Improving The Representation Of Human Error In The Use Of The Flight Crew Human Factors Integration Tool

In May 1996, the FAA announced a new and innovative approach to reach a goal of "zero accidents," known as the Global Analysis and Information Network (GAIN). This would be a privately owned and operated international information infrastructure for the collection, analysis, and dissemination of aviation safety information, that would involve the use of a broad variety of worldwide aviation data sources, coupled with comprehensive analytical techniques, to facilitate the identification of existing and emerging aviation safety problems. A major component of the GAIN approach is the application of innovative analysis capabilities to identify the types of human error that contribute to aviation accidents and incidents in order to develop prevention strategies. As part of its Flight Crew Accident and Incident Human Factors Project, the FAA Office of System Safety has developed a new process that uses a prototype website-based Integration Tool (IT) to access, integrate, and analyze flight crew human factors data relevant to safety. In September 1996, the FAA Office of System Safety funded the National Center of Excellence for Aviation Operations Research to initiate a program of research to provide human factors support for the GAIN concept. The first phase of this research performed a technical review of the results achieved to date by the flight crew human factors project and developed a strategic plan to lay the foundations for a sound scientific approach to the analysis of human factors issues within the framework of the GAIN concept. This report documents follow-on research activities directed at improving the representation of human error within the Integration Tool and developing better ways to identify error reduction strategies. While the current version of the IT performs a useful function by identifying specific records in a large database that meet certain criteria, and then allowing the user to display the contents of the database records for further review, its usefulness in analyzing the underlying causes of flight crew error and hence identifying strategies to reduce the frequency of occurrence of those errors is presently limited by several constraints