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The Application of Human Factors Analysis and Classification System

(HFACS) to Investigate Human Errors in Helicopter Accidents

Conference Paper · July 2013

DOI: 10.1007/978-3-642-39354-9_10

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 The Application of Human Factors Analysis and
Classification System (HFACS) to Investigate Human
Errors in Helicopter Accidents

Chia-Fen Chi1, , Shao-Yu Liu1* , Wen-Chin Li2

1
Dept. of Industrial Management, National Taiwan University of Science and Technology,
Taipei, Taiwan, R.O.C.
2
Graduate School of Psychology, National Defense University, Taipei, Taiwan, R.O.C.

davidliu735@gmail.com

Abstract. current study investigates 83 civil aviation and military services heli-
copter accidents in Taiwan between 1970 and 2010. The probable and latent
causes of those accidents are clearly defined, and statistically analyzed by error
related paths and Human Factors Analysis and Classification System (HFACS).
Results indicate that categories of the higher level have better predicted power
(between 4.25% and 24.9%) than categories of the lower levels (with odd ratios
between 0.19 and 8.67). Fallible decisions in upper command levels directly af-
fect supervisory practices which create pre-conditions for unsafe acts, impair
performance of pilots, and lead to unexpected accidents. By identifying the
higher level human errors leading to low level helicopter mishaps, HFACS is
useful a tool for accident investigations and accident prevention strategies. Cur-
rent study provides a practical suggestion to top managers for a better helicopter
operational safety environment.

Keywords: Human Factors Analysis and Classification System (HFACS), Hu-

man Errors, Helicopter Flight Operations.

1 Introduction

Taiwan is a mountainous island surrounded by Pacific Ocean and Taiwan Strait. Nat-
ural disasters such as typhoons and earthquakes have constantly led to catastrophic
damage in human livies and property. Helicopter, due to its maneuverability and
operational flexibility, is very adapted for emergent rescue missions such as ambu-
lance, observation on disastrous landscape, material transportation, and reconnais-
sance patrol over disastrous regions in Taiwan remote villages. The average flight
hours are, therefore, increased from 1,000 hours to more than 10,000 hours per year
since 1999 to 2008. (Aviation Safety Council, ASC, 2010). As a result, the average
helicopter accident rate in the past ten years had dramatically increased to 10.24 acci-
dents per 100,000 flight hours, which is 38.06 higher than the accident rate in the
United States of American (USA). This astonishing accident record has casted the

adfa, p. 1, 2011.
© Springer-Verlag Berlin Heidelberg 2011
public the image that the helicopter is one of the most unsafe transporter in Tai-
wan.The motivation of current study is to investigate the root causes of those acci-
dents through the application of Human Factors Analysis and Classification System
(HAFCS) and propose suggestions for top managers to improve organization aviation
safety by reducing those potential hazards. Among those categories of root causes,
human errors take part in 70% to 80% of civil and military aviation accidents.
(O’Hare, Wiggins, Batt, & Morrison, 1994;Wiegmann and Shappell, 1999). The root
causes of helicopter accidents in Taiwan are similar to scenarios worldwide that
57.14% were due to human factors, 28.50% were environmental factors, and 14.28%
were contributed as maintenance factors. Human-error related accidents are still rela-
tively high and stable over the last several years worldwide. (Shappell & Wiegmann,
1996). Therefore, Shappell and Wiegmann constructed HFACS as an analytical tech-
nique to look into the human error related incidents accidents qualitatively.The
HAFCS is based on Reason’s model of latent and active failures of an accident. In
addition, FAA and NASA, USA have also applied HFACS, as a complement tool to
pre-existing system with civil aviation in an attempt to capitalize on gains realized by
the military (Ford, Jack, Crisp, & Sandusky, 1999). The HFACS framework bridges
the gap between theory and practice by providing safety professionals with a theoreti-
cal-based tool for identifying and classifying the causes of human error aviation acci-
dents. Because the framework focuses on both latent and active failures and their
interrelationships, it facilitates the identification of the underlying causes of human
error. HFACS has been proven to be an useful tool within the context of military avia-
tion. This research examines the applicability of HFACS framework for the analysis
of helicopter accidents investigation.

2 Literature review

Many human factors accident analysis frameworks, taxonomies and analysis strate-
gies have been devised over the years (e.g. Diehl, 1989; Feggetter, 1991). In recent
years, accident investigation the scientific focus has shifted away from psychomotor
skill deficiencies and emphasis is now more placed upon inadequacies in decision-
making, attitude, supervisory factors and organizational culture as being the primary
causal factors (Diehl, 1991; Jensen, 1997, and Klein, 2000). Dekker (2001) has pro-
posed that human errors are systematically connected to features of operators' tools
and tasks, and error has its roots in the surrounding system: the question of human or
system failure alone demonstrates an oversimplified belief in the roots of failure. By
examining and correlating information across a number of accidents, predictors may
be identified which may then be applied to individual crews or situations in order to
develop effective prevention strategies.Wiegmann & Shappell (2001) claim that the
HFACS framework bridges the gap between theory and practice by providing safety
professionals with a theoretically based tool for identifying and classifying the human
errors in aviation mishaps. Since its It is based on a sequential or chain-of-events
theory of accident causation and was derived from Reason’s (1990), the classification
system was originally developed for use within the US military both to guide investi-
gations and to analyse accident data (Shappell & Wiegmann, 2000b). Development
has been used in a variety of transport and occupational settings including aviation,
road and rail transport (Shappell & Wiegmann, 2000a; Federal Railroad Administra-
tion, 2005; Gaur, 2005; Li & Harris, 2005). It has also been used by the medical, oil
and mining industries (Reinach and Viale ,2006). HFACS has also been used to ana-
lyse major flying operations (ex,commercial) and specific accident types, such as
controlled flight into terrain (CFIT). Within the US aviation studies, the results have
been consistent over time, with only small changes in the percentage of accidents
associated with unsafe acts observed between earlier and later studies (Wiegmann &
Shappell,2001;2005).The application of HFACS has also been effective for conduct-
ing comparisons between countries. Studies comparing US aviation accidents and
those of other countries including China, Greece and India have been consistent.
Their results indicated that while there were differences in the contributory factors
between the countries, skill-based errors were associated with the greatest number of
accidents in each of the countries followed by decision errors, violations and percep-
tual errors respectively (Gaur, 2005; Li & Harris, 2005).The system focuses on both
latent and active failures and their inter-relationships, it facilitates the identification of
the underlying causes of human error. However, as aviation accidents are the result of
a number of causes, the challenge for accident investigators is how best to identify
and mitigate the causal sequence of events leading up to an accident. whether this
framework is suitable to meet needs of aviation accident’s classification and investi-
gation.

3 Method

Data: A total of 83 helicopter accidents and reported incidents, from 1970 to 2010
in Taiwan, is investigated. The aviation accident reports were obtained from Aviation
Safety Council(ASC),Civil Aeronautical Administration(CAA), and Ministry of De-
fense(MOD) of Taiwan, R.O.C.There were same types of helicopter involved in the
accidents, including commercial and Military aviation. All accidents and serious inci-
dents conformed to the definition within the 9th edition of the Convention on Interna-
tional Civil Aviation, Annex 13 (International Civil Aviation Organisation, 2006).
Classification framework: HFACS framework proposed by Wiegmann and
Shappell (2003). HFACS Level-1: ‘unsafe acts of operators’ is the probable cause that
directly lead to an accident. This Level-1 comprises four categories which are ‘deci-
sion errors’; ‘skill-based errors’; ‘perceptual errors’ and ‘violations’. HFACS Level-2
is concerned with ‘preconditions for unsafe acts’. This Level-2 has seven categories
including : ‘adverse mental states’; ‘adverse physiological states’; ‘physical /mental
limitations’;‘crew resource management’; ‘personal readiness’;‘physical environ-
ment’ and ‘technological environment’.HFACS Level-3 is concerned with ‘unsafe
supervision’ which includes the four categories ‘inadequate supervision’; ‘planned
inappropriate operation’; ‘failure to correct known problem’ and ‘supervisory viola-
tion’. Level-4,the highest level in the framework is labelled ‘organizational influ-
ences’ and comprises of three sub-categories: ‘resource management’; ‘organizational
climate’ and ‘organizational process’.
Coding process: Each accident report was scrutinized and coded by two senior
aviation investigators whose expertises are instructor pilot and aviation psychologist,
respectively. Qualified investigators should possess at least 12-hour HFACS training.
The presence (code 1) or the absence (code 0) of each HFACS category was carefully
assessed in each accident report, narrative. To avoid over-representation from any
single accident, each HFACS category was counted a maximum of only once per
accident. The count acted simply as an indicator of presence or absence of each of the
18 categories in a given accident..

4 Analysis

In total instances of 626 category assignments were made to described the causal
factors underlying the 83 accidents. The inter-rater reliabilities calculated on a catego-
ry-by-category basis were assessed using Cohen’s Kappa. The values obtained ranged
between 0.62 and 1.0 (see table 1). Fourteen HFACS categories exceeded a Kappa of
0.60 indicating substantial agreement (Landis & Koch, 1977). As Cohen’s Kappa can
produce misleadingly low figures for inter-rater reliability where the sample size is
small or where there is very high agreement between raters associated with a large
proportion of cases falling into one category (Huddlestone, 2003), inter-rater reliabili-
ties were also calculated as a simple percentage rate of agreement. These showed
reliability figures between 89.2% to 100%, further indicating acceptable reliability
between the raters. See Li & Harris (Li & Harris, 2006) for further details. Relatively
few categories had exceptionally low counts. Only the categories of ‘Failed to correct
known problem’;’Personal readiness’ and ‘adverse physiological state’ failed to
achieve double figures. The results reported only to the instances where the PRE was
in excess of 5%. The data were cross tabulated to describe the association between the
categories at adjacent levels in the HFACS analytical framework. Goodman and
Kruskall’s lambda (λ) was used to calculate the proportional reduction in error (PRE)
(Goodman, 1954). The Lambda statistic is analogous to the R squared statistic for
continuous data. For categorical data (such as that found in contingency tables), its
value reflects the PRE when predicting the outcome category from simply the base-
line prevalence as compared to using information from the predictive category. For
the purposes of this study the lower level categories in the HFACS were designated as
being dependent upon the categories at the immediately higher level in the frame-
work, which is congruent with the theoretical assumptions underlying HFACS: from
this standpoint, lower levels in the HFACS cannot affect higher levels. Finally, odds
ratios were also calculated which provide an estimate of the likelihood of the presence
of a contributory factor in one HFACS category being associated concomitantly with
the presence of a factor in another category. However, it must be noted that odds rati-
os is an asymmetric measure and so are only theoretically meaningful when associat-
ed with a non-zero value for lambda.
 Table 1. The frequency and percentage of 83 accidents by HFACS categories
Inter-rater Cohen’s
HFACS category Frequency Ordinal Percentage
reliability Kappa
Decision errors 68 2 81.9% 92.8% 0.788
Level 1

Skill-based Errors 57 4 68.7% 90.4% 0.792

Perceptual Errors 24 11 28.9% 98.8% 0.970
Violations 17 14 20.5% 98.8% 0.962
Adverse mental State 55 5 66.3% 100.0% 1.000
Adverse physical state 8 16 9.6% 98.8% 0.927
Physical/Mental limitation 47 7 56.6% 98.8% 0.976
Level 2

Crew resource management 73 1 88.0% 89.2% 0.624

Personal readiness 2 18 2.4% 100.0% 1.000
Physical environment 67 3 80.7% 100.0% 1.000
Technical environment 20 13 24.1% 100.0% 1.000
Inadequate supervision 49 6 59.0% 91.6% 0.830
Level 3

Planned inappropriate Operation 25 10 30.1% 96.4% 0.911

Failed to correct known problem 5 17 6.0% 100.0% 1.000
Supervisory violation 10 15 12.0% 100.0% 1.000
Resource management 32 9 38.6% 96.4% 0.922
Level 4

Organizational climate 24 11 28.9% 95.2% 0.877

Organizational processes 43 8 51.8% 94.0% 0.880

5 Result

All these relationships were also associated with high odds ratios, suggesting that
inadequate performance in the higher level HFACS categories was associated with
much increased levels of poor performance at the lower levels.The strength analysis
on HAFCS level-4 ‘organizational influences’ associated with adjacent HFACS level-
3 ‘unsafe supervision’ indicates that, among possible 12 pairs of relationships, 3 asso-
ciations are significant (p<0.05), From statistical analysis, ‘Inadequate supervision’ is
5.28 times more likely to occur when organizational level associates with poor ‘Re-
source management’; ‘Supervisory violation’ is 0.83 times more likely to occur when
organizational level associates with poor organizational climate; Similarly, ‘inade-
quate supervision’ is 2.55 times more likely to occur in the presence of poor organiza-
tional processes.The strength analysis on HAFCS level-3 ‘unsafe supervision’ associ-
ated with adjacent HFACS level-2 ‘pre-conditions for unsafe acts’ indicates that,
among possible 28 relationships, 6 associations are significant. (p<0.05).‘CRM’ is
0.91 times more likely to occur when supervision level associates with poor ‘inade-
quate supervision’ and ‘Adverse mental state’ is 0.07 times more likely to occur when
supervision level associates with poor ‘supervisory violation’; An issue also is associ-
ated with ‘Adverse physical state’ is 4.58 times more likely to occur when supervision
level associates with poor ‘planned inappropriate operations’ and is 8 times more
likely to occur when supervision level associates with poor ‘failed to correct a known
problem’; ‘Personal readiness’ is 1.25 times more likely to occur when supervision
level associates with poor ‘Supervisory violation’, and ‘CRM’ is 0.71 times more
likely to occur when supervision level associates with poor ‘Supervisory viola-
tion’.The strength analysis on HAFCS level-2 ‘pre-conditions for unsafe acts’ associ-
ated with adjacent HFACS level-1 ‘unsafe acts of operators’ indicates that a possible
28 relationships, 8 pairs of associations are significant (p<0.05)
Table 2. Significant association between upper level and adjacent downward level categories
in the HFACS framework

χ2 test τ (PRE) Odds rati

Value p-level Value p-level
Organizational process vs Inadequate supervision 4.25 .004 .005 .040 5.27
Organizational climate vs supervisory violation 4.63 .005 .056 .033 0.83
Resource management vs Inadequate supervision 10.62 .001 .128 .001 2.55
Inadequate supervision vs Crew resource management 9.33 .002 .112 .002 0.19
Inadequate supervision vs Adverse mental state 16.38 .000 .197 .000 0.70
Planned inappropriate operations Vs adverse Physical state 4.41 .050 .053 .037 4.58
failed to correct a known problem vs adverse Physical state 5.63 .071 .068 .018 8.00
Supervisory violation vs Crew resource management 15.45 .002 .186 .000 0.07
Supervisory violation vs Personal readiness 14.96 .013 .180 .000 1.25
Adverse mental state vs Perceptual errors 9.74 .002 .117 .002 8.66
Physical/mental limitation vs Decision errors 6.35 .001 .077 .050 0.27
Crew resource m nagement vs Violations 24.92 .300 .039 .000 4.56
Crew resource management vs Decision errors 10.90 .004 .131 .001 0.11
Personal readiness vs Decision errors 4.49 .096 .054 .035 0.29
Physical environment vs Decision errors 5.79 .017 .070 .017 0.11
Technological environment vs Perceptual errors 5.57 .025 .067 .019 5.53
Technological environment vs Decision errors 4.58 .046 .055 .033 0.20

‘Decision errors’ is 0.27 times more likely to occur when pre-condition level associ-
ates with poor ‘Physical/mental limitation’; Similarly, ‘Decision errors’ is 0.12 times
more likely to occur in the presence of poor ‘CRM’; ‘Decision errors’ is 0.29 times
associated with poor ‘Personal readiness’；‘Decision errors’ is 0.11 times associated
with poor Physical environment, and ‘Decision errors’ is 0.21 times associated with
poor technological environment. Perceptual errors are over 8.67 times more likely to
occur when there are pre-conditions level issues associated with poor ‘adverse mental
state’ and over 5.54 times associated with poor ‘Technological environment’. Similar-
ly, Violations is 4.56 times more likely to occur in the presence of poor ‘CRM’.
 Fig. 1. The significant association of Chi-square (χ2) and Tau (τ)

6 Discussion

In application of HFACS framework, inadequacies in the following categories of

Level-4: ‘Organizational processes’ particularly result from excessive time pressures,
poor mission scheduling, poor risk management programs, inadequate management
checks for safety, failing to establish safety programs and ‘Resource management’
which involves the staff selection, training of human resources at an organizational
level, excessive cost cutting, unsuitable equipment, and failure to remedy-design
flaws also shows strong correlation with the level-3 categories of ‘inadequate supervi-
sion’.Untrained supervisors and general loss of situation awareness at the supervisory
level(Li et al,2006a,b;2008). ‘Organizational climate’ including inadequacies in chain
of command, poor delegation of authority, inappropriate organizational customs and
beliefs. however, it is strongly correlated with the 'Supervisory violations'. hypothe-
size that inappropriate decision-making by upper-level management can adversely
influence the personnel and practices at the supervisory level (Reason, 1990; Wieg-
mann & Shappell, 2003). It is strongly correlation with two categories of ‘CRM’,
such as Poor ‘CRM’ including ‘Lack of teamwork’ and ‘Adverse mental states' such
as ‘Failure to provide proper training’ or ’Adequate rest periods’(Li and Harris,
2006a,b). In addition, Adverse mental state includes ‘Lack of mental fatigue’ and
‘stress’. Inadequacies in ‘adverse mental practices’ are particularly influenced by the
level-3 category of ‘inadequate supervision’. This category encompasses issues such
as ‘failure to provide adequate rest periods’and performance of personnel’ (Reason,
1990). These erroneous actions need not be confined to either 'Inadequate supervi-
sion’ or ‘Adverse mental’. Poor 'Supervisory violations' includes ‘authorizing an un-
qualified crew for flight’and ‘Supervisors violating procedures’, it also shows strong
relationships with the level-2 two categories of ‘CRM’ and ‘Personal readiness’.The
Poor CRM includes lack of teamwork and ‘failures of leadership’. This category en-
compasses issues such as ‘failure to provide authorizing an unqualified crew for
flight’. Moreover, poor ‘Personal readiness’ includes lack of selfmedication’and over-
exertion while off duty. Inadequacies in ‘Personal readiness’ practices are particularly
influenced by the category of ‘Supervisory violations'.This category encompasses
issues such as failure to provide ‘supervisors violating’ inadequate documentation and
willful disregard of authority by the supervisor (Li and Harris’, 2008). The ‘precondi-
tions for unsafe acts’ category poor ‘Adverse physiological states’ encompasses is-
sues associated with inadequate training, self-medication and overexertion while off
duty. Inadequacies in 'Adverse physiological states' practices are particularly influ-
enced by the level-3 category of' ‘Planned inadequate operations' and ‘Failures to
correct inappropriate behavior’. The Poor ‘Planned inadequate operations' includes
poor crew pairings and excessive task/workload, ‘Failures to correct inappropriate
behavior’, failing to remove a known safety hazard, failing to report unsafe tenden-
cies. This category in HFACS framework encompasses issues such as failure to pro-
vide poor crew pairings, failure to establish if risk outweighed benefit. Current study
clearly provides evidence that inadequacies at HFACS level-2 ‘preconditions for un-
safe acts’ has associations with further inadequacies at HFACS level-1 'unsafe acts of
operators'(Table2). The most frequently occurring category is ‘Decision errors’ which
is also a particularly important factor at this 'unsafe acts of operators'. ‘Decision er-
rors’ encompasses issues associated with failure of selecting inappropriate strategies
during mission. The next most frequent category are lack of teamwork, poor commu-
nication, failure of leadership and inadequate briefing. The 'Technological environ-
ment' category covers issues such as equipment design, cockpit display interfaces,
automation and checklist layout (Li el al, 2006a；2008).The level-1'unsafe acts of
operators' category of 'Perceptual errors'. Poor 'Perceptual errors' included encom-
passed issues associated with experiencing spatial disorientation and descent rate
during IMC. 'Perceptual errors' practices were particularly influenced by the level-2
category of' 'adverse mental states' and 'Technological environment'. This category in
the HFACS encompasses issues such as a failure to provide, 'adverse mental states'
included issues such as over-confidence, stress, distraction, and task saturation (Li
and Harris 2008). Another 'Technological environment' by the effects of the low-
er.This accident involves ‘unsafe acts of operators’ category of ‘CRM’ which in-
cludes Poor ‘CRM’ such as lack of teamwork, poor communication and inadequate
briefing. ‘CRM’ practices are particularly influenced by the level-2 category of' ‘vio-
lations’. 'Violations' in HFACS framework encompasses issues such as pilots fail to
provide or follow standard operation procedures (SOPs) ( Li et al, 2008).

7 Conclusion

The Human Factors Analysis and Classification System (HFACS) was developed as
an analytical framework for the investigation of the role of human factors in aviation
accidents, becoming one of the most commonly used and is the one used herein as a
basis for the current work. Strategies in application of HFACS on accident investiga-
tions have been successfully verified by many aviation psychological scholars.
(Diehl, 1989; Wiegmann & Shappell, 2003). The benefit of HFACS is that the con-
tributing human errors in any single accident can be properly categorized regardless
the aircraft type of helicopter accident, and provide a preventive strategy for safety
assurance. In most cases, space Disorientation and CFIT are two major probably
causes for helicopter accidents.Consequently, strategy for helicopter safety promotion
suggested from current study to the top management of helicopter organization is as
follows. First, supervision on flight plan and pre-condition briefing requires rein-
forced compliment, particular on violators. Second, safety equipment promotion such
as all weather radar and terrain detection radar increases the quality on decision-
making of crewmembers.

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