w?’’”

PROJECT

SAFETY ANALYSIS

HUMAN FACTORS AND

ORGANIZATIONAL ISSUES

IN CONTROLLED FLIGHT

INTO TERRAIN (CFIT) ACCIDENTS

1984-1994

ContmUed flight into termin (CF1’T)Hnman Factm and O~anizational lksues

1. This is an update on the activities of the International Civil Aviation Organization (ICAO)Air Navigation Bureau (ANB) with respect to controlled flight into terrain (CFIT) occurrences, within thecontext of its Flight safety and Human factors Programme.

2. Since October 1993, the ANB has reviewed and analymd data available from ofl~citdsources in an attempt to identify the Human Factors and organizational issues underlying CFIToscumences. The review has produced the data which is attached. The attachment also includes adescription of the methodology used by the ANB in conducting the analysis of the data.

3, The accidents selected for analysis involved commercial air transport turboprop/ turbojetaircrafl accidents investigated by States between 1984 and 1994, independent of aircraft mass or seatingcapacity, The data gathered reflects factual data extracted from the States’ official investigation reports,without inferences or assumptions by the Secretariat. The purpose of the analysis was to determinewhether there exists a set of human petiormance issues involved in CFIT accidents which consistentlyemerge from oflicial investigation reports. This analysis applied the Reason Model (succinctly discussedin the attachment) in an attempt to define the “anatomy” of a CFIT accident from the perspective ofHuman Factors.

4. It has been a fundamental premise of the ICAO Flight Safety and Human Factorsprogramme since its inception that operational personnel performance does not take place in a socialvacuum, but within operational contexts which either resist or foster inherent human weaknesses andflaws. This became obvious as the analysis of the official accident reports progressed. Lapses in humanperformance were cited in all CFIT reports analyzed. All the reports also disclosed flaws and deficienciesin the aviation system which adversely affected human performance in the particular circumstances underwhich accidents occurred.

5. The a&lysis thus discloses a dual pathway leading to CFIT accidents: an “active”pathway, generated by actions or inactions of front-line operational personnel (i.e., pilots, controllers,mechanics and so forth) ; and a “latent” pathway, generated by deficiencies in various aspects of theaviation system, for which managers and decision-makers are responsible.

.

6. The data indicates a preponderance of the “latent pathway” (approximately 88%), overthe “active pathway”, (slightly above 12Yo),in the genesis of CFIT occurrences. Figure 2 in the attachmentprovides an integrated picture of the Human Factors and organizational issues underlying CFIToccurrences. Figures 2 through 7 present a breakdown of the data obtained from the analysis,

7. The ANB intends to establish further correlations among this data. Likewise, theSecretariat will distribute this information among selected parties, including the Flight Safety and HumanFactors Study Group, in an attempt to obtain feedback to further the analysis in depth. The analysisnevertheless clearly suggests the multi-dimensional aspects of Human Factors in CFIT accidents, Thisreaffkms the need for a systemic, collective approach to safety and prevention.

1. Sources of data

1.1 All accident information examined was extracted fxum the official investigation reportspnxh.wd by the States’ safety agencies. The list of aviation accidents included in the study comptisesthe following.

Aircrafi Occurrence Report, Nahanni Air Services Ltd.&Havilland of Canadd DHC-6-1OOC-FPPL, FortFranklin, Northwest Territories, 9 October 1984. Report Number 84-H40004

Aviation Occurrence Report, Labrador Airways Ltd. &Havilland of Canada DHC-6-1OOC-FAIYS,GooseBay, Lubrador, Ntn@ound@d, II October 1984. Report Number 84-H40005

Aviation Occurrence Report, Simpson Air Ltd., BeechcrajlKing Air B-90 C-GDOM, Fort Simpson Airport,Northwest Terntories, 16 October 1988. Report Number A 88W0234

Aircraft Accident Report, Embraer 110 Bandeirante, OH-EBA, in the vicinity of Ibnajoki Ai~ort, Finland,November 14, 1988. Major Accident Report NO. 2/1988, Hei2inki, 1990. Ministry @Justice, IbnajokiAircrqfi Accident Investigation Board

Aviation Occurrence Report, Voyageur Airways Ltd. Beechcrajl King Air A-100 C-GJUL, Chapleu,Ontario, 29 November 1988. Report Number8800491

Aviation Occurrence Report, Air Creebec Inc., Hawker Sidde&y HS 748-2A C-GQSV, Wdwganish,Quebec, 3 December 1988. Report Number A88Q0334

Aircr@ Accident Report, Fiu”rchildSwearingen Merlin HI SA226T, A?26RT,Hel.sinki-Vantaa Airport,Finhnd, February 23, 1989. Accident report No. 1/1989, Heikinki, 1989. Ministry of Justice, PlanningCommisswn for the Investigation of Major Accidents

Aviation Occurrence Briqf, Ptarmigan Airways Ltd., Piper PA-31T Cheyenne C-GAMJ, Hall Beach,Northwest Territories, 17 April 1989. Brief Number A89C(X)69

Aviation Occurrence Report, S@iink Airlines L&., Faa”rchiidAircraji Corporation SA227 Metro III C-GSLB, Terrace Airport, British Columbia, 26 Sept&r 1989. Report Number 89HOO07

Aircrajl Accident Report, Aloha Islandair, Inc.. Flight 1712, de Havilland Twin Otter, DHC-6-300,N707PV, Hakzwa Point, Molokai, Hawaii, October 28,1989

Report on the Accident to Indian Airlines Airbus A-320 Aircrajl VT-EPN on 14th February, 1990 atBangatore. Government of India, Ministry of Civil Aviation.

Aviation Occurrence Report, Frowner Air Ltd., Beechcrqfl C99 Airliner C-GFAW, Moonsonee, Ontario,30 April 1990. report Number A90HOO02

Accident Investigation Report, Beech King Air E90 VH-LFH, Wonddi, Queensland, 26 July 1990. BASIReport B/901/1047

Finat report of the Federal AircrajlAccidents Inquiry Board concerning the Accident of the aircraftDC-9-32, AL17XLIA. Flight No. AZ404, I-ATJA on the Stadlerberg, Weiach, 14 November 1990

A-3

Table1. Organizationalprocesses

Gml-smillg Cunlmilnicatingpolicy-making m@@fYmOrganizing Purchasing~g SqportingPbnning RawuchingSdwduling MarketingM8MgingOpclations sellingMllnagingmdntmmx hfornution-handlingManagingprojects MotivuingMmsgingrafcty MonitoringManagingchange checkingFn’mcing AuditingBndgdng InspectingAlkating rcsourccs (%ntrolling

2.1.2 Defenq barriers and saf~ards

These are masures aimed at xemoving, mitigating or pmt.ecting agatnst qxrationa.1personnel hazards. They seine different functions and pnxent diffenmt modes of application. Table 2introduces a classification of defences, barriers and safeguards.

2.12.1 Corporate culture

A set of beliefs, values, norms and assumptions that the organization makes atwut itself,the nature of people in general and its environment. A set of unwritten rules that govern acceptablebehaviour within and outside the organization (“The way we do business hen?”).Although not a distinctcomponent of the model employed as analytical tool, corporate culture deserves a special mention, sinceit has been recognized by IKXXntmarch undetien by organizatiomll psychology as one of the mostimportant and effective barriersagainst hazards and safety breakdowns in high-technology systems.

Table 2 Defenq barriers and safeguards

Modes of application

o Engineered safety devices (automaticdetectionand shutdown,etc.)o Policies stamiards and controls (administrative and managerial measums designed to

pmrnote standardksed and safe working practices-together they constitute the safetymanagement system and have as their adjuncts techniques (cause-consequence analyse&etc.)

o Procedures, instructions and supervision (measures aimed at providing local task-relatedknow how).

a Training, briefing, drills (the provision and consolidation of safety awaxeness and safetyknowledge).

o Personal protective equipment (anything fium safety boots to space suits).

A-4

2.1.3 Latent Failures

Decisions taken in the managerial and organizational spheres. These are people separatedin time and space from the operational interface. Latent failures are originated in flawed organizationalprocesses which break though systems defences, barriers and safeguards. Latent failures may remainundetected for considerable periods of time, before they combine with active failures and local triggersto generate an accident.

2.1.4 Local working conditions

These are the factors that influence the efficiency and reliability of human performancein a particular work context. Table 3 and 4 present a breakdown of local working conditions and list theprincipal factors.

Table 3. Situational and task factors

Error factors Common factors Violation factors

Change of routine Time shortage Violations condonedNegative transfer Inadequate tools and Compliances goesPoor signal-noise ratio equipment unrewardedPoor human-system Poor procedures and Procedures protectinterface instructions (ambiguous or system not personPoor feedback from system inapplicable) Little or no autonomyDesigner-user mismatch Poor tasking Macho cultureEducational mismatch Inadequate training Perceived licence to bendHostile environment Hazards not identified rulesDomestic problems Undermanning Adversarial industrialPoor communications Inadequate checking climate (them and us)Poor mix of hands-on Poor access to job Low paywork and written Poor housekeeping Low statusinstructions (i.e., too much Bad supervisor/worker ratio Unfair sanctionsreliance on knowledge in Bad working conditions Blame culturethe head) Inadequate mix of Poor supervisory examplePoor shift patterns and experience and Tasks affording easyovertime working inexperienced workers shortcuts

A-5

Local working conditions (cont.)

Table 4. Personal factors

Error factors Common factors Violation factors

Attentional captwe Insufficient ability Age and genderPreoccupation Inadequate skill High risk targetDistraction Skill overeomes danger Behaviouml beliefs

Memory failures Unfamiliarity with task (gains outweigh risks)Eneodiig interference Age-related factors Subjective normsStorage loss Poor judgement ecmdoning violationsRetrieval failwe Illusion of control Pemeived behavioralProspective memory Lease effofi (cognitive eonttul

Strong motor programs economics) PersonaMyFrequeney bias Overconfidence Non-compliantSimilarity bias Performance anxiety Unstable extravert

Perceptual set (deadline plessules) Low moraleFalse sensations Arousal state Bad moodFalse pfXCt@OllS Monotony & IxmixIom Job dissatisfactionConfirmation bias Emotional stless Attitudes to systemSituational unawareness ManagementIncomplete knowledge SupqviscxxInaccurate knowledge DisciplineInferenee & reasoning Mispmeption of hazardsStress & fatigue Low self-esteemDisturbed sleep patterns Lamed helplessnessError proneness

2.1.5 Active Failures

13mrs and violations committed by operational pemonnel, the emsequenees of which amrevealed immediately and have an immdlate impact.

2.1.6 Local triggers

Technical faihnes, adverse weather conditions or any other particular (i.e., local)atypie.al/abnormalsystem operatingconditions.

—

—.———-—.

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