Air Traffic Control (ATC) Related Accidents and Incidents: A Human Factors Analysis

Anthony M. Pape, Douglas A. Wiegmann, Scott Shappell

Research output: Contribution to conferencePresentation

Abstract

To date, the nature and role of ATC personnel in aviation accidents and incidents has yet to be fully examined. To remedy this situation, a comprehensive review of ATC-related accidents and incidents that occurred between January 1985 and December 1997 was conducted using records maintained by the NTSB. Results of the analysis revealed that ATC-related accidents and incidents are infrequent events. However, when these events do occur they are likely to involve local controllers interacting with multiple aircraft in the air during daylight VFR conditions. An in depth analysis of the narrative reports using the Human Factors Analysis and Classification System (HFACS) revealed that skill-based errors (attention failures and memory lapses) were the most common type of error committed by ATC personnel. Supervisory and organizational factors such as controller training, procedures, and oversight were cited in only a small fraction of the incident and accident reports. However, current accident and incident reporting systems were not designed with ATC errors in mind, making the analysis of latent factors, such as supervisory and organizational issues, extremely difficult. What is needed is a new error-analysis framework that will facilitate the gathering of information during ATC-related accident and incident investigations.
Original languageAmerican English
StatePublished - Mar 2001
Externally publishedYes
Event11th International Symposium on Aviation Psychology - Columbus, OH
Duration: Mar 1 2001 → …

Conference

Conference11th International Symposium on Aviation Psychology
Period3/1/01 → …

Keywords

  • aviation accidents
  • safety
  • Human Factors Analysis and Classification System (HFACS)
  • air traffic control
  • air traffic controllers
  • human error

Disciplines

  • Other Psychology

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