Each service expends considerable effort to document human factors that cause or contribute to flight mishaps. One goal of this activity is to avoid repeating the same mistakes with the same undesired outcomes. The service safety centers generate mishap-related reports at several levels of granularity. In the Air Force, mishap summaries are routinely distributed and reviewed for applicability to academic or simulator training in accordance with the instruction that specifies Cockpit/Crew Resource Management (CRM) training. More detailed information regarding pilot/crew behavior exists in a Safety Center human factors database, and even more detailed information resides in Mishap Investigation Board reports. These more detailed data were rarely analyzed for training purposes in the past, but that is beginning to change. Detailed analyses of all human factors were recently completed for recent C-130, MH-53, F-16, and A-10 Class A mishaps. Pilot/crew error was causal in most. The most frequently cited factors usually corresponded to traditional CRM areas. All six Air Force CRM areas were frequently cited in tactical airlift mishap factors. However, only three CRM areas were frequently cited in F-16 and A-10 mishaps (situation awareness, task management, and risk assessment/decision making). The remaining areas were rarely mentioned. We describe our analytic approach, which addresses both frequency and severity of factors cited, and includes both quantitative and qualitative analyses. We also describe commonalities and differences across aircraft types and discuss underlying behaviors. The detailed information in human factors databases and formal mishap reports provide a robust bridge between mishaps and training that is often missing today. Our analytic approach builds on considerable work already accomplished by mishap investigation boards. Applications-to-date include tailored material for C-130 and A-10 mission qualification training and annual refresher CRM courses, and validating key CRM areas in a new Department of Defense human factors analysis and classification system.
Human Factors in Air Force Flight Mishaps: Implications for Change
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