Using Conditional Probabilities to Understand “Human Error” in Military Aviation Mishaps

Abstract

The Department of Defense Human Factors Analysis and Classification System (DoD HFACS) is the standardized taxonomy used by the services to classify human error identified in mishaps and hazards. DoD HFACS encourages safety investigators and professionals to examine how higher-level influences (e.g. organizational policy, supervisor ability, and technological environment) can impact perfor mance for the individuals executing the actual work (e.g. aviators flying the aircraft). The current project applied the well- known conditional probability formula of Bayes’ Theorem to better understand how the higher-level influences shape the specific types of performance deviations experienced by individuals involved in aviation mishaps.

Why Learning Opportunities From Aviation Incidents Are Lacking

“…In identifying risk factors for various errors and violations, we were able to confirm certain results of Miranda (2017) at a higher level of abstraction: A misinterpreted instrument is the strongest risk factor for a performance-based error. When evaluating the related reports, it became clear that misread instruments may also occur in connection with so-called mixed-fleet-flying (pilots have the license for aircraft types that differ only slightly from each other).…”

“…We could expand the state of research, indicating that lack of assertiveness is not only a risk factor for judgment and decision-making errors, but also for violations (cf. Miranda, 2017). This result is not surprising, considering that decisions in commercial cockpits are mainly made jointly by the pilots.…”

“…HFACS has also emerged as a reliable system in the framework of incident or weak signal analysis (e.g., Lee et al, 2017; Li & Harris, 2006; Madigan et al, 2016; Miranda, 2018; Munene, 2016). Miranda (2017), for example, was able to identify latent failures that are particularly conducive to certain types of unsafe acts when evaluating major accidents in a military context.…”

How Just Culture and Personal Goals Moderate the Positive Relation between Commercial Pilots’ Safety Citizenship Behavior and Voluntary Incident Reporting

“…The Human Factors Analysis and Classification System (HFACS), which is based on the Swiss Cheese Model, considers the occurrence of incidents as a linear failure in the areas of organizational influences, unsafe supervision, preconditions, and pilots' unsafe acts [58]. The appropriateness of HFACS for incident report analysis has also been demonstrated in scientific studies [59,60]. In HFACS, pilots' unsafe acts are divided into performance-based errors, judgment and decision-making errors, and violations.…”