Progress in Aerospace Sciences xxx (2017) 1–13

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Progress in Aerospace Sciences

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A review of human factors causations in commercial air transport accidents

and incidents: From to 2000–2016
Husam Kharoufah a, John Murray a, b, Glenn Baxter c, Graham Wild a, *
a
School of Engineering, RMIT University, Melbourne, Australia
b
School of Engineering, Edith Cowan University, Joondalup, Australia
c
School of Tourism and Hospitality Management, Suan Dusit University, Huahin Prachaup Khiri Khan, Thailand

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

Keywords: Human factors have been defined by the International Civil Aviation Organization (ICAO) as “about people in
Human factors their living and working situations; about their relationship with machines, with procedures and with the envi-
Aviation safety ronment about them; and about their relationships with other people (at work)”. Human factors contribute to
Accident investigation approximately 75% of aircraft accidents and incidents. As such, understanding their influence is essential to
improve safety in the aviation industry. This study examined the different human factors causations in a random
sample of over 200 commercial air transport accidents and incidents from 2000 to 2016. The main objective of
this study was to identify the principal human factor contributions to aviation accidents and incidents. An
exploratory research design was utilised. The qualitative data were recorded in a database, and were coded into
categories about the flights (including date, manufacturer, carrier, state of occurrence, etc). These categories were
then analysed using Chi-Squared tests to determine which were statistically significant in terms of having an
influence on the accidents/incidents. The most significant human factor was found to be situational awareness
followed by non-adherence to procedures. In addition, charter operations proved to have a significantly higher
rate of human factor related occurrence as compared to other type of operations. A significant finding was that
Africa has a high rate of accidents/incidents relative to the amount of traffic and aircraft movements. These
findings reflect some of the more noteworthy incidents that have received significant media attention, including
Air Asia 8501 on the 28th of December 2014, TransAsia Airways 235 on the 4th of February 2015, and Air France
447 on the 1st of June 2009; these accidents resulted in a significant loss of lives where situational awareness and
non-adherence to procedures were significant contributing factors.

1. Introduction 2. How are HFs causes distributed by type of operation in commercial

1.1. Aim
The purpose of this study is to assess the role of human factors (HFs)
in commercial air transport accidents and incidents from 2000 to 2016.
The aim of this assessment is to provide the aviation industry with
analytical insights to positively impact aviation safety. To provide better
granularity, differences were assessed across 1) world regions, 2) types of
commercial air operation, 3) phases of flight, and 4) type of human error.
To facilitate this assessment three research questions were identified.
1. What are the most common HFs causes in commercial air transport
accidents and incidents over the period from 2000 to 2016?
air transport accidents and incidents attributed to HFs causation over
the period 2000 to 2016?
3. How are HFs causes distributed by world region (both state of oper-
ator and state of occurrence) in commercial air transport accidents
and incidents attributed to HFs causation over the period 2000 to
2016?
1.2. Background
“Human Factors” as an idea is a relatively new subject. The concept
arose in aviation from work by the UK and North America around the
ending of the Second World War [53]. The usage of the term HFs began
informally in literature in British Air Force accident investigation reports

* Corresponding author.
E-mail address: graham.wild@rmit.edu.au (G. Wild).

https://doi.org/10.1016/j.paerosci.2018.03.002
Received 26 November 2017; Received in revised form 2 March 2018; Accepted 6 March 2018
Available online xxxx
0376-0421/Crown Copyright © 2018 Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: H. Kharoufah, et al., A review of human factors causations in commercial air transport accidents and incidents: From
to 2000–2016, Progress in Aerospace Sciences (2017), https://doi.org/10.1016/j.paerosci.2018.03.002
H. Kharoufah et al.
in the 1940s; however, it was first officially used in 1957. The term was
used to represent the application of scientific knowledge, facts, models,
and theories derived mostly from various areas of human science such as
sociology, psychology, physiology/medicine, engineering, management
science, and anthropometrics [38].
Human error is by no means unique to aviation; it plays a central role
in accidents and financial losses [93]. has defined human error as “any
member of a set of human actions that exceeds some limits of accept-
ability - it is an out of tolerance action, where the limits of acceptable
performance are defined by the system.” Nowadays, the contribution of
human error in aviation accidents has been a major factor as 66% of
hull-loss accidents were associated with flight crew in the period between
1992 and 2001 [22]. The impact of human error in general aviation is
even more significant. For example, 79% of the fatal accidents that
occurred in the United States in 2006 were attributed to pilot error [77].
In addition to safety issues, human error can cause huge financial
losses for the airline industry in the form of tools destroyed, modifica-
tions of flight schedules such as flight delays, and fuel costs. For instance,
92% of the collisions between aircraft and ground vehicles or structures
at airports that were contributed to human error, not including taxiway
operations, costs the airline industry globally about 10 billion US dollars
annually [79]. As such, it is essential to understand the role of human
errors in aircraft accidents and incidents.
2. Literature review
2.1. Flight crew selection
According to [56] for many years, the primary focus of flight crew
selection was on the identification of individuals with superior flying
skills and abilities. However [56], explains that, in recent years the
aviation community has become increasingly aware that for a flight crew
to complete their flight or mission, the flying skills and the ability to work
well in a crew situation during the different phases of the flight are
necessary. Crew resource management (CRM's) skill tests have been
designed to measure problem solving, decision making, and knowledge
of how individuals perform under pressure with crew members in the
cabin. The authors' findings illustrated that CRM has proved to be more
effective than traditional methods based on research from scientists
which stated that most aviation accidents are due to miscommunication
between crew members in the cockpit.
Another study about flight crew selection presented by Ref. [111];
focused on testing the individual skills of flight crew in addition to
conducting structured interviews to enable human resources to select the
best flight crew to fly their aircrafts [111]. conclusions were based on
substantial research that was completed to find the best method to select
pilots. The results illustrated that individuals' tests and structured in-
terviews is the best method, with the authors discovering a positive
relationship between good interview scores and continued employment
in addition to, a relationship between poor interview scores and flight
crew being terminated by the company [111].
Advancement in the aviation sector has led to the discovery of
innovative methods, such as profiling [74]. discusses profiling of flight
crew based on their personalities and mental health. The profiling pro-
cess consists of two methods; select-in and select-out. The select-in
method helps in estimating the level of knowledge, skills, and other ca-
pabilities the candidate has for a given job and consists of psychological
testing and measuring the personal traits executed from the analysis of
the job task. While the select-out method, includes medical techniques
and an assessment of psychopathology to observe psychiatric fitness
[74].
Another study about pilot selection authored by Ref. [41] focused on
the importance of situational awareness of flight crew in the process of
flight crew selection. The authors demonstrated the significance of
situational awareness for flight crew to execute the correct action in a
short period that can be less than a millisecond which can be very
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Progress in Aerospace Sciences xxx (2017) 1–13
decisive for the safety of the aircraft and passengers. The authors state
that the process of selecting flight crew and grouping them as per their
level of situational awareness consists of 5 vital individual skills which
are: Spatial, attention, memory, perception, and cognitive functions. The
5 skills were defined as:

Spatial: the capability of an individual to interact with the aircraft
systems through mental visualization and manipulating objects
spatially which are significant for navigational purposes.

Attention: is the focus on significant details in a demanding environ-
ment. The distribution of attention across several, competing sources
of information and tasks can be a vital challenge for flight crew during
the different flight phases.

Memory: Memory consists of working memory and long-term memory
stores. Comprehension and projection of future events that need high
levels of situational awareness must occur in working memory as
people try to integrate information from several sources, compare the
information obtained to the goals and objectives forecasted, and then
project future scenarios from known dynamics. While long-term
memory stores, can reduce the load on working memory. According
to the authors, a deft pilot is differentiated by his ability to know the
significance of the details during the flight to know whether the in-
formation should be stored in the long-term memory or not.

Perception: is the ability of an individual to perceive information in a
short period and to stay aware of infrequent signals to take decisive
actions.

Cognitive functions: is the capability of an individual to deal with
workload and circumvent issues under pressure and extreme envi-
ronment during the flight.
These five individual skills should be examined separately in the
process of flight crew selection to ensure pilots can withstand the
demanding and extreme environment during the flight. Therefore, flight
crew should be consistently monitored, trained, and developed to ensure
their readiness to face all sort of challenges to diminish aircraft accidents
in the aviation industry [41].
2.2. Trends in aviation human factors research
The term “human factors” has become increasingly popular in the
commercial aviation industry as human error has been recognized rather
than technical failure to underlie most aviation accidents and incidents.
HFs is a very extensive topic in both its knowledge base and scope. HFs
involve the collection of information about human abilities, limitations,
and other characteristics and implementing it to equipment, machine,
jobs, tasks, systems, and environments to generate a safe, comfortable,
and effective usage by a human. In aviation, the knowledge of how a
human and technology interact in a safe and effective is part of HFs. This
knowledge can then be implemented into various areas such as design,
training, policies, or procedures to enhance human performance [20].
Much research has been undertaken on the different HFs causes in
aviation accidents and incidents such as fatigue, situation awareness,
distraction in cockpit, and many other causes. The following sections
discussed the most significant HFs in aviation accidents and incidents
such as fatigue, situational awareness, and communication.
2.2.1. Fatigue
Fatigue is considered one of the most critical factors that has an
impact on the decision making of flight crew members. For instance [25],
presented a study of major accidents in domestic air carriers from 1978 to
1990 produced by the National Transportation Safety Board (NTSB), the
study estimated that fatigue contributed to between 4 and 7% of civil
aviation mishaps, and data from the US Army Safety Centre suggests
fatigue is involved in 4% of Army accidents. In addition, statistics from
the Air Safety Centre blame fatigue for 7.8% of Air Force Class-A mishaps.
The most significant issue that can be obtained from these data is the
H. Kharoufah et al.
financial cost of these accidents, as one major civil aviation accident can
exceed $500 million in total financial losses. This was the case in one of
the most infamous accidents in aviation history involving flight crew
fatigue, Korean Air Flight 801 in which 228 people died. Furthermore
[25], presented a survey of flight crew members in both the civilian and
military aviation sectors; the international crew surveyed indicated that
sleepiness and lethargy, cognitive slowness, and concentration diffi-
culties were common causes of flight crew fatigue. International pilots
regularly attribute fatigue to sleep deprivation and circadian distur-
bances related with time-zone transitions. Even though, long-haul pilots
are given opportunities to sleep during flights of 12 h or more, research
has proved that sleeping at home is more effective than sleeping in-flight
due to noise, turbulence, temperature, and other comfort factors. Do-
mestic pilots have indicated that their fatigue is due to sleep deprivation
and extreme workloads. The survey has indicated many common factors
for fatigue causation shared by international and domestic flight crew
such as night flights, jet lag, early wakeups, time pressure, several flight
legs, and successive duty sessions without efficient recovery breaks.
Another interesting fact indicated by the survey was that 71% of the
corporate/executive pilots surveyed reported that they had fallen asleep
during a flight. In fact, 90% of the flight crews surveyed recommended
flight scheduling as a major factor on diminishing fatigue within their
operational circumstances [25].
[26] also, discussed the effects of fatigue on aviators, from the
standpoint of flight crew performance where, fatigue plays a significant
role in:

Degrading accuracy and timing of flight crew;

Diminishing the ability of flight crew to integrate information from
flight instruments;

Narrowing the attention of flight crew and losing the capability to
efficiently time-share mental resources;

Decreasing the ability of flight crew to do physical activities;

Experiencing perceptual illusions and involuntary lapses into sleep
which may cause task-related details to be missed and failure of flight
crew responses can occur; and

Lowering problem solving and reasoning skills
In general, fatigue greatly affects the capability of flight crew to pay
attention to cockpit instruments, radio communications, the coordina-
tion of crew, and navigational tasks [26].
Another interesting study by Ref. [54]; discussed one of the recom-
mended methods to counter fatigue, napping. The author discussed the
benefits of strategic naps to flight crews during flights as they can help to
reverse performance deficiency due to sleep loss or disruption, in which
10 min can be very effective in reducing sleepiness and enhance neuro-
psychological performance. In addition, strategic naps can be efficient in
diminishing homeostatic deep drive, which is the gradually augmenting
pressure to sleep the longer a person has been awake. The study also
presented a survey of worldwide commercial airline accidents completed
by Boeing in 2015 that indicated the final approach and landing as the
most demanding phase of flight. Per the survey, the final approach and
landing phases of the flight had the most fatal accidents involving com-
mercial aircraft and indicated the importance of the pilot being fully
aware of the environment around him. Therefore, to maintain and
enhance alertness of flight crew during long-haul flights, commercial
airlines should increase the size of flight crews during the flight to allow
pilots to rest in selected bunk facilities, a practice implemented by most
air carriers. However, for airlines that do not have additional flight crew
during a flight, strategic napping can be very effective which can be taken
on the flight deck, although not all airlines allow this practice [54].
Other in-flight fatigue mitigation techniques discussed by Ref. [73]
which can be implemented during the flight to mitigate the impact of
fatigue are:

On-board sleep;
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Progress in Aerospace Sciences xxx (2017) 1–13

Cockpit naps;

Controlled rest breaks;

Caffeine;

Hydration and nutrition; and

Pharmaceutical options.
These techniques that were recommended by the authors in addition
to technological developments can significantly diminish the impact of
fatigue and enhance safety of in flight operations in even the most
difficult circumstances.
2.2.2. Situational Awareness
Another significant HF trend in aviation is situational awareness,
which is discussed by Ref. [53]. The author discussed ‘crew situational
awareness’ which is a unique subject as most in aviation discuss the
situational awareness for the pilots as individuals. The author believed
that there should be a greater focus on the crew situational awareness
rather than focus on the situational awareness of the pilot as an indi-
vidual, as most pilots fly as a member of the flight team. Moreover, the
author discussed the difference between shared and overlapping situa-
tional awareness [53]. stated that shared situational awareness is when
all flight crew members have a mutual and a final mutual understanding
of the flight circumstances. For instance, in the process of an Instrument
Landing System (ILS) approach with an individual pilot flying and the
other pilot observing the instruments, both pilots should have a shared
knowledge. However, in overlapping situational awareness which usu-
ally happens during the normal conduct of the flight, the flight crew will
not have that mutual understanding of the circumstances, in which there
are some mutual components between both pilots that ‘overlap’. In
general, flight crew members will be uniquely aware of different aspects
during the flight mission [53]. believed that seeking total shared situa-
tional awareness during the flight is ineffective and inadequate for
members of the flight crew.
Furthermore [24], observed situational monitoring, information
cross-checking, and activities coordination that are vital skills to set up
situational awareness between flight crew members [98]. had another
point of view, as he believed that orders from that pilot are significant to
create situational awareness among flight crew members. The author
claimed that the pilot's main task during the flight is to receive person
specific information about specific circumstances and translate it to a full
image to take actions. Furthermore, the author discussed that the degree
and quality of communication between flight crew members is significant
to enhance the degree of situational awareness assessment.
2.2.3. Communication
The failure of communication and cooperation between flight crew
members during flights has been identified as a main cause of many of
the accidents and incidents in commercial air transport. [49]; presented a
study on focus groups of crew members of airlines in which different vital
themes were identified. One of the most important themes identified
from this study were the barriers to communication during a flight in
which 6 barriers were identified, which were:
2.2.3.1. The protocols of interphone and the locked flight deck door. The
study has indicated that 81% of cabin crew agreed before discussion and
then a further 17% agreed after the discussion that a locked cockpit door
can be a physical and psychological barrier between crew members. The
study has indicated also the feel of hesitation from the cabin crew to use
the interphone as they were unmindful of the situation in terms of
workload in the cockpit. [49]; recommended the installation of video
cameras by the flight deck door to achieve safety in the cockpit and
effective communication among crew members.
2.2.3.2. Preflight briefings. Another barrier to communication is the lack
of combined cabin crew and pilot pre-flight briefing; 62% of subjects
H. Kharoufah et al.
agreed this barrier existed before discussion and a further 11% supported
after discussion. Although it was accepted, briefings were held in two
different buildings for international crews for all crew members due to
limited space [49].
2.2.3.3. Differences in terms and conditions. This aspect is essential to
effective communication between crew members. Usually, cabin crew
and flight crew stay in different accommodations on transit flights. This
results in less effective communication between crew members as they
are not able to communicate on the bus or get familiar with each other. In
general, differences in meals, accommodation, and allowances between
the two crew groups made communication less effective and adequate
between them [49].
2.2.3.4. Knowledge of basic aircraft terminology. The study has indicated
that many cabin crew members do not feel comfortable with the degree
of knowledge they have about the technical aspects of the aircraft in
which many of them face difficulties in describing technical issues that
occur during a flight. However, the study indicated that this was not an
issue in emergency situations but only in routine conditions [49].
2.2.3.5. Debriefings after incidents. The process of a debriefing after an
incident is significant for effective communication between crew mem-
bers. The study showed that cabin crew feel stressed, uncomfortable, and
curious wanting to know the causes of incidents. This was an issue for
18% of the crew members that were involved in the study [49].
2.2.3.6. Standard operating procedures. Cabin crew members have re-
ported that they were confused with the standard operating procedures
(SOPs), in addition to difficulties in understanding the situation in which
these procedures should be ignored for safety during the flight [49].
2.3. safety management systems- the human component
In the context of aviation, safety is defined by the [67] as “the state in
which the possibility of harm to persons or of property damage is reduced
to, and maintained at or below, an acceptable level through a continuing
process of hazard identification and safety risk management.”
It is well known that it is impossible for the aviation industry to be
free of hazards and related risk. However, the main objective is to
eliminate aircraft accidents and/or major incidents. Moreover, human
activities or human-built systems cannot be assured to be free from
operational faults and their consequences. Consequently, safety risk must
be progressively diminished as safety is considered a dynamic trait of the
aviation system. It is significant to recognise that the acceptability of
“safety performance” is usually affected by norms and culture. The
aviation system can still be managed to sustain the suitable equilibrium
between protection and production since safety risks are, to a significant
degree, under control [67].
[105]; defined a safety management systems as “a dynamic risk
management system based on quality management system (QMS) prin-
ciples in a structure scaled appropriately to the operational risk, applied
in a safety culture environment.” The safety management system consists
of four significant components which are then divided into 12 elements
which are required for an aviation industry organization to comply with
the program created by ICAO in its Advisory Circular 120-92A. This
recommendation has been adopted by many organizations around the
world such as United States Federal Aviation Administration (FAA) and
the Civil Aviation Safety Authority (CASA) [94].
The [47]; state that the four fundamental elements which safety
management systems are composed of, are:

Safety Policy – It is vital for the establishment of senior management's
commitment to gradually enhance safety; defines the procedures,
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Progress in Aerospace Sciences xxx (2017) 1–13
framework, and organization structure required to achieve safety
objectives identified by the organization.

Safety Risk Management – The safety risk management established the
requirements and quality of new or modified risk controls bases on
the assessment of acceptable risk.

Safety Assurance – Examines the progressive efficiency of the adopted
risk control techniques. In addition, it supports the identification of
new hazards.

Safety Promotion – This part of the safety management systems in-
cludes actions to establish a positive safety culture with all de-
partments of the organization such as training and communication.
[108]; discussed how HFs in safety management are considered a
competitive advantage. The authors discussed legacy viewpoints, that the
human component in the system should be replaced with reliable tech-
nical solutions as human performance is not constant or consistent.
Moreover, the positive view of the human in the system would observe
human error in a vital incident as the cause of technical or organizational
problems such as inefficient interfacing between human and machine or
understaffing. Furthermore, the number of serious events in the aviation
industry such as accidents and incidents compared to the amount of air
traffic yearly is very low [36]. recommends that when an organization
wants to seek the sources of failure, operational human errors should not
be assumed, but at a higher level away from the organization, since it is
believed that the humans are more than capable of adjusting their per-
formance based on circumstances which leads to success. Furthermore,
[108]; believe that the reason of both success and failure is identical: the
performance of the entire system including the human component can be
good or poor. The authors believe that the central resource for safety and
performance is highly adept, well-trained, and motivated staff.
Another significant aspect of safety management systems discussed
by Ref. [105] is the HFs Analysis and Classification System (HFACS) that
can be adopted by an airline and implemented into its database. HFACS is
one of the most implemented tools to assess the impact of HFs in accident
investigation, the system was used to review many military and general
aviation accident investigations. The HFACS methodology is imple-
mented in commercial aviation accidents and incidents to enhance safety
in the aviation industry [113].
The unique aspect about the HFACS methodology is that it is derived
from Professor James Reason's model of human error and Reason's
distinction between active and latent threats. The main difference be-
tween active threats and latent threats is that active threats are unsafe
acts made by an individual, usually the pilot flying the aircraft while
latent threats are environmental issues contributing to the occurrence of
an event [91].
[105]; state that HFACS was developed to enhance the completion of
accident investigation which consequently assists 4 levels of framework
connections of causes possibly contributing to accidents, initiating with
active and latent threats. However, the Federal Aviation Administration
(FAA) discovered that HFACS assists in supporting many of their objec-
tives in their Aviation Safety Action Program (ASAP) which encourages
employees in the organization to voluntarily report safety issues. The
HFACS methodology was found out to be very time consuming for pilots
to complete the process of submitting an incident report for ASAP. In fact,
the implementation of the HFACS methodology by the FAA illustrated
that the methodology is very complex for pilots to complete in one report.
3. Methodology
3.1. Research design
Post accident and incident analysis is important for the aviation in-
dustry to ensure safety is improved from lessons learned the “hard way”.
The goal being to ensure the lesson does not have to be repeated. As such,
providing an up-to-date post accident analysis of accidents and incidents
with HF causations is essential, given HFs is the biggest causal factor in
H. Kharoufah et al.
commercial air transportation [90]. This research problem required a
mixed method research design which was a combination of qualitative
and quantitative techniques. The mixed method approach that was
implemented in this research was the exploratory design [80].
The exploratory design consisted of two phases. The first phase uti-
lised a qualitative method (document analysis) to collect accidents and
incidents from various databases in addition to reports and documents of
accidents/incidents which were analysed to extract the required data.
The second phase of the research was a quantitative method using cat-
egorical data identified in the first phase. This phase of the research
focused on testing and generalizing the initial findings using statistics,
specifically Pearson's Chi-Squared Test. The second phase of the research
is significant as it displayed trends obtained from the data collected
which was vital to answer the research questions [34].
3.2. Data collection
In the aviation industry, when investigating an incident or accident
there are two basic groups of fundamental factors to consider:

Causative factors - failure of vital parts of equipment or human errors;
and

Contributory factors - feature of the job or conditions in which the
task is completed that stimulate failures of human.
Causative factors are easier to determine than contributory factors as
they are related to the sequence of events in an accident or an incident.
For instance, when a pilot fails to lower the landing gear the aircraft
crashes on landing. On the other hand, contributory factors are more
difficult to determine as these are only probabilistically associated with
the outcome of the accidents. For example, loss of situational awareness,
lack of communication, fatigue, etc., will not always result in an accident
or an incident; however, they can augment the possibility of human error
occurrence. Regarding investigation of HFs accidents and incidents, this
research focused mostly on contributory factors rather than causative,
which was a challenge as it is more difficult to determine contributory
factors than causative factors [53].
In this research, accidents and incidents data were collected from
several accidents and incidents databases, specifically:

Aviation Safety Network database sponsored by Flight Safety
Foundation;

National Transportation Safety Board (NTSB) aviation accident
database & synopses;

Australian Transport Safety Bureau (ATSB) National Aviation
Occurrence Database;

Planecrash Info database (planecrashinfo.com);

Aviation Safety Reporting System (ASRS) Database Online;

Bureau of Aircraft Accidents Archives (B3A);

FAA Accident and Incident Data System (AIDS); and

The Aviation Herald database.
The occurrences collected were logged into a database. The database
consisted of thirteen fields that were adopted from the National Trans-
portation Safety Board (NTSB) aviation accident database and synopses.
Specifically:

Type of Operation: The type of air carrier involved in the accident/
incident which are categorized into 6 types:
o Full Service Network Carrier
o Low Cost Carrier
o Cargo
o Regional
o Charter
o Ambulance (or aeromedical)

State of the operator: The country in which the airline operates.
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Progress in Aerospace Sciences xxx (2017) 1–13

Category: The type of event, specifically an accident or incident, that
occurred based on ICAO Annex 13.

Date of occurrence.

State of Occurrence: The country in which the accident/incident
occurred.

HF causation of incident/accident: The main HF causation that led to
the accident/incident. The causes have been adopted from Aviation
Safety Network which are divided into 8 categories:
o Alcohol & drug usage
o Situational Awareness
o Distraction in cockpit
o Incapacitation
o Fatigue
o Communication
o Non-adherence to procedures
o Flight Crew Selection

Aviation Occurrence: This term is used by Ref. [63] to categorize
aircraft accidents and incidents. The aviation occurrences for the
database were divided into 36 different categories.

Phase of flight: This term is used by Ref. [66] to categorize the part of
flight in which the accident/incident happened. Specifically:
o Takeoff
o Initial climb
o En route
o Approach
o Landing
o Taxi

Aircraft manufacturer.
Given the importance of data quality, the quality of data was assessed
based on the following criteria used by Ref. [67] in their safety man-
agement manual:

Validity: The data collected complied with the established criteria for
their proposed use.

Completeness: All relevant data is available.

Consistency: The degree to which measurement of a given variable is
consistent can be regenerated and circumvents errors.

Accessibility: Data is readily accessible for analysis.

Timeliness: Data should be suitable to the time period of interest and
obtainable promptly.

Security: Data is secured from inadvertent or malicious modifications.

Accuracy: Data is error-free.
3.3. Data analysis
Occurrence data was analysed using Pearson's chi-square test. Spe-
cifically, the chi-square test helped in comparing the relative frequencies
of accidents and incidents [80]. Pearson's chi-square is a statistic used to
measure the relationship between two different distributions. For
instance, if it was discovered that the distributions were the same, then it
could be inferred that the region or the type of commercial air trans-
portation etc, do not contribute to HFs related occurrences [50].
Pearson's chi-square test is ideally suited to analyse categorical data.
The test can assess if the observed frequencies significantly differ from
the expected frequencies, and if the observed frequencies are due to
chance or not. In this analysis, as it was vital to have a statistically sig-
nificant relationship, a 95% confidence level was used [18]. The statis-
tical hypotheses for a chi squared test are given as:
H0: pO,n ¼ pE,n
HA: pO,n 6¼ pE,n
where p is the proportions of the n-th category, for the observed, O, and
for the expected, E. The null hypothesis (H0) can therefore be expressed
as, “the proportions of HFs occurrences are equal to the proportions for
H. Kharoufah et al.
commercial air transport operations, for the different categories”.
Conversely, the alternative hypothesis (HA) is that “the proportions are
not equal”. The chi square statistic, or χ2, is given by Ref. [18],
X
n
ðOi
Ei Þ2
χ2 ¼ ; (1)
i¼1
Ei
where there are n categories. The number of degrees of freedom, ν, is
given as n – 1 for each test. The critical value was then determined from
the degrees of freedom using the χ2 table, with a 95% confidence level.
Finally, if χ2 was less than the critical value H0 was accepted, otherwise
H0 was rejected.
4. Quantitative analyses and discussion
4.1. Type of operation
4.1.1. Analysis
The accidents and incidents collected in the database were catego-
rized into 6 types of operation in commercial air transport. In the absence
of specific data by airline business model (number of flights operated on
annual basis by type of carrier) it was necessary to develop a proxy to
undertake the Chi-Squared test analysis. Knowledge and data for the
Australian Aviation industry was used for this proxy. Data was gathered
from Qantas Group (Qantas and JetStar Domestic), Virgin Australia
(Virgin Domestic, Tigerair, and Virgin Australia Regional Airlines),
Regional Express Australia, the Royal Flying Doctor Service, and the
Bureau of Infrastructure, Transport and Regional Economics (BITRE).
The Chi-Squared test was implemented to identify the difference
between the two sets of data; observed and expected. The analysis results,
as shown at the top of Fig. 1, shows that there was a significant difference
between the value calculated from the Chi-squared test and the expected
value from the chi-square distribution table for a 95% confidence level.
Thus, the null hypothesis of no difference between the different types of
operation for HF related accidents and incidents was rejected.
4.1.2. Discussion
As seen in Fig. 1, there are a number of significant differences for the
observed relative to the expected. Looking at the “individual chi squared
scores”, prior to the summation in (1), then both ambulances and LCC
present a significantly lower proportion of occurrences involving HF
causations. Similarly, cargo and charter present a significantly higher
proportion of occurrences involving HF causations.
For air ambulance, if we look at the expected value, which was based
on the large number of movements annually, we would expect to see
Fig. 1. Number of HF related accidents and incidents (count) categorized by
type of operation in commercial aviation. Note: LCC is Low Cost Carrier, and
FSNC is Full Service Network Carrier.
6
Progress in Aerospace Sciences xxx (2017) 1–13
more occurrences than for charter aircraft. However, the fact that only 1
in 207 was an occurrences involving an air ambulance show that these
have a high level of safety involving HFs. It is worth noting that only a
small number of aircraft (~67) are responsible for the 77 thousand
movements in the RFDA; as such, if the rate of occurrences per aircraft
were considered the result of air ambulances may be more significant,
highlighting a potential limitation with the data set.
It is commonly thought by many that LCCs are less safe than other
carriers, but this is not the case as LCCs have very good safety records; in
fact, many of the major budget carriers have never experienced an ac-
cident. LCCs operate within a budget by spending less money on
customer service while they get their savings from efficient operations;
however, they do not cut corners in regard to maintaining safety stan-
dards. For instance, Ryanair and EasyJet, Europe's two largest LCCs, have
never had major accidents or any fatalities during their operations. The
same scenario is in North America, in which JetBlue and Spirit had never
had major occurrences. Moreover, the Jet Airliner Crash Data Evaluation
Centre in Germany has rated four main LCCs in the world (JetBlue,
WestJet, Southwest and Ryanair) as safer than the American Airlines, the
largest carrier in the world. In regard to the Asian market environment
for LCCs, it is not that clear as regulatory standards differ from one
country to another. For instance, Malaysia and Indonesia have serious
issues in regards of their regulations which explain the reason Indonesia's
Lion Air is banned in Europe. However, other countries in Asia like
Singapore have highly regarded regulatory agencies which is illustrated
by the small number of occurrences in these countries [84]. In other
world regions, for example, Africa and South America, the LCCs are in
their relative infancy stage of their market development [87].
In regard to air cargo carriers, the observed value was significantly
greater than the expected value, therefore air cargo operations are more
prone to occurrences involving HF causations, relative to other type of
carriers such as air ambulance, LCCs, regional airlines, and FSNCs. The
Flight Safety Foundation have noted that the accidents rate of United
States all cargo operations are two to five times higher than the accident
rate in passenger and combined passenger/cargo operations. Moreover,
the Air Line Pilots Association (ALPA) claimed that freighter aircraft
pilots that have night shifts lose an approximately 2 h of sleep per day
which results in a total sleep deficit of more than 8 h at the end of the
week. Another issue found in the United States by the pilot's union is the
inconsistency in the establishment by airlines of modern safety programs.
For instance, in 2005, there was only one cargo airline of the 12 airlines
in the flight operational quality assurance (FOQA). Four cargo airlines
were included only out of the 32 aviation safety action programs. Also, of
16 line operations safety audits being conducted by air carriers, none was
by a cargo airline. It can be said that cargo operators in North America
have several issues in regards to their cargo operations [78].
Furthermore, the type of carrier with the most significance difference
between the observed and expected values were charter carriers. There
have been 19 occurrences observed in North America out of the 43
different occurrences which is almost 44%. Charter carriers are consid-
ered the most fatal type of carriers in the United States compared to other
type of carriers in commercial aviation. The issue with charter operations
in North America and particularly the United States that privately-owned
aircrafts are not regulated by U.S law. Another issue determined is that
the Federal Aviation Administration does not frequently inspect charter
operators, and most of the times pilots are the ones who decide when it is
safe to land or the total number of hours they have worked [81]. In
addition, the FAA does not impose age limits for charter pilots like other
commercial carriers in which they must retire at age 64 [89]. Therefore,
charter operators should adhere to stricter safety standards to diminish
the number of fatal accidents.
Surprisingly, regional carriers have a slightly lower observed value
than expected but not that significant; therefore, it can be said that
regional carriers have a good safety record. In regard to FSNCs, the
number of observed occurrences (69) is almost equal to the expected
value (73) which means that FSNCs did not have a significant impact on
H. Kharoufah et al.
the result of the Chi-Squared analysis. The FSNC comparison serves as a
metric to validate the proxy used for the expected values.
To address the second research question, it can be stated from this
section that charter carriers have the most number of HF-related acci-
dents and incidents over the period 2000 to 2014 in commercial aviation.
4.2. State of operator
4.2.1. Analysis
The HF occurrences were grouped into 7 different regions in the word
for state of operator. For this category, a Chi-Squared test was conducted
by testing the data collected in comparison with total fleet of aircraft in
2016 from Ref. [23] Current Market Outlook 2017–2036. A Chi-Squared
test was used to determine if there was a large difference between the
data collected and the expected values. The value calculated from the
chi-square test, top of Fig. 2, indicated that there was a significant dif-
ference with the expected value from the chi-square distribution table for
a 95% confidence level. Therefore, the null hypothesis of no difference
between the states of operator for HF related occurrences was rejected.
4.2.2. Discussion
From Fig. 2, we can note that North American operators had a lower
occurrence rate than the expected rate as with other operators in Asia and
the Middle East. While operators in Latin America and the Common-
wealth of Independent States (CIS) had almost equal observed and ex-
pected occurrences rates. However, the only region that had higher
observed rates than expected were European and African. Despite this,
Europe did not have a significant impact on the chi-square test result, but
African operators had a significant impact on the chi-square test result
after the chi-square test was repeated by removing the variables of the
corresponding regions. The [1] indicated that the below standard African
aviation safety records since 2000 can be clearly demonstrated by the
small, poorly regulated carriers in which, these pilots are poorly trained
and usually work long hours in a dangerous operating environment.
Many international organizations such as ICAO have identified poor
regulatory oversight as the top threat to safety in Africa, followed by poor
safety management. The African Development Bank Group has stated
that every region in Africa performs worse than the world average in
most cases by a factor of 2 in every single aspect of safety implementa-
tion. Moreover, these deficiencies are highly correlated with accident
rates, suggesting that the failure of operator's regulations in demon-
strating much of the poor African safety record. The International Air
Transport Association (IATA) stated in its 2006 safety report that with
each million aircrafts taking off in Africa, 4.31 become unusable due to
accidents compared to the world rate of 0.65. Another indication of
Africa's poor safety records is that 111 African airlines were banned in
Fig. 2. Chi-square test of HF related accidents and incidents categorized by state
of operator. Note: CIS is Commonwealth of Independent States.
7
Progress in Aerospace Sciences xxx (2017) 1–13
Europe due to safety concerns. Also, IATA had credited Africa with a rate
of 9.2 in 2005 for a much-required infrastructure enhancements and
technology developments on the region to enhance the safety records [8].
To address the first half of the third research question, it can be
concluded that Africa is the state of operator with the most number of HF-
related occurrences in commercial air transport from the year
2000–2016.
4.3. State of occurrence
4.3.1. Analysis
The HF accidents and incidents were categorized into 6 regions ac-
cording to their state of occurrences (where the occurrence happened, as
opposed to where the operator is based analysed in Section 4.2). In
regards to this category, a Chi-Squared test was implemented to examine
the HF related occurrences in each region collected in relative to aircraft
movements in each region that were extracted from the ICAO Facts and
Figures: 2015. Similar to the analysis of the state of operator, the regions
initially identified were edited to correspond to the ones used by
Ref. [68]. Therefore, the occurrences that happened in the CIS region
were placed in the Asian region to achieve consistent results. As can be
seen in Fig. 3, there was a significance difference between the observed
and expected value from the chi-square distribution table for a 95%
confidence level. Thus, the null hypothesis of no difference between the
states of occurrences for HF related accidents and incidents was rejected.
4.3.2. Discussion
From Fig. 3 we note that both North and Latin America and the
Middle East observed values are below the expected. Asia Pacific and
Europe had almost equal observed and expected rates which meant that
they do not have a significant impact on the chi-squared value. However,
the only region that had a significance difference between its observed
and expected values was Africa in which the observed rate was signifi-
cantly greater than the expected rate.
The reasons in which many occurrences happened in Africa are
similar to the reasons mentioned in the discussion of the state of operator.
However, as most of the African airlines excluding a few FSNCs such as
Ethiopian airlines (a member of Star Alliance), and Kenya Airways, are
banned from flying into Europe and the limitation of flights into other
regions. Therefore, in relative to the analysis it can be said that most of
the flight accidents were regional within Africa in which the main rea-
sons of these accidents according to [95] were:

The prohibition of carriers from maintaining and upgrading their
aircraft and infrastructure due to the lack of resources.
Fig. 3. Chi-square test of HF related accidents and incidents categorized by state
of occurrence.
H. Kharoufah et al.

The underdeveloped air traffic control infrastructure contributes to
poor safety of many carriers.

Poor airport infrastructure that led to fears from international orga-
nizations about the safety of air traffic in this region.
This answers the second half of the third research question; that is,
Africa is the state of occurrence with the most number of HF-related
accidents and incidents in commercial air transport from the year
2000–2014.
4.4. HF causation
4.4.1. Analysis
The HF occurrences were grouped into 8 different HF causations. The
Chi-Squared test was undertaken to test the association between the
observed and expected values. Here, no specific expected distribution
was expected, and hence what needed to be determined was if the pro-
portions of HF occurrences were uniform or not. The value calculated
from the chi-square test, Fig. 4, indicates that there was a significant
difference with the expected value from the chi-square distribution table
for a 95% confidence level. Therefore, the null hypothesis of no differ-
ence between the HF causations for HF related occurrences was rejected.
4.4.2. Discussion
From Fig. 4, it is noted that situational awareness (SA) was the most
significant HF causation in the sample. The increase rate of occurrences
contributed to situational awareness can be due to the difficulty in
achieving accurate situational awareness [86]. state that to achieve ac-
curate situational awareness at least eight individual skills are required,
to establish a minimum skill set. After achieving situational awareness,
other critical skills such as effective threat and error management,
making decisions concerned of risk and managing the aircraft's systems,
stimulate an additional level above situational awareness. Consequently,
this controls the situation which is vital to maintain ideal and safe flight
path management.
Another common HF causation in sample was the non-adherence to
procedures by flight crew members. The high number of occurrences
associated with this type of HF causation, can be clearly seen in the ATSB
database as it recorded 197 different occurrences only in 2014 [10] [37].
intensively studied Lufthansa incidents from 1997 to 1999 in which 2070
pilots participated. The study found that flight crews were aware about
the importance of Standard Operating procedures (SOPs), nevertheless
the procedures were breached several times, either knowingly or un-
knowingly. The study has grouped non-adherence to procedures that
contributed to 77% of the incidents to four categories which were:
Fig. 4. Chi-square test of HF related accidents and incidents categorized by HF
causation. Note: SA is Situational Awareness.
8
Progress in Aerospace Sciences xxx (2017) 1–13

Unstabilized approach: The unstabilized approach proved to have
vital role in 20% of all incidents. The violations were:
o 58% too high
o 57% too fast
o 27% due to lateral offset
o 17% too low
o 21% due to incorrect configuration

Deviation from ATC clearances: The error ensues almost always un-
consciously, which shows the level of pressure in the cockpit. The
type of error contributed to 19% of all occurrences. Out of these
incidents:
o 45% contributed to flying at an uncleared flight level
o 22% is attributed to course deviation
o 21% is attributed to deviation from a standard terminal arrival
route (STAR) and Standard instrument departure (SID)
o 10% is attributed to takeoff or landing without clearance

Basic flying: The study proved that there are deficiencies with flight
crew members flying capabilities in which this type of error
contributed to 19% of all incidents. Out of these incidents:
o 60% happened while target parameters were corrected
o 33% happened in the landing phase
o 21% happened in the taxiing phase
o 10% happened during go-around

Equipment operation: The study proved that crew members are well
familiar with the aircraft and its functions; it is all a matter of self-
discipline to solve this issue. This error accounts to 18% of all in-
cidents. Out of these incidents:
o 30% is attributed to wrong inputs
o 20% is attributed to mistakenly omitted component actuation
o 14% is due to stimulating the wrong switch
o 14% is attributed to actuating the incorrect mode.
Unsurprisingly, the consumption of alcohol and drugs in regard to HF
related occurrences showed a significantly lower observed value than
what was expected. The low rate of HF occurrences involving the con-
sumption of alcohol and drugs was mainly due to the strict laws and
regulations in regards to this issue. For example, the Civil Aviation Safety
Authority (CASA) in Australia developed the Drug and Alcohol Man-
agement Plans (DAMP) program under CASR Part 99 in 2009. The part
99 established a legislative framework for the developments of DAMP in
addition to a no-notice alcohol and other drug (AOD) testing adminis-
tration for all individual involved in safety sensitive aviation activities.
The purpose of the DAMP program is to guarantee that all individual
under the effect of AOD while undertaking any sensitive aviation activ-
ities are determined and tested [32]. Since DAMP related violations are
so uncommon, especially in commercial air transport, it is not surprising
to note that when it does happen it is highly publicised, like the recent
incident in Canada, which ultimately resulted in a jail term [100].
Other HF causations almost had equal or slightly different observed
and expected values with no significant impact on the result of the Chi-
squared test. This section contributes significantly to answering the
first research question, such that situational awareness and non-
adherence to procedures are the two most significant HF causations.
4.5. Aviation occurrence category
4.5.1. Analysis
The HF occurrences collected in the database were placed in 18
different aviation occurrence categories. The comparative data was taken
from the ICAO iSTARS API Data Service [70]; that is, the expected value
was all ACCIDENTS reported by ICAO, including HF and non-HF occur-
rences. The reduction in categories was necessary as a limitation of the
Chi Squared test is that no more than 80% of the categories can contain
an expected value less than 5 [18]. As such, all the less significant cate-
gories were omitted (for example, turbulence and wildlife, which are
external factors to the aircraft). Although significant in size, the unknown
H. Kharoufah et al. Progress in Aerospace Sciences xxx (2017) 1–13

category was also omitted. As displayed in Fig. 5, the chi-square value 4.6. Phase of flight
calculated was significantly greater than the critical value so it can be
said that there was a significant difference between the between the 4.6.1. Analysis
observed and expected values for a 95% confidence level. This led to It is vital to know the phase of flight in which HF occurrences happen.
reject the null hypothesis of no difference between the aviation occur- Therefore, the occurrences collected in the database were categorized
rences associated with HF accidents and incidents. into the main 6 phases of flight. To implement the Chi-Squared test, the
phases of flight used in Ref. [23] Statistical Summary of Commercial Jet
4.5.2. Discussion Airplane Accidents from 1959-2016 were aligned to match the phases used
Fig. 5 shows that the loss of control-inflight (LOC-I) and controlled in the database which were taken from Ref. [66]. The Chi-Squared test
flight into terrain (CFIT) were the most statistically significant aviation conducted proved that there is a significance difference between the
occurrence categories for the HF occurrences from 2000 to 2016. That is, chi-squared value and the expected value from the chi-square distribu-
their observed values were significantly larger than the expected values tion table for a 95% confidence level. Accordingly, the null hypothesis of
[3]. indicate the two main accident categories that accounted for the no difference between the different phases of flight in association with
majority of aviation accidents were loss of control-inflight (LOC-I) and HF related accidents and incidents was rejected.
controlled flight into terrain (CFIT). The statistical analysis report
generated by Airbus shows that LOC-I was responsible for the most 4.6.2. Discussion
number of fatal occurrences from the period 1995–2014 while it was Fig. 6 shows that the phase of flight that had a significantly greater
considered the third main source of hull losses during the same period. observed value than expected was en route. This meant that the en route
Regarding CFIT, it was considered the second main sources of fatal ac- was the phase of flight in which most HFs occurrences happened more
cidents while it is the third main source of hull losses in aviation. The than expected [110]. states that the most fatal aviation phase is when the
individual score for overshoot or undershoot is also statistically signifi- aircraft descend from its cruising altitude in establishing its approach to
cant, indicating that HF occurrences result is a greater number of these its destination. This phase of the flight is considered part of the en route
then other contributing factors. The lack of HF occurrences that result in
system component failures is significantly less than expected, which is
not surprising. That is, a significant degree of automation has removed
many of the direct ways in which human error by the pilot can directly
result in a system or component failure. In legacy aircraft where a flight
engineer was responsible for starting and maintaining engine settings,
damaging an engine could be easily achieved with a lack of situational
awareness. Of more interest are runway excursions and abnormal runway
contact, which are much less than expected; it would also be plausible to
hypothesis that these would be closely related to HF causations. It should
also be noted that for comparison, all ICAO occurrences was also
considered for the expected distribution; however, the only category that
was significantly different statistically, was SCF, which was even more
common for all ICAO occurrences, and the resultant chi squared value
was 876.
The conclusion of this section also adds to the answer of the first
research question, indicating that HF causations are strongly linked to a
spike in loss of control in flight occurrences.
Fig. 6. Chi-square test of HF related accidents and incidents categorized by
phase of flight.

Fig. 5. Chi-square test of HF related accidents and incidents categorized by aviation occurrence category.

9
H. Kharoufah et al.
phase which combines climb, cruise, and descent as mentioned in the
ICAO phase of flight taxonomy. As reported by Boeing, 59% of the fatal
accidents that occurred between 2007 and 2016 occurred during descent,
approach, and landing. However, accidents that occur during the cruising
part of the en route phase tend to be very catastrophic. For instance, the
42 occurrences documented in the Boeing study claimed 2226 lives,
which accounted for 58% for all commercial airline fatalities.
Unsurprisingly, the phase of flight which showed significantly less
observed values than expected was aircraft taxing phase because this type
of occurrences generally happen at a very low speed. In the [23] study of
commercial aviation that covered most aircraft manufacturers and re-
gions, it was stated that 10% of all fatal aviation accidents over the last
decade happened when aircraft were taxing, unloading or loading pas-
sengers and baggage, being towed or parked. In fact, only one passenger
died during a taxing accident in a decade [110].
Both takeoff and initial climb were the next most significant phases,
much more significant than approach and landing. That is, takeoff and
initial climb have slightly high proportions for HF occurrences relative to
all occurrence from 2007 to 2016. This contributes to answering the first
research question, where HF causations result in a larger proportion of
occurrences while en route, followed by takeoff and initial climb.
4.7. Aircraft manufacturer
4.7.1. Analysis
The HF related occurrences collected in the database were grouped by
aircraft manufacturer. The expected aircraft fleet data was taken from
airfleets.net and ch-aviation.com databases to undertake the Chi-Squared
test for this category. As it can be seen in Fig. 7, the chi-squared value
calculated is significantly greater than the expected value from the chi-
square distribution table for a 95% confidence level. Accordingly, it
can be said that the null hypothesis of no difference between aircraft
manufacturers in relation with HF related accidents and incidents was
rejected.
4.7.2. Discussion
As shown in Fig. 7, many aircraft manufacturers have proved to have
poor safety records. However, the aircraft manufacturer with a signifi-
cantly poor safety record that had a significant impact on the result of the
analysis was the Russian manufacturer, Ilyushin in which 3 occurrences
were observed out of the 11 aircraft in operation. However, it seems that
Fig. 7. Chi-square test of HF related accidents and incidents categorized by aircraft manufacturer.
10
Progress in Aerospace Sciences xxx (2017) 1–13
the issue is not only with Ilyushin, as according to the chi-squared test
conducted as seen in Fig. 7, all aircraft manufacturers that are established
in the Commonwealth of Independent States (CIS) and especially
Ukrainian and Russian aircraft manufacturers such as Antonov and
Tupolev have proved that they have relatively poor safety records [101].
indicates that the Russian and Ukrainian aircraft manufacturers have
recorded 56 fatal crashes. Antonovs are still used in 80 countries around
the world [51], the Ilyushins are mostly used for air cargo operations in
which Cubana airlines have 4 of the 11 that are still in operation [5],
while for the Tupolevs, especially the Tu-54 are mostly used in the CIS
region, by the national carrier of North Korea, Air Koryo and a charter
carrier in Egypt, Cairo Aviation [33].
In an article written in Forbes magazine by Ref. [82]; the reason for
the Russian and Ukrainian aircraft manufacturers' poor safety records as
explained by the author is the famous hyperinflation in Russia in the
1990s which caused the aviation industry to collapse. Accordingly, the
production of aircrafts dropped to dozens instead of increasing by hun-
dreds, this has made Russian and Ukrainian aircrafts rare which made it
difficult and costly to service these aircrafts. Moreover, other aircraft
manufacturers like Boeing have integrated an extensive worldwide
network to rush parts to grounded aircraft, finding a part for a broken
Antonov or Ilyushin could take several weeks and sometimes it is
impossible to find some of the aircrafts' parts. This did not only result in
losses for Russian operators flying old Russian aircrafts but also issues for
these manufacturers, who, in the beginning of 2000s resorted to be
known as “aviacannibalism”: the breakdown of aircrafts for parts to
service other aircrafts.
Other major aircraft manufacturers such as Boeing, Airbus, and
Embraer proved to have unsurprisingly very good safety records as
observed values were less than what was expected. Conventionally,
Airbus and Boeing tend to avoid safety comparisons when selling their
aircrafts to operators [109]. It can be said that manufacturers with more
aircraft in operation tend to have better safety records than the ones with
fewer aircrafts.
5. Qualitative analyses and discussion
A qualitative analysis of three recent airline accidents indicates the
importance of situational awareness in the operational setting and how
the degradation of situational awareness amongst crew is a significant
contributory factor in an accident. As with an earlier study [72] most
H. Kharoufah et al.
situational awareness errors within the reviewed accidents were at
Endsley's [39] perception (Level 1) or understanding (Level 2) levels of
situational awareness. Also, noted as occurring in the accidents is the
different levels of situational awareness developed by different members
of the crew which has been identified by Ref. [103].
5.1. Air France 447
On the 1st of June 2009, an A330 operated by Air France while on
cruise from Rio de Janerio to Paris stalled and crashed killing all 228
people aboard. The triggering event was the freezing over of the pitot
tubes resulting in inconsistent airspeed measurements. The active error
was the loss of situational awareness amongst the crew leading to the
aircraft departing from the flight envelope [106].
The loss of situational awareness arose when the auto pilot and auto
throttle disengaged due to inconsistent airspeed measurements arising
from blocked pitot tubes, surprising the crew with control of the aircraft
changing from normal law to alternate2B law [16].
The response of the pilots on the flight deck (the captain had earlier
left the flight deck for a rest period) was to take control. The aircraft
rolled to the right because of turbulence and the pilot flying attempted to
correct with a left sidestick input that also had a nose-up input. The stall
warning sounded twice briefly.
The Pilot Not Flying began to perceive (Level 1) the status of the
changed operating environment when he announced that speeds had
been lost and that alternate law protections were now in place. However,
“erroneous airspeed indications and ECAM (Electronic centralised
aircraft monitor) messages did not help with the diagnosis” and the pilots
did not fully perceive what was happening nor ascend to Level 2 of
situational awareness through integration of the various pieces of in-
formation regarding the status of the flight allowing the pilots to arrive at
an understanding of what was happening.
The lack of Level 1 SA can be noted in both pilots failing to
acknowledge the stall warning and the lack of Level 2 situational
awareness is seen in the crew not identifying the aircraft had reached a
stalled condition, [17].
However, it would appear the Pilot Not Flying developed a fuller
awareness of the situation when he told the Pilot Flying the aircraft was
climbing “and asked the Pilot Flying several times to descend” [16]; (p.
22). The report summarises these callouts as “imprecise flight path cor-
rections. They were, however, essential and sufficient for short-term
management of the situation.” (p. 199).
In response to the PNF the PF attempted nose-down inputs but the
aircraft continued to climb. The stall warning again sounded, this time
for 54 s. The aircraft also experienced strong airframe buffeting. The PF
increased throttle setting to TO/GA (take-off/go around) and maintained
nose-up input. The report identifies that the aircraft reacted correctly to
the inputs from the pilot controls. The aircraft remained in a stalled
condition until the end of the flight when it collided with the ocean.
Enhancing the situational awareness of a crew is finding the “right
adequacy between the cognitive capacities of pilots and the signals that
are provided to them to understand and act on” [106]; (p. 8). In the case
of AF447 the blocked pitot tubes meant there was confusion about the
inconsistency of the airspeed on different displays including the inte-
grated standby instrument system (ISIS) which in part contributed to the
pilots not perceiving the changing elements regarding the status of the
flight hindering the development of their Level 1 and Level 2 situational
awareness.
5.2. TransAsia airways 235
For [40]; when a crew is confronted with equipment failure the level
2 situational awareness required by the crew is the understanding of the
impact of the failure on the performance of the aircraft and the level 3 is
knowing the projected path of the aircraft after the failure (p. 13). This
was the situational awareness required to be developed by two pilots of
11
Progress in Aerospace Sciences xxx (2017) 1–13
an ATR72 as they took off from Taipei's Songshan Airport in February
2015.
As the aircraft climbed through 1200 feet after take-off the propeller
of number 2 engine shut down and feathered and a warning that the
number 2 engine had flamed out was displayed in the cockpit.
The crew's response began with the Pilot Flying stating that he would
retard the number 1 engine throttle, which was the still working engine.
The Pilot Not Flying asked to firstly cross-check but the number 1 engine
throttle was already being retarded. As the crew communicated about the
required checks they identified that the number 2 engine had failed when
the monitoring pilot announced, “okay now number 2 engine flameout
confirmed” [12–14]. (P. 12). Despite this the number 1 engine throttle
remained in a retarded position. From the information being provided to
the pilots they did not correctly perceive which engine had failed.
With a continuing climb attitude the stall warning sounded. The
response of the pilot monitoring was to call, “okay push, push back”
[12–14] (p. 13) a very confusing command in the cockpit. If the intention
was to lower the angle of attack of the aircraft – a correct response to a
stall warning – the control column would normally be pushed forward as
against it being pulled back if the intention was to have the aircraft climb.
There was then a call from the Pilot Not Flying for a throttle to be
advanced. The number 2 (the dead engine) was advanced and the
number 1 throttle (the operating engine) fully retarded to the idle posi-
tion. A bank to the left was experienced by the aircraft.
The Pilot Not Flying now identified that they had “lost both sides” and
the Pilot Flying's response was to call for a restart of the engine (called for
eight times). The report does not state if the Pilot Flying stated which
engine he wanted re-started as it would appear that he still had not
correctly identified which engine had originally failed. However, the
number 1 throttle was partially moved forward. Seven seconds later the
PF acknowledges his lack of awareness of what was happening with his
aircraft when he states; “wow pulled back the wrong side throttle”
[12–14] (p. 13).
The partial movement of the number 1 throttle lead to a large amount
of drag being generated on the left side of the aircraft without an increase
in generation of thrust. The asymmetric drag lead to the aircraft yawing
and rolling to the left.
Seven seconds after acknowledgement of their incorrect diagnosis
and actions the EGPWS sounded, the aircraft increased its roll to the left
(approximately 80 ), contacted a road bridge and a car on the bridge and
hit the river in an inverted position. Forty-three crew members and
passengers were killed and the remaining passengers survived with
serious injuries.
5.3. Indonesia Air Asia QZ8501
During a routine flight from Surabaya, Indonesia, to Singapore on 28
December 2014 poor pilot responses to a developing situation caused by
equipment failure led to QZ8501 an A320 aircraft entering a stall the
pilots did not recover from and the flight ended with it crashing into the
ocean killing all 162 people aboard the flight.
Weather near the aircraft was originally thought to have played a role
in the accident but although the pilots had requested a deviation to the
route because of weather build-up ahead in fact weather did not nega-
tively affect the flight or play a role in the accident, [75].
During cruise, there were, over a period of 12 min, 3 warnings dis-
played in the cockpit indicating a rudder travel limiter unit failure. For
these warnings, the PIC reset the Flight Augmentation Computer (FAC)
push buttons to OFF and then ON as advised by the ECAM, which
appeared to solve the problem.
There were following warnings which were regarding the FAC. They
were responded to by the pilots in a manner which did not adhere to
procedures when the FAC circuit breaker was reset by the crew. The
result was the disengagement of the autopilot and auto thrust and a
reversion to alternate law from normal law [75] (p. 112). Thus, the pilots
now had to manually fly the aircraft.
H. Kharoufah et al.
In developing an awareness of a situation, the crew may draw upon
the contents of the long term memory to recognise and make sense of the
current situation. Past experiences form stored prototypical situations or
schema allows for “pattern matching between the current situation and
schema (and) people can instantly recognise classes of situations” [39];
(p. 98). Three days earlier the captain had, when on the ground, expe-
rienced a similar warning to that which he received in flight. He watched
the engineers reset the FAC circuit breaker which appeared to solve the
problem. This prior experience may have been used by the pilot in
command during the flight to develop his situational awareness of the
developing situation despite the resetting the FAC circuit breaker in flight
not being a permitted action.
During the disengagement of the autopilot the rudder deflected 2 .
The pilots failed to input any manual control movements for 9 s after the
autopilot disengaged with a resulting roll to the left of 54 . The Pilot
Flying responded with a roll command to the right to maximum deflec-
tion [75] (p. 108) and a nose-up input. Roll control of the Airbus at angles
of bank of less than 33 did not need pitch correction but when the angle
of bank was greater than 33 nose-up input was required to maintain
level flight. The maximum deflection roll command caused the aircraft
the roll from 54 left to 9 left in 2 s. The rapid roll led the pilot to reverse
the roll back to the left and the aircraft rolled back to 53 left. The Pilot
Flying then rolled the aircraft back to near wings level at a gentler rate of
roll.
The pitch-up inputs remained however, and with an increasing angle
of attack Angle of Attack (AoA) caused by the pitch up command the stall
warning sounded as the aircraft went past 8 (AoA). The pilot corrected
with a nose pitch down command which lowered the AoA and silenced
the stall warning. However, a short period after the stall warning stopped
the nose was pitched up to 12 AoA and the aircraft resumed climbing at
12,000 feet per minute. In response to the increasing AoA the captain
confusingly called, “pull down …. pull down” [75] (p. 109). It is a normal
command to” pull back” to pitch the aircraft up and if the nose of the
aircraft is to be pitched down the call would be to “push forward”. (The
Indonesian report contains a diagram illustrating the movement of the
side stick for pitch control. To pitch the nose up the description is
“sidestick pulled” and to lower the nose attitude the description is
“sidestick pushed” 75(p. 35).
Using the word “down” the captain may have correctly assessed the
situation as being a stalled state and wanted the aircraft to be pitched
down. Unfortunately, the perception of the circumstances confronting
the flight was to respond to the word “pull” as spoken by the captain and
the handling pilot further increased the back pressure on the side stick
further increasing the AoA which then reached 48 . Despite a constant
stall warning sounding and the aircraft experiencing buffeting the back
pressure on the side stick was maintained by the Pilot Flying.
Different team members may develop an awareness of the developing
situation at different rates and ascending to different levels. In this flight
the PIC appears to have developed an understanding (Level 2) of the
circumstances of the flight and attempted to call out a solution which
may have been misunderstood by the PF from which can be noted the
distributed SA of the system, [97].
6. Conclusion
The impact of human error has been massive through the history of
aviation in terms of casualties, injuries, apparatus destructed, costs of
operations, and loss of productivity. In aviation, the consequences of
human errors are projected to augment as traffic volume increases, sys-
tems getting more complicated, and the increase intentions of organi-
zations in the aviation industry to cost-cutting strategies as a response to
the current economic conditions. The research implemented an explor-
atory research design which is a mixed method that combines qualitative
data obtained from the analysis of accidents and incidents reports and
quantitative data extracted from the database generated which contains
about 200 accidents and incidents from different specialized safety
12
Progress in Aerospace Sciences xxx (2017) 1–13
databases. The research covered several areas associated with HFs in
aviation to provide the public with an extensive literature that expands
the knowledge of readers about the impact of HFs in aviation. Therefore,
this research investigated in hundreds of HFs associated accidents and
incidents in the commercial sector of the aviation industry to answer the
research questions.
The answers of the research questions were: What were the most
common HFs causes in commercial air transport accidents and incidents
over the period from 2000 to 2016? Situational awareness was the most
common HF causation followed by non-adherence to procedures in
commercial air transport accidents and incidents over the period from
2000 to 2016. These were associated with greater loss of control in-flight
occurrences, and to an increase in occurrences en route. What type of
commercial air transport operation has more HF-related accidents and
incidents over the period 2000 to 2016? Charter carriers are the type of
commercial air transport operation that has the most HF-related acci-
dents and incidents over the period 2000 to 2016. Were there any dif-
ferences by world region (both state of operator and state of occurrence)
in the commercial air transport accidents and incidents attributed to HF
causation over the period 2000 to 2016? Africa is the region (both state
of operator and state of occurrence) with the most number of HF related
accidents and incidents compared over the period 2000 to 2016.
This study has a vital role in enhancing safety in the aviation industry
as it provided aviation safety specialists and the public with an extensive
investigation about the different HF causations in commercial aviation
which will inspire aviation specialists in discovering strategies to miti-
gate the impact of human errors in aviation accidents and incidents as
well as, promote the awareness of the public about the significance of HFs
in aviation.
When considering the worst-case scenario of these findings, a CIS
built aircraft, operating in an African country, on charter or for cargo, and
during takeoff, climb out, or en route, the recent accident in the Ivory
Coast accident on the 14th of October 2017 is not surprising [99], and is
similar to the accident in South Sudan on the 4th of November 2015
where 36 people were killed [58].
References
[1] African Development Bank Group, A poor safety record—largely attributable to low
standards and lax supervision—is the greatest challenge facing the air transport
industry in Africa today viewed 12/10/2015. http://www.infrastructureafrica.org/
key-msg/sector/poor-safety-record%E2%80%94largely-attributable-poor-safety-
standards-and-lax-supervision%E2%80%94-la, 2011.
[3] Airbus, Commercial Aviation Accidents 1958-2014: a Statisitcal Analysis, 2015.
Blagnac Cedex, France.
[5] Airfleets.net, Iliouchine Il-96, 2015, 24/10/2015, http://www.airfleets.net/listing/
il96-1.htm.
[8] Associated Press, Africa's Air Safety Record Among World's Worst, NBC News, 2007,
5 August 2007.
[10] ATSB, ATSB National Aviation Occurrence Database, 2015. Canberra, Australia,
Occurrences, http://data.atsb.gov.au/QuickCounts/Results.
[12] Aviation Safety Network, Accident Description: TANS Flight 222, Flight Safety
Foundation, USA, 2015a, 27/09/2015, http://aviation-safety.net/database/record.
php?id¼20030109-0.
[13] Aviation Safety Network, Accident Description: Vladivostokavia 352, 2015 viewed
29/09/2015, http://aviation-safety.net/database/record.php?id¼20010704-0.
[14] Aviation Safety Network, Accident Description: Yemenia Airways Flight 626, 2015
viewed 30/09/2015, http://aviation-safety.net/database/record.php?
id¼20090630-0.
[16] BEA, Final Report on the accident 1 June 2009 to the Airbus A330 203 registered F-
GZCP operated by Air France flight AF 447 Rio de Janeiro – Paris. Author, 2012
(Paris, France).
[17] BEA, Safety Investigation into the Accident on 1 June 2009 to the Airbus A330-203,
Flight AF447. Author, 2011 (Paris, France).
[18] E. Berman, X. Wang, Essential Statistics for Public Managers and Policy Analysts,
fourth ed., SAGE Publicating, Los Angeles, CA, 2017.
[20] Boeing, The role of human factors in improving aviation safety, Aero Magazine (no.
8) (1999).
[22] Boeing, Statistical Summary of Commercial Jet Airplane Accidents, Worldwide
Operations 1992-2001, 2006. Seattle.
[23] Boeing, Current Market Outlook 2017-2036, 2017. Seattle, USA.
[24] L. Bolman, Aviation accident and the “theory of the situation”, in: Paper Presented
to Resource Management on the Flight Deck, 1979 (San Francisco, California).
[25] J. Caldwell, Fatigue in aviation, Trav. Med. Infect. Dis. 3 (no. 2) (2005) 85–96.
H. Kharoufah et al.
[26] J. Caldwell, Crew schedules, sleep deprivation, and aviation performance, SAGE
journals 21 (no. 2) (2012) 85–89.
[32] CASA, Drug and Alcohol Management Plans, 2015 viewed 21/10/2105, https://
www.casa.gov.au/operations/standard-page/drug-and-alcohol-management-plans.
[33] Ch-aviation.com, Aircraft Quick Search, 2015, 24/10/2015, http://ch-aviation.
com/portal/aircraft/quick?ac_manufacturer¼TDB&ac_aircraft¼%25.
[34] J. Creswell, V. Clark, Designing and Conducting: Mixed Methods Research, SAGE
Publications, London, United Kingdom, 2011.
[36] S.W.A. Dekker, The Reinvention of Human Error, Lund University School of
Aviation, Ljungbyhed, Sweden, 2002.
[37] H.J. Ebermann, J. Scheiderer, Human Factors on the Flight Deck, Springer-Verlag,
Berlin Heidelberg, Frankfurt, Germany, 2013.
[38] E. Edwards, Introductory overview, in: E.L. Wiener, D.C. Nagel (Eds.), Human
Factors in Aviation, Academic Press, San Diego, California, 1988.
[39] M.R. Endsley, Situation awareness, in: J.D. Lee, Kirlick (Eds.), A. The Oxford
Handbook of Cognitive Engineering, Oxford University Press, Oxford, UK, 2013.
[40] M.R. Endsley, Situation awareness misconceptions and misunderstandings, Journal
of Cognitive Engineering and Decision Making 9 (no. 1) (2015) 4–32.
[41] M.R. Endsley, C.A. Bolstad, Individual differences in pilot situation awareness, Int.
J. Aviat. Psychol. 4 (no. 3) (1994) 241–264.
[47] FAA, Safety Management System, 2014 viewed 25/08/2015, https://www.faa.gov/
about/initiatives/sms/explained/components/.
[49] J. Ford, R. Henderson, D. O'Hare, Barriers to intra-aircraft communication and
safety: the perspective of the flight attendants, Int. J. Aviat. Psychol. 23 (no. 4)
(2013) 369–387.
[50] J. Goode, Are pilots at risk of accidents due to fatigue? J. Saf. Res. 34 (2003)
309–313.
[51] A. Gribanova, Ukraine's Antonov Bureau Showcases its New Transport Aircraft, vol.
16, BBC, 2015. April 2015.
[53] D. Harris, Human Performance on the Flight Deck, Ashgate Publishing Limited,
England, 2011.
[54] B.M. Hartzler, Fatigue on the flight deck: the consequences of sleep loss and the
benefits of napping, Accid. Anal. Prev. 62 (2014) 309–318.
[56] J.W. Hedge, K.T.B.W.C. Borman, M.A. Hanson, K.K. Logan, Selecting pilots with
crew resource management skills, Int. J. Aviat. Psychol. 104 (no. 5) (2000)
377–392.
[58] S. Hradecky, Crash: Allied Services AN12 at Juba on Nov 4th 2015, Impacted Hill in
Initial Climb, 2015. The Aviation Herald viewed 28/09/2015, http://avherald.
com/h?article¼48ed283e.
[63] ICAO, Aviation Occurrence Categories, 2011 viewed 29/08/2015, http://www.
icao.int/APAC/Meetings/2012_APRAST/OccurrenceCategoryDefinitions.pdf.
[66] ICAO, Phase of Flight, 2013 viewed 29/08/2015, http://www.
intlaviationstandards.org/Documents/PhaseofFlightDefinitions.pdf.
[67] ICAO, Safety Management Manual, 2013 (Montreal, Canada).
[68] ICAO, Annual Report of the ICAO Council: 2014, 2015.
[70] ICAO, iSTARS API Data Service, 2017 viewed 3/11/2017, https://www.icao.int/
safety/iStars/Pages/API-Data-Service.aspx.
[72] D.G. Jones, M.R. Endsley, Sources of situation awareness errors in aviation, Aviat
Space Environ. Med. 67 (no. 6) (1996) 507–512.
[73] C. Kennedy, G. Kay, Aeromedical Psychology, Ashgate Publishing Limited,
Farnham, England, 2013.
[74] R.E. King, Personality (and psychopathology) assessment in the selection of pilots,
Int. J. Aviat. Psychol. 24 (no. 1) (2014) 61–73.
[75] KNKT, Aircraft Accident Investigation Report: PT Indonesia Air Asia Airbus
A320–216 PK-AXC, 2015. Karimata Strait Author Republic of Indonesia.
[77] N.C. Krey, The Nall Report 2007: Accidents Trends and Factors for 2006, AOPA Air
Safety Foundation, Frederick, MD, 2007.
[78] M. Lacagnina, Balancing Cargo Safety, Flight Safety Foundation, 2006.
[79] M. Lacagnina, Defusing the Ramp, AeroSafetyWorld, 2007 viewed 12/08/2015,
http://flightsafety.org/asw/may07/asw_may07_p20-24.pdf?dl¼1.
13
Progress in Aerospace Sciences xxx (2017) 1–13
[80] P. Leedy, J. Ormord, Practical Research: Planning and Design, Pearson, New Jersey,
United States, 2013.
[81] A. Levin, Private Jets Have More Fatal Accidents than Commercial Planes,
Bloomberg, 2015, 15 May 2015.
[82] J. Loffe, Why Russia is the world's deadliest place to fly, Forbes (no. 21) (2011), 2
November 2011.
[84] I. Mangla, Are low-cost airlines less safe than their full-service counterparts?
International Business Times, 2015, 25 March 2015.
[86] P. Murray, W. Martin, Beyond situational awareness: a skill set analysis for
situational control, in: Paper Presented to 9th International Australian Aviation
Psychology Association Symposium, 2012 (Sydney, Australia).
[87] S. Muwanga, African Challenges to Low-cost Carrier Airlines, Global Travel Industry
News, 2015, 1 May 2015.
[89] T. Patterson, Rivera Crash Puts Spotlight on Charter Jet Safety, CNN, 2012, 14
December 2012.
[90] W. Rankin, MEDA investigation process, Boeing Aeromagazine 2007 (no. 2) (2007)
15–21.
[91] J. Reason, Human Error, Cambridge University Press, New York, United States,
1990.
[93] L.V. Rigby, The nature of human error, in: Paper Presented to Annual Technical
Conference Transacations of the ASQC, 1970 (Milwaukee, Winconsin).
[94] C. Rodrigues, S. Cusick, Commercial Aviation Safety, fifth ed., McGraw-Hill, United
States, 2012.
[95] S. Rupp, African Airlines: Looking beyond the Statistics, Consultancy Africa
Intelligence, 2013 viewed 16/10/2015, http://www.consultancyafrica.com/index.
php?option¼com_content&view¼article&id¼1183:african-airlines-looking-
beyond-the-statistics-&catid¼57:africa-watch-discussion-papers&Itemid¼263.
[97] P.M. Salmon, G.H. Walker, N.A. Stanton, Broken components versus broken
systems; why it is systems not people that lose situation awareness, Journal of
Cognitive Engineering and Decision Making 17 (2015) 179–183.
[98] D. Schwartz, Coordination and Information Sharing, Flight Safety International,
1990. https://trid.trb.org/view/345884 (Houston, Texas).
[99] J. Sharman, Ivory Coast plane crash: aircraft goes down in atlantic ocean near
abidjan, Independent (2017). https://www.independent.co.uk/news/world/africa/
ivory-coast-plane-crash-abidjan-aircraft-atlantic-sea-storm-a8000231.html.
Saturday the 14th of October 2017.
[100] Sky News, Drunk Pilot Jailed in Canada, Sky News, 2017. Tuesday 4th of April
2017.
[101] O. Smith, Least safe' aircraft models revealed, The Telegraph (2013), 19 June
2013.
[103] N.A. Stanton, R. Stewart, D. Harris, R.J. Houghton, C. Baber, R. McMaster,
P. Salmon, G. Hoyle, G. Walker, M.S. Young, M. Linsell, R. Dymott, D. Green,
Distributed situation awareness in dynamic situations: theoretical development
and application of an ergonomics methodology, Ergonomics 49 (no. 12–13)
(2006) 1288–1311.
[105] A. Stolzer, C. Halford, J. Goglia, Safety Management Systems in Aviation, Ashgate
Publishing Limited, Farnham, England, 2008.
[106] J.P. Troadec, History of the Air France Flight 447 Accident Investigation. ISASI
Forum, 2013. January – March 2013.
[108] J. Vogt, J. Leonhardt, B. Koper, S. Penning, Human factors in safety and business
management, ResearchGate 53 (no. 2) (2010) 149–163.
[109] R. Wall, A. Rothman, Airbus Says A350 Design Is 'lower Risk' than Troubled 787,
Bloomberg, 2013, 18 January 2013.
[110] R. Walker, When Do Planes Crash? the Globalist, 2015.
[111] L.C. Walters, M.R. Miller, M.J. Ree, 'Structured interviews for pilot selection: No
incremental validity, Int. J. Aviat. Psychol. 3 (no. 1) (1993) 25–38.
[113] D. Wiegmann, S. Shappell, A Human Error Approach to Aviation Accident
Analysis, Ashgate Publishing Limited, Hants, England, 2003.