A Human Error Analysis of General Aviation Controlled Flight Into Terrain Accidents Occurring Between 1990-1998

Abstract : Although all aviation accidents are of interest to the Federal Aviation Administration (FAA), perhaps none is more disconcerting than those in which a fully functioning aircraft is inexplicably flown into the ground. Referred to as controlled flight into terrain (CFIT), these accidents continue to be a major safety concern within aviation, in particular general aviation (GA). A previous study as part of the FAA's Safer Skies agenda examined 165 CFIT accidents using root cause analysis and developed 55 interventions to address their causes. While the study represented the work and opinions of several experts in the FAA and industry, the findings might have benefited from a more detailed human error analysis involving a larger number of accidents. In this study, five pilot-raters independently analyzed more than 16,500 GA accidents occurring between 1990-1998 using the Human Factors Analysis and Classification System (HFACS). Of the GA accidents examined, 1407 were identified as CFIT and compared with non-CFIT accidents using HFACS. The analysis revealed a number of differences in the pattern of human error associated with CFIT accidents. Findings from this study support many of the interventions identified by the CFIT Joint Safety Analysis Team (ISAT) and Joint Safety Implementation Team (JSIT), permitting safety professionals to better develop, refine, and track the effectiveness of selected intervention strategies.

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