€nmez and Uslu, 2016).
Krivonos (2007) stressed the importance of communication for
aviation safety in his study. He also examined examples of
communication-related accidents and highlighted the importance of
lessons to be learned from these accidents. As a result, he emphasized
that communication is the key factor for aviation safety and that effec­
tive coordination can only be achieved through effective communica­
tion. In this context, teaching effective coordination is essential for
aviation safety training (Krivonos, 2007).
Kaps et al. (1999) showed that CRM is a crucial issue for aviation
committees and airline companies, but that there was not any literature
research covering CRM studies at the time. As a result, they searched
various databases according to certain criteria and collected summaries
of important studies made between 1993 and 1998 in this study. These
summaries were evaluated under four headings; the current status of
CRM training and research, the evolution of CRM concepts, measuring
methods, and the application of CRM (Kaps et al., 1999).
Salas et al. (2001) examined and compared 58 CRM trainings pub­
lished up to that date. As a result, they emphasized that CRM training
improves learning and develops desirable behavioral changes. However,
they were not sure of the effects of CRM on the extreme layers of the
organization (such as safety) (Salas et al., 2001).
Salas et al. (2006) evaluated CRM training from 28 different areas
(aviation, medicine, offshore oil production, maintenance, marine, and
nuclear energy fields) with regard to the effects on learning and
behavioral changes and reached different results according to each field.
They also stated that it remained unclear as to how CRM affects factors
extreme layers of the organization such as safety (Salas et al., 2006).
As a result of our study, CRM was identified as a key factor in
9
Journal of Air Transport Management 84 (2020) 101784
aviation incidents. Therefore, it can be said that CRM training is one area
to focus on in order to reduce and preventing aviation incidents and
accidents. The failed to communicate and coordinate factor was
observed in more than half of all cockpit crew-related incidents. This
emphasizes once again the importance of communication and coordi­
nation in aviation and, as it is under the CRM causal category, shows
how vital good CRM is for the sector.
5.2. Management effect
As a result of the relationship analysis carried out in the study, very
important findings were obtained about the violations: organizational
process and supervisory violations were found to be statistically signif­
icant in relation to the violations of operators. The analysis shows us that
the probability of crew violations increases by 3–4 times when there are
supervisory violations. In order to better understand the relationships
between these factors it is necessary to examine their common defini­
tions. The organizational process title is composed of three main factors.
These are; operations, procedures and oversight. The concept of oper­
ations here can be defined as the working conditions presented to
workers by management. This factor includes subjects such as opera­
tional tempo, time pressure, production quotas, incentives, measure­
ment/appraisal, schedules and deficient planning. If any of these
conditions are not suitable for employees’ safety is threatened. Pro­
cedures include official methods on how to do the job. These are; stan­
dards, documentation, clearly defined objectives, and instructions. The
oversight factor is the continuous monitoring of resources, organiza­
tional process and organizational climate for a safe and productive
working environment. The oversight factor includes risk management
and security programs (DOD, 2005a). The deficiencies and errors in
these factors can be related to the violations made by the cockpit crew.
Supervisory violations include factors such as; authorized unnec­
essary hazard, failed to enforce rules and regulations, and authorized
unqualified crew for flight (Shappell and Wiegmann, 2000). Supervisory
violations are described as a deliberate violation of rules by managers.
For example; The permission to allow an aircraft or personnel to fly
without the necessary qualification and license. The deficiencies in the
enforcement of rules and laws can also be examined under the heading
of supervisory violations. Violations at management level can also cause
the cockpit crew to violate the rules. Therefore, these chains of viola­
tions can lead to aircraft incidents and accidents.
In the unsafe supervision level, the most common factor was failed to
provide correct data, which was observed in 18% of cockpit crew related
incidents. This factor is under the planned inappropriate operations
causal category. This causal category was found to be statistically sig­
nificant in relation to the CRM causal factor in HFACS level 2. DOD
defined the planned inappropriate operations factor as planning oper­
ational tempo and schedule so as to put the crew at unacceptable risk.
Such planned inappropriate operations are often unavoidable in emer­
gency situations but unacceptable for routine operations. This category
includes topics such as inappropriate crew matching. It is inevitable that
problems will arise if two people with a great difference in talent are
matched. In the same way, pairing two inexperienced pilots for a diffi­
cult operation will not be a sensible act. Planned inappropriate opera­
tions can be described as the incapacity of managers to assess the risks
that would put the operation at risk and allow unnecessary hazards
(DOD, 2005a). It is therefore inevitable that this factor is directly related
to the CRM factor, which includes crew communication and coordina­
tion. In fact, according to the results of the analysis carried out in this
study, the possibility of the occurrence of a problem in the crew resource
management factor increases by about 11 times under the existence of
planned inappropriate operations. The relationship between these two
factors statistically proves that decisions or acts at the supervision level
directly influences the performance of the cockpit crew.
In the organizational influences level, the organizational process
factor was found to be statistically related to all unsafe supervision
K. D€
onmez and S. Uslu
factors of HFACS. The oversight factor, which is under the heading of
organizational process, was the most frequent organizational influence
observed in 27% of cockpit crew related incidents.
Organizational process concept described previously in detail. As can
be understood from the above definitions, deficiencies in these concepts
at the level of organization and higher management affect lower man­
agement levels.
Another factor that is related to lower levels of management under
the heading of organizational impacts is resource management.
Resource management can be examined in three sub-sections; human
resources, budget management, hardware and resource budgeting.
Human resources include qualification, assignment and training. Budget
management includes issues such as the lack of funding and extreme
cuts. Equipment/facility resources includes issues such as poor design
and the purchasing of unsuitable equipment (DOD, 2005a). The resource
management causal factor covering the above concepts was found to be
significantly related to all factors under HFACS unsafe supervision
causal category (except for planned inappropriate operations).
As emphasized at the beginning of the study, the biggest deficiency of
HFACS is its post-accident applicability. The applicability of HFACS to
accidents has been proven in most of the studies given in the literature
section. In this study, HFACS was applied to incidents which occurred
between 2000 and 2018, not accident, to turn this into an advantage.
Because the structure of the incident and accident reports published by
NTSB are extremely similar, the applicability of the HFACS model to the
incidents made it easier. In this study, the obtained kappa values which
describes the compatibility between coders can provide evidence of the
applicability of the model.
As a result, the significant associations in human factors which were
present in the occurrence of incidents were revealed. In addition, it was
statistically shown how decisions and errors at the management level
affect the unsafe acts of operators. Considering these associations ob­
tained from incidents, precautions can be taken before accidents
happen. In fact, an accident is known to be just one of many incidents,
resulting in disaster. Therefore, if accidents are desired to be prevented,
a proactive approach will be demonstrated by conducting researches
with focusing on incidents. This study may well serve as a guide for
human factor-based incident researches. Further similar work in this
area will provide evidence which could reduce future aviation incidents;
consequently, further research is suggested using other data pools. It
should not be forgotten that the struggle for the prevention of aviation
accidents or incidents starts with the analysis of the previous event.
CRediT authorship contribution statement
Kadir Do € nmez: Conceptualization, Methodology, Formal analysis,
Validation, Investigation, Writing - original draft, Writing - review &
editing, Supervision. Suat Uslu: Validation, Investigation.
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://doi.
org/10.1016/j.jairtraman.2020.101784.
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