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Accident Investigation Guide: 2005 Edition

Exhibit 9-2

Aviation Human Factors Analysis

Sensory and Perceptual Factors

• Misjudgment of distance, clearance, altitude, speed, and so forth.
  
  
• False perception caused by visual illusion. Conditions that impair visual performance:
  • Featureless terrain (such as a desert, dry lake, water, or snow).
  • Darkness and poor visibility.
  • Smoke and changing smoke patterns.
  • “ Black-hole” effect.
  • No horizon or false horizon (unreliable visual attitude reference).
  • Mountainous terrain or sloping runway.
  • Helicopter-rotor downwash effects.
  • Anomalous light effects that cause flicker vertigo.
  • Low contrast of objects to background or poor illumination.
  • View into bright sunlight or moonlight.
  • Shadows.
  • Whiteout (such as rotor downwash in snow).
    
    
• False perception because of inner-ear (vestibular) disturbance. Types:
  • Spinning sensation caused by inner ear over stimulation (coriolis).
  • Gravity-induced false sensation of a pitch-up (somatogravic).
  • False sensation of rotation (somatogyral).
    
    
• Spatial disorientation and vertigo. Types:
  • Unrecognized loss of attitudinal awareness.
  • Recognized vertigo.
  • Incapacitating (such as vestibular-ocular decoupling induced by rapid acceleration and deceleration forces).
    
    
• Conditions that affect sense of body position or aircraft attitude:
  • Loss of visual cues and attitude reference. (especially with no natural horizon).
  • Acceleration (G-forces).
  • Adverse medical condition or physiological condition (alcohol and drug effects, hangover, dehydration, fatigue, and so forth).
  • Moving head up and down, looking in and out to change radios, making notes in a low-level environment while banking, accelerating, climbing, and descending.
    
    
• Loss of situational awareness. Types:
  • Geographic disorientation at low level in similar terrain, frequently in adverse conditions.
  • Geographic disorientation (such as deviation from route, operation outside chart limits, loss of position awareness).
  • General loss of situational awareness (such as failure to perceive hazardous condition).
  • Erroneous situational assessment (misinterpretation of situation or condition).
  • Failure to predict or anticipate changing conditions.
  • False hypothesis confirmation bias (persistent false perception or misconception of situation).
    
    
• Attention failure (such as failure to monitor or respond when correct information is available). Types:
  • Failure to visually scan outside the aircraft for terrain and other aircraft.
  • Omission of checklist items, standard calls, or crew challenge.
  • Failure to monitor flight progress or to maintain instrument scan.
  • Failure to respond to communication or warning.
  • Control-action error:
    • Failure to set, move, or reset control switch (lapse).
    • Unintentional activation of control switch (slip).
    • Control-substitution error (slip).
    • Control-reversal error (slip).
    • Control-adjustment or precision error (slip).
      
      
• Conditions that affect attention and situational awareness:
  • Inattention (focus on information unrelated to flightdeck tasks or flying).
  • Channelization, fixation (psychological narrowing of perception).
  • Distraction (preoccupation with internal [mental] event or with external event).
  • Task overload due to aircraft systems.
  • Task overload due to aircraft systems mission factors.
  • Cognitive workload (problem-solving concentration or information overload).
  • Habit influence or interference.
  • Excessive flight crew stress or fatigue.
  • Excessive mission tasking or workload.
  • Inadequate briefing or flight preparation.
  • Inadequate training or experience for mission.
  • Miscommunication (such as during transition to new aircraft).
  • Adverse meteorological conditions.
  • Tactical-situation overload or display-information overload.
  • Inadequate flight crew motivation or inadequate flight vigilance.
  • Inadequate flightdeck design (control or display location or data format).

Medical and Physiological

• Carbon monoxide poisoning.
• Self-medication (without medical advice or against medical advice).
• Motion sickness.
• Incompatible physical capabilities.
• Overexertion while off duty.
• Influence of drugs or alcohol.
• Cold or flu (or other known illness).
• Excessive personal stress or fatigue.
• Inadequate nutrition (such as omitted meals).
• G-induced loss of consciousness or G-induced illusion.
• Hypoxia.
• Heat.
• Cold.
• Stress induced by heightened state of alertness.
• Affects of smoke.
• Dehydration.
  
  
• Other medical or physiological condition. Conditions that may cause adverse medical or physiological state:
  • Mission tasking or job fatigue (such as being on duty more than 14 hours, performing late-night or early morning operations).
  • Cumulative fatigue (such as excessive physical or mental workload, circadian disruption, or sleep loss).
  • Cumulative effects of personal or occupational stress (beyond stress-coping limit).
  • Emergency flight condition or workload transition (from normal operation to emergency operation).
  • Medical or physiological preconditions (health and fitness, hangover, dehydration, and so forth).

Knowledge and Skill

• Inadequate knowledge of systems, procedures, and so forth (knowledge-based errors). Types:
  • Knowledge-based.
  • Inadequate knowledge of systems, procedures.
  • Use of improper procedure.
  • Ill-structured decisions.
  • Failure in problem solving.
    
    
• Inadequate flight control and airmanship, or inadequate accuracy and precision of flight maneuvering (skill-based error). Types:
  • Breakdown in visual scan.
  • Failure to see and avoid.
  • Poor flight control and airmanship.
  • Over or under reacting.
  • Over or under controlling.
  • Inadequate experience for complexity of mission.
  • Improper takeoff technique.
  • Improper landing technique.
    
    
• Misuse of procedures or incorrect performance of flight-deck tasks (rule-based error), such as:
  • Failure to perform required procedure.
  • Use of wrong procedure or rule(s).
  • Failure to conduct step(s) in prescribed sequence.
  • Failure to complete performance computations for flight.
    
    
• Conditions that lead to inadequate operational performance:
  • Lack or variation of standards.
  • Loss of situational awareness in varying environment.
  • Performance below required proficiency standards or currency standards.
  • Inadequate performance or documented flightaptitude deficiencies.
  • Limited flight hours (total or type).
  • Inadequate essential training for specific task(s).
  • Inadequate recent experience or inadequate experience in flight condition (such as instrument flight rules, night, weather).
  • Transition (learning new aircraft system).
  • Lack of sensory input.
  • Limited reaction time.

Mission Factors

• Failure of dispatch to provide correct critical information (such as frequencies, location, other aircraft).
• Poor communication with other resources (such as ground personnel or other aircraft).
• Inadequate or faulty supervision from supervisory tactical aircraft.
• Inadequate or faulty supervision of tactical aircraft by ground personnel.
• Lack or variation of standards.
• Nonparticipant or noncommunicative aircraft onscene.
• Loss of situational awareness in varying environment.
• Change of plans or tactics (change of teams on incidents).
• Unanticipated change of radio frequencies.
• Intentional deviation from procedures.
• Unintentional deviation from procedures.
• Performance below required or current proficiency standards.
• Inadequate performance or documented flight-aptitude deficiencies.
• Limited flight hours (total or type).
• Inadequate essential training for specific task(s).
• Inadequate recent experience or inadequate experience in flight condition (such as instrument flight rules, night, weather).
• Transition (learning new aircraft system).
• Inadequate knowledge of tactical situation.
• Lack of sensory input.
  
  
• Limited reaction time. Conditions that lead to inadequate special-use mission performance:
  • Smoke.
  • Wind shifts.
  • Changes in fire behavior.
  • Low visibility.
  • Turbulence.
  • Unexpected or nonparticipant aircraft.
  • Mission intensity.
  • Mission creep (scope of the mission increases).
  • Mission urgency.
  • Failure to recognize deteriorating conditions.
  • Time compression.
  • Diversion to new incidents.
  • Excessive communication demands.
  • Past mission success was based on high-risk behavior.

Personality and Safety Attitude

• Overconfidence in flying ability.
• Excessive motivation to achieve mission.
• Reckless operation.
• Anger or frustration on the job.
• Stress-coping failure (such as anger).
• Overly assertive or nonassertive.
• Inadequate confidence to perform tasks or activities.
• Acquiescence to social pressure (from organization or peers) to operate in hazardous situation or condition.
• Failure to report or act upon incidents of misconduct.
• Tolerance of unsafe acts and behaviors.
• Poor flight preparation.

Judgment and Risk Decision

• Acceptance of a high-risk situation or mission.
• Misjudgment of mission risks (complacency).
• Failure to monitor flight progress or conditions (complacency).
• Use of incorrect task priorities.
• Intentional deviation from safe procedure (imprudence).
  
  
• Intentional violation of standard operating procedure or regulation. Types:
  • Violation of orders, regulations, SOP.
  • Crew rest requirements.
  • Inadequate training.
  • Violation of agency policy or contract.
  • Failure to comply with departmental manuals.
  • Night training or special mission with PAX.
  • VFR filing in marginal weather conditions.
  • Failure to use radar advisories from ATC.
  • PIC knowingly accepted noncurrent crew.
  • Performance of unauthorized acrobatic maneuver.
  • Scud running (avoiding a weather pattern).
  • Failure to obtain valid weather brief.
  • Acceptance of unnecessary hazard.
  • Not current or qualified for mission.
    
    
• Intentional disregard of warning (by human or aircraft system).
• Noncompliance with personal limits.
• Noncompliance with published aircraft limits.
• Noncompliance with prescribed mission profile or parameters.
  
  
• Acquiescence to social pressure (from organization or peers). Conditions leading to poor safety attitude and risky judgment:
  • History of taking high risks (personality-driven).
  • Pattern of overconfidence (aggrandized self-image).
  • Personal denial of wrongdoing.
  • Documented history of marginal performance or failure.
  • Excessive motivation (did not know limits).
  • Reputation as a reckless pilot.
  • Failure to cope with life stress (anger or frustration).
  • Overly assertive or nonassertive (interpersonal style).
  • Influenced by inadequate organizational climate or safety culture (such as lack of adequate supervision).

Communication and Crew Coordination

• Inadequate mission plan or brief or preflight.
• Inadequate or wrong mission information conveyed to flight crew (dispatch errors).
• Failure to communicate plan or intentions.
• Failure to use standard or accepted terminology.
• Failure to work as a team.
• Inability or failure to contact and coordinate with other aircraft or ground personnel.
• Inadequate understanding of communication or failure to acknowledge communication.
  
  
• Interpersonal conflict or crew argument during flight. Conditions leading to inadequate communication or coordination:
  • Inadequate training in communication or crew coordination.
  • Inadequate standard operating procedures for use of crew resources.
  • Inadequate support from organization for crewcoordination doctrine.
  • Failure of organizational safety culture to support crew resource management.
    
    
• Internal communication on aircraft:
  • Inadequate crew coordination (challenge, cross-check).
  • Intentional withholding, by a crewmember, of vital safety data.
  • Failure of the pilot-in-command to lead or delegate.
  • Failure of the pilot-in-command to use all available resources.

System Design and Operation

• Use of wrong switch, lever, or control.
• Misinterpretation of instrument indication.
• Inability to reach or see control.
• Inability to see or interpret instrument or indicator.
• Failure to respond to warning.
• Selection or use of incorrect avionics system-operating mode (mode confusion).
  
  
• Overreliance on automated system (automation complacency). Conditions that contribute to design-induced flight crew errors:
  • Inadequate primary aircraft control or display arrangement.
  • Inadequate primary display data or data format.
  • Incompatible flightdeck control or display activation, or aircraft-response mapping.
  • Inadequate hazard advisory or warning display.
  • Inadequate flight deck design (controls or displays outside crew vision or reach).
  • Inadequate human-computer-display interface or usability (error-prone design).
  • Inadequate system instructions or documentation.
  • Inadequate aviation-system support or facilities. (navigation aids, airport, air traffic control).
  • Nonstandard flightdeck layouts that may cause confusion.
  • Inappropriate type or level of automation, or excessive mode complexity.
  • Maintaining current skills in operating multiple aircraft.

Supervisory and Organizational

• Failure to adhere to rules and regulations.
• Inappropriate scheduling or crew assignment.
• Failure to monitor crew rest or duty requirements.
• Failure to establish adequate standards.
• Failure to provide adequate briefing for mission.
• Inadequate training.
• Lack of professional guidance.
• Failure to support or poor support of flight crews.
• Failure to monitor compliance with standards.
• Failure to monitor crew training or qualifications.
• Failure to identify or remove a known high-risk pilot.
• Failure to correct inappropriate behavior.
• Failure to correct a safety hazard.
• Failure to establish or monitor quality standards.
• Failure of standards, either poorly written, highly interpretable, or conflicting.
• Risk outweighs benefit.
• Poor crew pairing.
• Excessive mission tasking or workload.
• Intentional violation of a standard or regulation.
  
  
• Failure to perceive or to assess mission risks correctly, with respect to:
  • Unseen or unrecognized hazards.
  • Environmental hazards or operating conditions.
  • Mission tasking and flight crew skill level.
  • Aircraft and equipment limitations.
    
    
• Conditions leading to supervisory failures:
  • Excessive operations or organizational workload (imposed by the organization or imposed by organizational chain of command).
  • Inadequate organizational safety culture.
  • Supervisor is over-tasked.
  • Supervisor is untrained.
  • Inattention to safety management (inadequate safety supervision).
  • Inadequate work standards or low performance expectations.
  • Inadequate or poor example set by supervisors.
  • Inadequate safety commitment or emphasis by supervisors.
  • Organization lacks an adequate system for monitoring and correcting hazardous conditions.
  • Supervisors do not promote and reward safe behavior or quickly correct unsafe behaviors.
  • Organization lacks adequate policies and procedures to ensure high quality work performance.
  • Organization had inadequate job qualification standards or a training program.
  • Organization lacks internal communication.
  • Organization has no system or an inadequate one for management of high-risk pilots.
  • Organization lacks adequate process or procedures for operational risk management.
  • Organization provide inadequate aeromedical or human factors training.
  • Organization lacks sufficient involvement of medical and occupational health specialists.
  • Organization has not established or enforced acceptable medical or health standards.

Maintenance

• Procedures.
  • Unwritten.
  • Unclear, undefined, or vague.
  • Not followed.
    
    
• Records.
  • Discrepancies entered—but not deferred to—or resolved.
  • Entries not recorded or not recorded in correct book(s).
  • Improper entries or unauthorized signature or number.
  • Falsification of entries.
    
    
• Publications, manuals, guides.
  • Not current.
  • Not used for the procedure.
  • Incorrect manual or guide used for procedure.
  • Not available.
    
    
• Training.
  • Not trained on procedure.
  • Training not documented.
  • Falsified.
  • Not current.
    
    
• Personnel.
  • Improperly licensed.
  • Insufficient (staffing).
  • Improper or insufficient oversight.
  • Insufficiently rested.
    
    
• Management.
  • Nonexistent.
  • Ineffective.
  • Understaffed.
  • Ineffective organization of assigned personnel.
  • Insufficiently trained.
    
    
• Quality Assurance.
  • Nonexistent.
  • Insufficient training.
  • Ineffective.
  • Not used.
    
    
• Inspection Guides.
  • Unavailable.
  • Procedures not followed.
  • Insufficient.
  • Not current.
  • Not approved.
  • Not signed off.
  • Falsified.
  • Unapproved signature or number.
    
    
• FAA 337s.
  • Not completed for major repair or alteration.
  • Incomplete.
  • Not turned into the Federal Aviation Administration.
  • Not with records or flight manual.
  • Not being complied with (inspection or procedure or limitations).
  • Falsified (improper signature or number).
  • Instructions for Continued Airworthiness (ICAs).
  • Nonexistent.
  • Not followed.
  • Insufficient.
    
    
• Tools or Equipment.
  • Improper use or procedure.
  • Not calibrated.
  • Not trained for the special equipment or tool.
  • Not used.
  • No tool control program.

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since July 21, 2005