Human factors Forensic investigation Erin morrissey 4/18/2016

Human error and commercial aviation accidents: An analysis using the human factors analysis and classification system SHAPPELL, S., DETWILER, C., HOLCOMB, K., HACKWORTH, C., BOQUET A., & WIEGMANN, D. A.

HFACS Organizational Influences Unsafe Supervision Climate Process Resource Management Unsafe Supervision Inadequate Violations Preconditions for Unsafe Acts Environmental Personnell Unsafe Acts Errors

Purpose of study to extend our previous HFACS analyses beyond military and GA to include commercial aviation to combine the power of a theoretically derived human error framework with traditional situational and demographic variables from the commercial aviation database, such as visual conditions, injury severity, and regional differences to examine any relationships over an extended period of time (i.e., 13 years).

Method 13 years of data as recorded by National Transportation Safety Board (NTSB) National Aviation Safety Data Analysis Center (NASDAC) Included air carrier operations (FAR Part 121) & commuter/on-demand operations (FAR Part 135) 6 pilots, 1,000 min flight hours, 16 hrs. instruction on HFACS SMEs in HF w/ aviation psych background Pilots - % 85 agreement Pilots/HF SMEs - < %5 disagreement

Commuter/on-demand operations : environmental factors Instrument meteorological conditions (IMC) Visual meteorological conditions (VMC) Clear = VMC + daylight Impoverished = IMC + twilight or night

results No regional differences (Alaska vs. lower 48) Flight into IMC under visual flight rules were 5Xs more likely to be attributed to accidents in visually impoverished conditions. Fatal & non-fatal accidents: Skill-based errors Decision errors Violations* Perceptual errors *Violations 3Xs as likely to be associated with fatal accidents.

discussion Are violations a form of decision error? Violations= willful disregard of rules driven by hazardous attitudes Decision errors= lack of knowledge Novice pilots -> plan continuation errors Experienced pilots -> social pressure, overconfidence Framing a rerouting decision: Loss or gain?

Application of a human error framework to conduct train accident/incident investigations Reinach, S., & Viale, A.

Purpose To modify the HFACS to other domains Retrospective and prospective data collection/analysis (Janus) Provides consistency to investigation Ensures thoroughness Counteracts heuristics & biases Enables comparison of contributing factors across industries.

Remote control locomotive In an effort to reduce operating costs and increase safety, RCL operation have been implemented in railroad switching yards. Teams work in pairs

Method FRA reportable accidents & incidents from all 7 U.S. & Canadian Class I freight railroads. Accidents = collisions and derailment > $6700 damages Incidents = employee injuries requiring more than basic first aid May – Oct, 2004 6 accidents/incidents investigated further using the HFACS-RR framework

HFACS-RR framework Outside factors* Organizational factors Economic/Political/Social/Legal Environment Organizational factors Organizational climate; Resource mgmt.; processes Supervisory factors Inadequate supervision; Supervisory contraventions Preconditions for operator acts Environmental; Personnel factors; Condition of operators Operator acts Errors; Contraventions

In 6 months… 29 collisions 25 derailments 13 employee injuries ----Select 6 -------- 46 contributing factors 36 probable contributing factors

Discussion Operating remotely eliminates visual, aural, and kinesthetic feedback to operator reducing SA Staffing & Training demands increase as experienced employees retire while rail volume increases Importance of identifying latent conditions