Examining ATC Operational Errors Using the Human Factors Analysis and Classification System
FEDERAL AVIATION ADMINISTRATION OKLAHOMA CITY OK CIVIL AEROMEDICAL INST
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In the literature of aviation accidents and incidents, human error has been recognized as the predominant factor contributing to aviation mishaps. Consequently, a number of human error models and taxonomies have been adapted to study the unique characteristics of flying an aircraft. However, relatively few attempts have been made to apply the same tools toward understanding the human factors causes of air traffic control ATC operational errors OEs. An operational error is an occurrence attributable to an element of the air traffic system in which aircraft separation minima are not maintained. As a first attempt to systematically examine the underlying human causes of OEs, we report on the results of a study that consisted of three phases 1 conducting a literature review to identify candidate error models and taxonomies, 2 selecting an appropriate error model or taxonomy for use in the ATC environment, and 3 applying the selected error model, or taxonomy, to a subset of the items identified by the FAA as OE causal factors. The results of our study revealed that, of the models and taxonomies examined, the Human Factors Analysis and Classification System HFACS was the taxonomy most readily adapted for use in an initial examination of ATC OEs. Causal factor items from 5,011 OE reports were classified using the HFACS taxonomy. Most items were classified as decision errors and skill-based errors. Additional research is needed to develop a more comprehensive understanding of the factors that contribute to ATC decision errors and skill-based errors.
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