Browsing by Author "Harris, Don"
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Item Open Access Aeronautical decision-making (ADM) training : the identification of training needs, developing a training program and evaluating the effectiveness of a training intervention(Cranfield University, 2006) Li, Wen-Chin; Harris, DonFlying a high-technology fighter with high stakes and under high g-force is not only an issue of skilled psychomotor performance but also of real-time decision-making involving situation awareness, choice amongst alternatives, time pressure and risk assessment. There is no aeronautical decision-making (ADM) training program for military pilots in existence neither in the R. O. C. Air Force nor around the world, although academic research had recognized the training needs for aeronautical decision-making. This research consists of three studies described in six chapters to develop an effective solution for ADM problems in order to improve military pilots' decision-making in a dynamic and time-limited tactical environment. The first chapter is an executive summary comprised by three studies. The second chapter identified ADM training needs by applied the Human Factors Analysis and Classification System (HFACS). Without good analysis it is impossible to identify precisely the training needs and the nature of the training content required for improving pilots' performance. The third chapter examined five ADM training mnemonics in six different decision-making scenarios for developing an ADM training program. There are many ADM mnemonics available. However, there was lack of empirical research investigating the efficiency of those ADM mnemonics in the real-time tactical environment. The fourth chapter evaluates the effectiveness of ADM training program by simulator trials and pencil and paper trials. The fifth chapter is overall discussion, followed by the final chapter containing conclusions and recommendations. This research demonstrated that ADM training program did improve pilots' in-flight decision-making performance. Improvements in pilots' situation assessment and risk management were obtained, but these were traded-off for response time. To improve the quality of pilots' decision-making, the ADM training program needs to be coordinated with real-time simulator scenarios training. The findings have demonstrated that the ADM training program significantly improved pilots' situation assessment and risk management. However, it still needs to be established if these performance gains continue to be evident at a later date during actual operations.Item Open Access The application of aeronautical decision-making support systems for improving pilots' performance in flight operations(Aeronautical and Astronautical Society of the Republic of China, 2014-06-01) Li, Wen-Chin; Li, Lun-Wen; Harris, Don; Hsu, Yueh-LingOperating a high-technology commercial airliner is not only an issue in psychomotor skill performance but also of a real-time decision-making involving situation awareness and risk management within a limited-time condition. The number of aircraft accidents attributable solely to mechanical failures has decreased markedly in recent years, but the contribution of human error has declined at a much slower rate. Previous research demonstrated a belief rule-based decision support system has provided more reliable and informative performance after training. The purpose of this research was to identify the best mnemonic-based method of decision support systems for improving commercial pilot's performance in the advanced cockpit. A total of 157 airline pilots, all qualified on the Boeing 747-400 evaluated the suitability of four different ADM methods: SHOR (Stimuli, Hypotheses, Options, Response); PASS (Problem identification, Acquire information, Survey strategy, Select strategy); FORDEC (Facts, Options, Risks & Benefits, Decision, Execution, Check); and DESIDE (Detect, Estimate, Set safety objectives, Identify, Do, Evaluate). Each was evaluated for six different types of decisions: go/no go; recognition-primed; response selection; resource management; non-diagnostic procedural; and creative problem-solving. Pilots regarded the FORDEC methodology as being the best in all decision-making scenarios, irrespective of the time available to make the decision. It was also rated as the best ADM method for promoting crew coordination. However, it was advised that practicing the FORDEC mnemonic in flight simulator was important before attempting to apply it in a real life situation.Item Open Access Approaches to accident investigation by investigators from different cultures(2009-09-09T00:00:00Z) Li, Wen-Chin; Young, Hong-Tsu; Wang, Thomas; Harris, DonCultural characteristics play a significant part in aviation (Helmreich & Merritt, 1998). The collective nature of Chinese society is consistent with broad, contextual view of the world and their belief that events are highly complex and determined by many factors. On the other side, the individualistic nature of Western society seems consistent with the focus on particular objects in isolation from their context and with Westerners’ belief that they can know the rules governing objects and therefore can control the objects’ behavior (Nisbett, 2003). Westerners have a strong interest in categorization, which helps them to know what rules to apply to the objects, and formal logic plays a role in problem solving. Chinese attend to objects in their broad context. The world seems more complex to Chinese than to Westerners, and understanding events always requires consideration of many factors that operate in relation to one another in no simple way. From the I-Ching (ancient Chinese philosophical book), ‘for misery, happiness is leaning against it; for happiness, misery is hiding in it. Who knows whether it is misery or happiness? There is no certainty. The righteous suddenly becomes the vicious; the good suddenly becomes the bad’. Chinese is less concerned with finding the truth than with finding the harmony way to live in the world. As the result, Chinese failure to develop science can be attributed in part to lack of curiosity to the true, but the absence of a concept of nature would have blocked the development of science in any case.Item Open Access Breaking the chain: An empirical analysis of accident causal factors by human factors analysis and classification system(2006-09-14T00:00:00Z) Li, Wen-Chin; Harris, DonThis research analyzed 523 accidents in the R.O.C. Air Force between 1978 and 2002 using the Human Factors Analysis and Classification System (HFACS) framework described by Wiegmann & Shappell (2003). This study provides an understanding, based upon empirical evidence, of how actions and decisions at higher levels in the organization to result in operational errors and accidents. Suggestions are made about intervention strategies focusing on the categories at higher levels of HFACS. Specific targets for remedial safety actions should be aimed in the areas that share the strongest and greatest number of significant associations with ‘Organizational Influences’ (for example, ‘organizational process’, ‘inadequate supervision’ and ‘Crew Resource Management’). The greatest gains in safety benefit could be achieved by targeting these areas. Furthermore, this study also demonstrates that the HFACS framework is a useful tool for guiding accident investigations and for targeting potentially cost-effective remedial safety actions for breaking the chain of accidents.Item Open Access The development of a multidimensional scale to evaluate motor vehicle dynamic qualities.(Taylor & Francis, 2005-06-01T00:00:00Z) Harris, Don; Chan-Pensley, J; McGarry, SAdvances in motor vehicle engineering will allow greater refinement of the dynamic qualities of passenger cars in the near future. This paper describes the development and initial validation of a reliable and valid multidimensional scale to assess these parameters based upon a technique previously developed to evaluate aircraft handling qualities. The scaling methodology developed emphasizes the interaction between the vehicle's dynamic behaviour and the category of vehicle (e.g. sports car, executive saloon). This three-part study describes the initial extraction and the subsequent verification of the scale dimensions from an analysis of the opinions of circa 500 drivers, followed by an evaluation of the sensitivity and diagnosticity of the scale to distinguish between the road behaviour exhibited by vehicle types. The results suggest that the scale shows both content and construct validity, being able to distinguish both between broad categories of vehicle and different models of vehicle within a particular category in a consistent and meaningful manner.Item Open Access The development of usability scales for flight management systems (volumes one and two)(2002) Lane, Karen P.; Harris, DonUsability is a multidimensional concept, and although a number of techniques have been developed for assessing usability, none have been developed specifically for the civil flight deck or its components. The requirement for Human Factors tools to support civil flight deck certification have been well documented (e.g. FAA, 1996). This thesis reports on a research programme that resulted in the development of a series of scales to assess the usability of Flight Management System (FMS) Control and Display Units (CDUs). Since the goal of this research was to produce scales that could be used by certification authorities and FMS manufacturers, demonstrating that the scales had appropriate psychometric properties was critical. A rigorous and systematic approach to the construction of the usability scales was therefore adopted. The research was conducted in three studies. The first study involved the development of a 49-item questionnaire that was distributed to airline pilots. A series of analyses on the data collected demonstrated that a reliable and valid usability factor structure was produced. The second study focused on the production of usability scales and examined the impact of flight phase on usability ratings. Analyses demonstrated that the factor structure produced in the first study was reliable, and was valid for data collected for the cruise and descent and approach phases of flight. A series of internally consistent usability scales was therefore produced which demonstrated evidence of discriminant, face, content, and construct validity. The third study involved a content analysis on a large volume of participant comments derived during studies one and two, and examined the usability problems associated with current FMSs and suggested improvements for future FMSs. The content analysis produced evidence of construct validity for the usability scales developed, and permitted recommendations for FMS designers and certification authorities to be made.Item Open Access Do cultural characteristics affect investigation?(2009-04-01T00:00:00Z) Li, Wen-Chin; Young, Hong-Tsu; Wang, Thomas; Harris, DonSeparating the people from the problem assumes an individualist value set underlying the Western approach to investigation. In collectivist cultures, where relationships prevail over tasks, this is an almost impossible demand. Effective investigation for aviation accidents within different cultural contexts demands insight into the range of cultural values to be expected among partners from other countries, in addition to an awareness of the investigator’s own culturally determined values. Effective international investigations also demand language and communication skills to guarantee that the messages sent to the other professional investigators from different cultures with different approaches to accident investigation will be understood in the way they were meant to be. The global interaction between different cultures involves sharing the values of all partners. It is important to know more about the similarities and differences in culture-influenced accident investigation philosophies, e.g., when European and Asian culture collaborate together. The cognitive orientation and mechanisms of Eastern and Western cultures are sufficiently different that they may draw completely different inferences from the same set of data (as in this case), especially in the case where human factors are concerned. The best approach may be to try to understand the events in the accident from the viewpoint of the culture of the pilots/airline involved in the accident and not from the cultural viewpoint of the investigator. This way there might be a better chance that culturally congruent remedial actions can be proposed. However, by better understanding these cultural differences it seems highly likely that they can only serve to complement and enrich each other.Item Open Access Eastern minds in western cockpits: A cross-cultural comparison of aviation mishaps by applying human factors analysis and classification system(2006-05-16T00:00:00Z) Li, Wen-Chin; Harris, DonAviation accident rates are varied in different regions; Asia and Africa have higher rates than Europe and America. There has been a great deal of discussion about the role of culture in aviation mishaps, however, culture is hardly ever mentioned as a causal factor of accidents. It is hypothesized that different cultures will show different patterns in the underlying causal factors in aircraft accidents. Method: This research examined statistical differences in the 18 categories of HFACS across accidents in the Republic of China (Taiwan, a feminine, collectivist, strong uncertainty avoidance, and high power-distance culture); India (a masculine, collectivist, weak uncertainty avoidance, and high power-distance culture); and the USA (a small power distance, weak uncertainty avoidance, individualist, and masculine culture). Results: Ten HFACS categories exhibited significant differences (p<0.05) between these three regions. These were related to organizational processes; organizational climate; resource management; inadequate supervision; personal readiness; physical/mental limitations; adverse physiological states; adverse mental states; skilled-based errors; and decision errors. The pattern of results was congruent with what would be expected from Hofstede’s descriptions of national culture. Conclusion: Culture may be a soft issue in aviation operations, but it certainly can have hard consequences. Overall, the evidence from this research supports the observation that national cultures have an impact on aviation safety but adds further explanatory power with regards to why this should be so.Item Open Access The evaluation of product and process for in-flight decision-making training(2006-09-28T00:00:00Z) Li, Wen-Chin; Harris, Don; Hsieh, Chih-ChaoForty-One male pilots from ROC Air Force Tactical Training Wings participated in the study. The flying experience of participants was between 354 and 220 hours with an average of 292 hours. Participants were randomly divided into two groups, 21 pilots in the experimental group, and 20 pilots in control group. Two ADM mnemonic methods, SHOR and DESIDE, that had been previously been assessed by instructor pilots as being the most applicable and having the potential to significantly improve the quality of military pilots’ decision-making formed the basis of the ADM training programs. Overall, results from both the simulator-based trials (which assessed the product of the ADM training programme) and the pencil-and-paper tests (which assessed the process that the trainees applied) showed gains being made in both Situation Assessment and Risk Management skills attributable to the decision making training course. The results strongly suggest that such a short training course can be effective in terms of improving pilots’ skill in situation assessment and risk management. However, these gains were at the cost of a decreased speed of responding. Nevertheless, it is suggested that a simple, short, cost-effective training program in the appropriate use of ADM mnemonic methods may ultimately produce significant gains in flight safety. Such a course may easily be integrated into current CRM or simulator-based training programs.Item Open Access The evaluation of the decision making processes employed by cadet pilots following a short aeronautical decision-making training program(Federal Aviation Administration Academy, 2006) Li, Wen-Chin; Harris, DonMany aeronautical decision-making (ADM) mnemonic-based methods exist. However, there is no empirical research that suggests that they are actually effective in improving decision-making. Klein (1993), in his study of naturalistic decision making suggested that the decision-making process centers around two processes; situation assessment to generate a plausible course of action and mental simulation to evaluate that course of action for risk management. In this study a short, ADM training course was constructed around two mnemonic methods, SHOR (Stimuli, Hypotheses, Options, and Response) and DESIDE (Detect, Estimate, Set safety objectives, Identify, Do, Evaluate). Forty-one pilots from the Republic of China Tactical Training Wing participated: half received a short ADM training course and half did not. After training, the procedural knowledge underpinning their Situation Assessment and Risk Management ability, two skills essential for successful decision-making, were evaluated using pencil and paper-based knowledge tests based upon several demanding tactical flight situations. These scenarios were designed to encompass the six basic types of decision making described by Orasanu (1993); go/no go decisions; recognition-primed decisions; response selection decisions; resource management decisions; non-diagnostic procedural decisions, and decisions requiring creative problem-solving. The results show gains attributable to the decision making training course in both situation assessment and risk management skills. The results strongly suggest that ADM is trainable and such a training course is effective in improving the bases of in-flight decision-making.Item Open Access How to apply mnemonic-methods for improving pilots in-flight decision-making(2007-06-05T00:00:00Z) Li, Wen-Chin; Harris, Don; Yu, Chung-SanTwo ADM mnemonic-based methods, SHOR (Wohl, 1981) and DESIDE (Murray, 1997), have been demonstrated to significantly improve military pilots’ in-flight decision-making performance in six different tactical situations (Li & Harris, 2005). However, there is little research concerning how to apply these mnemonics in real world. Method: This research applied focus groups consisting of three senior flight instructors and one aviation human factors specialist, to investigate how to apply the SHOR and DESIDE techniques in different types of decision-making scenarios. Results: The qualitative data suggested that SHOR was the best mnemonic in the recognition-primed decision making scenarios; DESIDE was the best mnemonic for the scenarios concerning non-diagnostic procedural decisions and creative problem-solving. Discussion: Pilots would apply SHOR in time-limited and urgent situations as a result of its concise, logical structure. They chose to use DESIDE when time was available for a more comprehensive consideration of the situation.Item Open Access Human error prevention: using the human error template to analyze errors in a large transport aircraft for human factors considerations(2009-10-01T00:00:00Z) Li, Wen-Chin; Harris, Don; Stanton, Neville A.; Hsu, Yueh-Ling; Chang, Danny; Wang, Thomas; Young, Hong-TsuFlight crews make positive contributions to the safety of aviation operations. Pilots have to assess continuously changing situations, evaluate potential risks and make quick decisions. However, even well trained and experienced pilots make errors. Accident investigations have identified that pilots’ performance is influenced significantly by the design of the flight deck interface. This research applies Hierarchical Task Analysis (HTA) and utilizes the - Human Error Template (HET) taxonomy - to collect error data from pilots during flight operations when performing a go-around in a large commercial transport aircraft. HET was originally developed in response to a requirement for formal methods to assess compliance with the new human factors certification rule for large civil aircraft introduced to reduce the incidence of design-induced error on the flight deck (EASA Certification Specification 25.1302). The HET taxonomy was applied to each bottom level task step in an HTA of the flight task in question. A total of 67 pilots participated in this research including 12 instructor pilots, 18 ground training instructor, and 37 pilots. Initial results found that participants identified 17 operational steps with between two and eight different operational errors being identified in each step by answering to the questions based either on his/her own experience or their knowledge of the same mistakes made previously by others. Sixty-five different errors were identified. The data gathered from this research will help to improve safety when performing a go-around by identifying potential errors on a step-by-step basis and allowing early remedial actions in procedures and crew coordination to be made.Item Open Access Identifying training deficiencies in military pilots by applying the human factors analysis and classification system(Ablex Publishing Corporation, 2013-03-01T00:00:00Z) Li, Wen-Chin; Harris, DonWithout accurate analysis, it is difficult to identify training needs and develop the content of training programs required for preventing aviation accidents. The Human Factors Analysis and Classification System (HFACS) is based on Reason’s system-wide model of human error. In this study 523 accidents from the R.O.C. (Republic of China) Air Force were analyzed in which 1,762 human errors were categorized. The results of the analysis showed that errors of judgment and poor decision-making were commonly reported amongst pilots. As a result it was concluded that there was a need for military pilots to be trained specifically in making decisions in tactical environments. However, application of HFACS also allowed the identification of systemic training deficiencies within the organization further contributing to the accidents observed.Item Open Access The influence of human factors on operational efficiency(Emerald, 2006) Harris, DonThis paper adopts a socio-technical systems approach is taken to examine how airline operational efficiency can be enhanced from a human factors perspective. Four case studies are examined from this viewpoint: increasing operating efficiency on the airport ramp; increasing efficiency through flight crew rostering; increasing efficiency by promoting direct routing; and increasing efficiency through greater flight deck automation. It is argued that the increases in operational efficiency (which is taken to be almost synonymous with cost) taking solely a human factors perspective will be minimal. To truly enhance operating efficiency the human component in any system cannot be examined in isolation from all other components.Item Open Access International cooperation and challenges: Understanding cross-cultural issues in the processes of accident(2007-09-03T00:00:00Z) Li, Wen-Chin; Young, Hong-Tsu; Wang, Thomas; Harris, DonThe idea that national cultural characteristics play a part in aviation safety had been suggested by Helmreich & Merritt (1998). This research involved around 45 aviation accident investigators from different cultural backgrounds and investigated attribution of causal factors in the Ueberlingen accident report through the application of the Human Factors Analysis and Classification System (Wiegmann & Shappell, 2003). Hofstede’s (1991 & 2001) cultural dimensions draw a clear picture of the attributable patterns of human errors based on cultural differences. As a result it is necessary to develop a better understanding of the differences in attribution of accident causes and contributory factors across cultures to promote both aviation safety and international cooperation for accident investigation will be achieved. Furthermore, when suggesting safety enhancements resulting from accident investigations it needs to be noted that the same remedy may not work in different cultures. Remedial actions must be 'culturally congruent'. This process starts with understanding the cultural factors at work in the accident investigation process itself.Item Open Access International cooperation and challenges: Understanding cross-cultural issues in the processes of accident investigation(2007-10-01T00:00:00Z) Li, Wen-Chin; Young, Hong-Tsu; Wang, Thomas; Harris, DonThe idea that national cultural characteristics play a part in aviation safety had been suggested by Helmreich & Merritt (1998). This research involved around 45 aviation accident investigators from different cultural backgrounds and investigated attribution of causal factors in the Ueberlingen accident report through the application of the Human Factors Analysis and Classification System (Wiegmann & Shappell, 2003). Hofstede’s (1991 & 2001) cultural dimensions draw a clear picture of the attributable patterns of human errors based on cultural differences. As a result it is necessary to develop a better understanding of the differences in attribution of accident causes and contributory factors across cultures to promote both aviation safety and international cooperation for accident investigation will be achieved. Furthermore, when suggesting safety enhancements resulting from accident investigations it needs to be noted that the same remedy may not work in different cultures. Remedial actions must be 'culturally congruent'. This process starts with understanding the cultural factors at work in the accident investigation process itself.Item Open Access Investigating accidents related to errors of aeronautical decision-making in flight operations(2010-09-16T00:00:00Z) Li, Wen-Chin; Harris, Don; Li, Lun-Wen; Hsu, Yueh-Ling; Wang, ThomasAeronautical decision-making (ADM) is defined by the FAA (1991) as ‘a systematic approach to the mental process used by aircraft pilots to consistently determine the best course of action in response to a given set of circumstances’. Jensen and Benel (1977) found that decision errors contributed to 35% of all nonfatal and 52% of all fatal general aviation accidents in the United States. Diehl (1991) proposed that decision errors contributed to 56% of airline accidents and 53% of military accidents. This research analyzes 51 accident reports obtained from ROC Aviation Safety Council (ASC) published between 1999 and 2008. Each accident report was independently analyzed using the Human Factors Analysis and Classification System (HFACS) framework (Weigmann and Shappell, 2003). The presence or the absence of each HFACS category was evaluated from the narrative of each accident report. Statistical relationships linking fallible decisions in upper management were found to directly affect supervisory practices, thereby creating the psychological preconditions for unsafe acts and hence indirectly impairing the performance of pilots’ decision-making. It was observed that 68% of accidents in this sample included a decision error. The results show clearly defined, statistically-described paths with pre-cursors to decision errors at both the immediately adjacent and also higher levels in the organization. This study provides an understanding, based upon empirical evidence, of how actions and decisions at higher managerial levels in the operation of commercial aircraft result in decision errors on the flight deck and subsequent accidents. To reduce the accident rate resulting from decision errors in flight operations the ‘paths to failure’ relating to these organizational and human factors issues must be addressed.Item Open Access A misjudged approach to a high accident rate : exploration of accident causes and instructor decisons relating to inexperienced glider pilots(Cranfield University, 2009-02) Jarvis, Stephen; Harris, DonVery little research has focussed on inexperienced pilots and there is a notion in literature and popular texts that such pilots are one of the safest groups. Despite this, ‘early-solo’ UK glider pilots were found to have a higher accident rate than any other group. Research was conducted in order to investigate the issues surrounding this. It was identified that accidents sustained by these pilots tended to be initiated by events in the approach and landing phases of fight, and caused by misjudgement of the approach path and landing flare. Most accidents to more experienced pilots were found to be different in all respects. It was subsequently found that instructors believed the highest accident likelihood to be associated with more experience pilots, in line with literature. It was also found that instructors wrongly believed that the ‘approach’ phase was the least likely in-flight phase to be associated with accident causes for low-hours pilots. Critical Incident Technique was used to investigate instructor decisions with regard to sending pilots solo. An initial model of the decision process was put forward. It was found that, with one critical exception, when events occurred on assessment flights that were similar to causal accident factors (from the accident analysis), instructors disallowed solo flight. An absence of potential accident factors was apparently insufficient to allow solo flight by itself; instructors required further evidence in order to confirm that students were ready to fly alone. Exceptionally, pilot performance in terms of the approach path did not appear to be a critical factor when instructors considered disallowing solo flight, highlighting a possible gap in the instructor decision process. It was recommended that further research be conducted to validate and extend the decision model, and that the approach phase be focussed upon more in both training and assessment.Item Open Access Modelling naturalistic decision making using neural networks(2000-01) Duggan, S.; Harris, DonThis thesis describes two studies conducted within a naturalistic decision making paradigm. Study One examines the choice of university for master level education. This decision is presented as a consequential choice decision task. Students, who had been offered placements at Cranfield University for the 1998/99 term, participated in this research. Factors influencing the participant’s decision to attend or not to attend Cranfield were collected with a questionnaire specifically designed for this purpose. The final data set contained 267 questionnaires. Study two describes a decision where a disruptive passenger threatens a hypothetical flight. Sixty-five professional members of flight crew participated in a series of semi-structured telephone interviews during which they described their decision-making process for dealing with this situation. This decision process is presented as a pattern-matching task. Artificial neural networks were used to model the decision on the basis of the input variables (questionnaire items in study one and interview variables in study two) undertaken to produce an empirically verifiable model of the participants decision making process. Cross-validation of the results showed that decision outcomes could be predicted on the basis of the models. The cross-validation results, in terms of classifications are compared with discriminant function analysis classification results, to determine if neural networks or discriminant function analysis is a more appropriate form of analysis for modelling a naturalistic decision. Both studies show that neural networks outperformed the discriminant function analysis results in terms of classification. Press’s Q analyses also support this finding. It is suggested that neural networks may be a viable way of modelling naturalistic decisions.Item Open Access Pilot error and its relationship with higher organizational levels: HFACS analysis of 523 accidents(Aerospace Medical Association, 2006-10) Li, Wen-Chin; Harris, DonIntroduction: Based on Reason’s model of human error, the Human Factors Analysis and Classification System (HFACS) was developed as an analytical framework for the investigation of the role of human error in aviation accidents. However, there is little empirical work that formally describes numerically the relationship between the levels and components in the model (the organizational structures, psychological pre-cursors of errors, and actual errors). Method: This research analyzed 523 accidents in the Republic of China (ROC) Air Force between 1978 and 2002 through the application of the HFACS framework. Results: The results revealed several key relationships between errors at the operational level and organizational inadequacies at both the immediately adjacent level (preconditions for unsafe acts) and higher levels in the organization (unsafe supervision and organizational influences). Conclusions: This research lends support to Reason’s model that suggests that active failures are promoted by latent conditions in the organization. Fallible decisions in upper command levels were found to directly affect supervisory practices, thereby creating preconditions for unsafe acts, and hence indirectly impaired performance of pilots, leading to accidents. The HFACS framework was proven to be a useful tool for guiding accident investigations and developing accident prevention strategies.