Aviation Research Lab
Institute of Aviation
University of Illinois
at Urbana-Champaign
1 Airport Road
Savoy, Illinois 61874
Human Error and Accident
Causation Theories, Frameworks
and Analytical Techniques:
An Annotated Bibliography
Douglas A. Wiegmann and Aaron M. Rich
Aviation Research Lab
and Scott A. Shappell
Civil Aeromedical Institute
Technical Report ARL-00-12/FAA-00-7
September 2000
Prepared for
Federal Aviation Administration
Oklahoma City, OK
Contract DTFA 99-G-006
ARL
1
ABSTRACT
Over the last several decades, humans have played a progressively more important causal
role in aviation accidents as aircraft have become more. Consequently, a growing number of
aviation organizations are tasking their safety personnel with developing safety programs to
address the highly complex and often nebulous issue of human error. However, there is generally
no “off-the-shelf” or standard approach for addressing human error in aviation. Indeed, recent
years have seen a proliferation of human error frameworks and accident investigation schemes to
the point where there now appears to be as many human error models as there are people
interested in the topic. The purpose of the present document is to summarize research and
technical articles that either directly present a specific human error or accident analysis system,
or use error frameworks in analyzing human performance data within a specific context or task.
The hope is that this review of the literature will provide practitioners with a starting point for
identifying error analysis and accident investigation schemes that will best suit their individual or
organizational needs.
2
Adams, E. E. (1976, October). Accident causation and the management system.
Professional Safety, 26-29.
The paper explores accident causation in the context of management philosophy and support for
the safety professional. An underlying theme is that management’s thoughts and actions
influence work conditions and worker behavior. Accident prevention is then discussed as a two
level task. The first level consists of technical problem solving for correcting tactical errors. The
second level consists of management analysis and strategic planning for the correction of
operational errors. Heinrich’s domino philosophy of accident prevention is also analyzed in
regards to its relevance to management behavior.
Air Force Safety Center: Life Sciences Report (LSR) and USAF HF Taxonomy. (1998).
(NASA Aviation Data Sources Resource Handbook).
The Life Sciences Report and USAF human factors taxonomy are described. The human factors
category of the Life Science Report Investigations was designed to allow for a broader secondary
analysis of human factors issues. The data is limited to aircraft accidents only. The report relies
on the use of a logic tree. The human factors category is broken down into two main categories
with multiple subcategories within each. The first is the environmental category that incorporates
operations, institutions and management, logistics and maintenance, facilities services, and
egress/survival. The second is the individual category that is comprised of
physiological/biodynamic, psychological, and psychosocial subcategories.
AIRS Aircrew Incident Reporting System. (1998). (NASA Aviation Data Sources Resource
Notebook).
The AIRS is a reporting system developed by Airbus Industrie to assess how their aircraft are
operated in the real world, to gather human factor information, learn what role human factors
play in accidents, and inform other operators of the lessons learned from these events. A
taxonomy was designed for the database that is based on five categories of factors. The first
category is crew actions. There are three main components of this category.
(1) Activities of handling the aircraft and its systems
(2) Error types (based on Reason’s model of human error)
(3) Crew resource management teamskills
The other categories include personal influences (emotion, stress, motivation, etc),
environmental influences (ATC services, technical failure, other aircraft, etc.), organizational
influences (training, commercial pressure, etc.), and informational influences (checklists,
navigational charts, etc.). A keyword system to access the database has also been designed. This
keyword system is separated into two categories, crew behavior and contributory factors. An
advantage of the AIRS as a reporting system is that it allows for plots of error chains which
represent active and latent failures instrumental to an incident occurrence. It also supports trend
analysis.
　
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