Mishap Reports Research Articles

Over a decade of UAV incidents: A human factors analysis of causal factors

This analysis examined systemic causes of Uncrewed Air Vehicle (UAV) accidents identifying operator, environmental, supervisory, and organisational factors through the use of the Human Factors Analysis and Classification System (HFACS). HFACS is a system-based analysis method for investigating the causal factors associated with accidents and incidents and has previously been used to reliably and systematically identify active and latent failures associated with both military and general aviation accidents. Whilst HFACS has previously been applied to UAV accidents, the last known application was conducted in 2014. Using reports retrieved from nine accident investigation organisations’ databases, causal factors were coded against unsafe acts, preconditions, and failures at the supervisory, organisational, and environmental levels. Causal factors were assessed on 77 medium or large UAV mishaps/accidents that occurred over a 12-year period up to 2024. 42 mishap reports were deemed to involve a human factor as a causal factor. A large proportion of the mishaps contained factors attributed to Decision Errors at level 1 (Unsafe Acts) which was found to be associated with both the Technological Environment and Adverse Mental State at level 2 (Pre-conditions). Causal factors were identified at each of the other 3 levels (Supervisory, Organisational and External) with a number of emergent associations between causal factors. These data provide support for the identification and development of interventions aimed at improving the safety of organisations and advice of regulators for Uncrewed Air Systems.

Toward a Probabilistic Risk Assessment (PRA) Method for Assessing Mishaps in Legacy Systems Using Mishap Reports

AbstractThere is a significant delta between the acknowledged probability of potential mishaps under the current safety assessment approach derived from Military Standard 882E (MIL‐STD‐882E), Department of Defense Standard Practice of System Safety, and what is observed from actualized mishaps being reported. When assessing systems safety during the design process, the approaches used that comply with MIL‐STD‐882E simplify the mishap scenario by assuming a single initiating mechanism. By decomposing mishap reports from legacy systems, fault and event trees are used to identify common failure modes that were not adequately assessed under the current process. Each of the mishap reports assessed has identified more than one initiating mechanism. As such, this work suggests a greater mishap probability than was originally acknowledged. To address the current limitation, this work develops (1) an approach for decomposing mishap scenarios for legacy systems to identify mishaps resulting from multiple failure modes, (2) a method for systematically implementing the mishap decomposition on the assessed system or newly designed systems, and (3) a list of characteristics for an improved systems safety method.

Fatigue-Related Aviation Mishaps

INTRODUCTION: Fatigue is a critical safety issue to U.S. Air Force (USAF) flight and ground crew. Nearly 15 yr of mishap reports were analyzed to determine how fatigue affects USAF operations with the goal of improving fatigue risk management policies and tools.METHODS: Summary data for 19,920 aviation mishap reports dating back to 2003 were collected from the Air Force Safety Automated System (AFSAS). Fatigue-related mishaps were identified based on designations provided within AFSAS. Other metrics examined were characteristics such as timing, cost, and aircraft metrics, among others. Contingency tables built from these metrics were used to assess fatigue-related trends across the aviation community.RESULTS: While only 3.88% of all mishaps were identified as fatigue-related, they are associated with 2.1 billion of medical expenses and property damage, or 18% of the 11.7 billion total cost of all mishaps included in the study. Nearly a quarter of the fatigue-related mishaps fall into the most severe mishap category and more than half occurred between 0100 and 0700, local time. Fatigue-related mishaps tended to be more common for Remotely Piloted Aircraft (RPA) and ground operations.DISCUSSION: Fatigue is very costly to the USAF despite the relatively low incidence rate of fatigue-related mishaps. This is because larger proportions of severe mishaps were found to be fatigue-related. RPA and ground maintenance operators might be especially susceptible to fatigue and potentially lack adequate fatigue mitigation support and training tailored to their unique operational environment, suggesting a need to improve upon fatigue mitigation tools and strategies.Gaines AR, Morris MB, Gunzelmann G. Fatigue-related aviation mishaps. Aerosp Med Hum Perform. 2020; 91(5):440447.

Understanding Human Error in Naval Aviation Mishaps.

To better understand the external factors that influence the performance and decisions of aviators involved in Naval aviation mishaps. Mishaps in complex activities, ranging from aviation to nuclear power operations, are often the result of interactions between multiple components within an organization. The Naval aviation mishap database contains relevant information, both in quantitative statistics and qualitative reports, that permits analysis of such interactions to identify how the working atmosphere influences aviator performance and judgment. Results from 95 severe Naval aviation mishaps that occurred from 2011 through 2016 were analyzed using Bayes' theorem probability formula. Then a content analysis was performed on a subset of relevant mishap reports. Out of the 14 latent factors analyzed, the Bayes' application identified 6 that impacted specific aspects of aviator behavior during mishaps. Technological environment, misperceptions, and mental awareness impacted basic aviation skills. The remaining 3 factors were used to inform a content analysis of the contextual information within mishap reports. Teamwork failures were the result of plan continuation aggravated by diffused responsibility. Resource limitations and risk management deficiencies impacted judgments made by squadron commanders. The application of Bayes' theorem to historical mishap data revealed the role of latent factors within Naval aviation mishaps. Teamwork failures were seen to be considerably damaging to both aviator skill and judgment. Both the methods and findings have direct application for organizations interested in understanding the relationships between external factors and human error. It presents real-world evidence to promote effective safety decisions.

The Design of the UAS Ground Control Station: Challenges and Solutions for Ensuring Safe Flight in Civilian Skies

Growing civil demands for uninhabited aircraft systems (UASs) are creating pressure to determine minimum design standards and required capabilities for UAS ground control stations (GCSs). This panel will discuss recent and ongoing research initiatives, regulatory guidance, and lessons learned from military UAS operations and mishap reports to shed light on the potential for GCS designs to support safe and non-disruptive UAS operations in the national airspace system (NAS). As part of this discussion, panelists will present GCS design challenges related to the preservation of NAS safety and traffic flow and will suggest strategies for overcoming them.

Mechanisms of Flag-Football Injuries Reported to the HQ Air Force Safety Center: A 10-Year Descriptive Study, 1993–2002

Flag (touch or intramural) football is a popular sport among the U.S. Air Force (USAF) active duty population and causes a substantial number of lost-workday injuries. The purpose of this study is to describe the mechanisms of flag-football injuries to better identify effective countermeasures. The data were derived from safety reports obtained from the USAF Ground Safety Automated System. Flag-football injuries for the years 1993-2002 that resulted in at least one lost workday were included in the study conducted in 2003. Narrative data were systematically reviewed for 32,812 USAF mishap reports; these were then coded in order to categorize and summarize mechanisms associated with flag football and other sports and occupational injuries. Nine hundred and forty-four mishap reports involving active duty USAF members playing flag football met the criteria for inclusion into this study. Eight mechanisms of injury were identified. The eight mechanisms accounted for 90% of all flag-football injuries. One scenario (contact with another player) accounted for 42% of all flag-football injuries. The most common mechanisms of injury caused by playing flag football can be identified using the detailed information found in safety reports. These scenarios are essential to developing evidence-based countermeasures. Results for flag football suggest that interventions that prevent player contact injuries deserve further research and evaluation. The broader implications of this study are that military safety data can be used to identify potentially modifiable mechanisms of injury for specific activities such as flag football.

Mechanisms of Basketball Injuries Reported to the HQ Air Force Safety Center: A 10-Year Descriptive Study, 1993–2002

Background Basketball is the most popular sport among the U.S. Air Force (USAF) active duty population and causes a large number of lost-workday injuries. The purpose of this study is to describe how basketball injuries occur to allow development of effective countermeasures. Methods This study used data derived from safety reports obtained from the USAF Ground Safety Automated System. Basketball injuries for the years 1993–2002 that resulted in at least one lost workday were included in the study conducted in 2003. Narrative data from 32,818 safety reports were systematically reviewed and coded in order to categorize and summarize mechanisms associated with these injuries. Results A total of 2204 mishap reports involving active duty USAF members playing basketball were documented by the study. This study identified seven mechanisms causing basketball injury. Two similar causes involving jumping (landing awkwardly and landing on someone's foot) accounted for 43% of basketball injuries followed by collisions with other players (10%). Conclusions This study shows that mechanisms of basketball-related injury can be identified using the detailed information found in USAF safety reports. Knowledge of leading hazards or mechanisms for basketball injuries can be used to prioritize and develop prevention strategies. Basketball is the most popular sport among the U.S. Air Force (USAF) active duty population and causes a large number of lost-workday injuries. The purpose of this study is to describe how basketball injuries occur to allow development of effective countermeasures. This study used data derived from safety reports obtained from the USAF Ground Safety Automated System. Basketball injuries for the years 1993–2002 that resulted in at least one lost workday were included in the study conducted in 2003. Narrative data from 32,818 safety reports were systematically reviewed and coded in order to categorize and summarize mechanisms associated with these injuries. A total of 2204 mishap reports involving active duty USAF members playing basketball were documented by the study. This study identified seven mechanisms causing basketball injury. Two similar causes involving jumping (landing awkwardly and landing on someone's foot) accounted for 43% of basketball injuries followed by collisions with other players (10%). This study shows that mechanisms of basketball-related injury can be identified using the detailed information found in USAF safety reports. Knowledge of leading hazards or mechanisms for basketball injuries can be used to prioritize and develop prevention strategies.

Mechanisms of Slow-Pitch Softball Injuries Reported to the HQ Air Force Safety Center: A 10-Year Descriptive Study, 1993–2002

Softball is a popular sport in civilian and military populations and results in a large number of lost-workday injuries. The purpose of this study is to describe the mechanisms associated with softball injuries occurring among active duty U.S. Air Force (USAF) personnel to better identify potentially effective countermeasures.Data derived from safety reports were obtained from the USAF Ground Safety Automated System in 2003. Softball injuries for the years 1993-2002 that resulted in at least one lost workday were included in the study. Narrative data were systematically reviewed and coded in order to categorize and summarize mechanisms associated with these injuries.This report documents a total of 1181 softball-related mishap reports, involving 1171 active duty USAF members who sustained one lost-workday injury while playing softball. Eight independent mechanisms were identified. Three specific scenarios (sliding, being hit by a ball, and colliding with a player) accounted for 60% of reported softball injuries.Mechanisms of injury for activities such as playing softball, necessary for prevention planning, can be identified using the detailed information found in safety reports. This information should also be used to develop better sports injury coding systems. Within the USAF and U.S. softball community, interventions to reduce injuries related to the most common mechanisms (sliding, being hit by a ball, and colliding with a player) should be developed, implemented, and evaluated.

How fire can be tamed

Combustion dies at the interface between breathable air and macroscopic pieces of certain involatile fuels. If fed only them, in a compressed oxygen chamber, it makes an almost sunlike flame that cannot run wild. If upon dilution to manageable coolness the ash drops to the chamber bottom, and from there can be removed without the diluent, true harnessbrokenness is possible. Excess oxygen can be the diluent without thereby being wasted. It can rid itself of the diluted flame's heat, and spare many trees from becoming newsprint bearing motor fuel mishap reports, by working in a thermodynamic cycle. Some ashes, especially boria, both precipitate well from the diluted flame and travel well. By visiting faraway solar or fission power stations, and returning to the chamber as regenerated fuel, they can make combustion both docile, and subsidiary to docile primary energies.

A Methodology for Identifying Human Error in U.S. Navy Diving Accidents

To better understand how human error contributes to U.S. Navy diving accidents. An analysis of 263 U.S. Navy diving accident and mishap reports revealed that the human factors classifications were not informative for further analysis, and 70% of mishaps were attributed to unknown causes; only 23% were attributed to human factors. Five diving fatality reports were examined using the consensual qualitative research (CQR) method to develop a taxonomy of six categories and 21 subcategories for classifying human errors in diving. In addition, 15 critical incident technique (CIT) interviews were conducted with U.S. Navy divers who had been involved in a diving accident or near miss and analyzed using the dive team error taxonomy. Overall, failures in situation awareness and leadership were the most common human errors made by the dive team. The dive team human error taxonomy could aid in accident investigation and in the training and evaluation of U.S. Navy divers. The development of the dive team human error taxonomy has generated a number of considerations that researchers should take into account when developing, or adapting, an error taxonomy from one industry to another.

Making Sense Out of Team Performance Errors in Military Aviation Environments

Teams perform tasks across a wide variety of environments, including transportation. In transportation environments, team performance is essential for the optimal performance of team tasks. Consequently, when teams fail, the outcome can be devastating. Therefore, the identification of factors contributing to ineffective team performance is crucial. In this study we examine factors and skills that contribute to breakdowns in team performance. To accomplish this, we utilize mishap reports of teams operating within a military aviation environment. Results indicate that human error, team skill breakdowns, and contextual variations are involved in aviation team accidents. Implications for future research and training are discussed.