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Human Factors: The Last Frontier of Aviation Safety?

Article in International Journal of Aviation Psychology · October 2004

DOI: 10.1207/s15327108ijap1404_1

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 This is a pre-publication draft, it may not include changes made prior to publication.
For the final version of this paper, refer to:
Hobbs, A. (2004). Human factors, the last frontier of aviation safety? International Journal of Aviation
Psychology, 14(4), 335–341

Human factors, the last frontier of aviation safety?

Alan Hobbs

San Jose State University

1
 This is a pre-publication draft, it may not include changes made prior to publication.
For the final version of this paper, refer to:
Hobbs, A. (2004). Human factors, the last frontier of aviation safety? International Journal of Aviation
Psychology, 14(4), 335–341

Abstract

It has been claimed that human factors emerged as a significant challenge to flight safety

only after the frequency of technical failures diminished in the early years of aviation. An

examination of 100 aircraft accidents that occurred between 1921 and 1932 revealed that

pilot factors contributed to most accidents, while technical failures contributed to

significantly fewer accidents. Accident data from World War 1 also show this pattern.

The results suggest that human factors have been the primary flight safety issue since the

early days of aviation.

2
 This is a pre-publication draft, it may not include changes made prior to publication.
For the final version of this paper, refer to:
Hobbs, A. (2004). Human factors, the last frontier of aviation safety? International Journal of Aviation
Psychology, 14(4), 335–341
Human factors, the last frontier of aviation safety?

Human factors are widely identified as contributing to most aircraft accidents (Boeing,

2003; Hawkins, 1993). A view expressed widely in the safety literature is that human

factors have not always had such a primary place in accident causation, but emerged as a

residual problem as aircraft became more reliable (ICAO, 1984; Nagel, 1988). In line

with this view, the human factor is sometimes referred to as the “last frontier” of aviation

safety.

The hypothesized trends of human and airworthiness factors in accidents have been

expressed in a widely-reproduced diagram (figure. 1). At the left of the figure can be seen

the supposed historical period in which more accidents were caused by technical failures

than by human factors. As time passes however, the situation is reversed as technical

failures become less common, and human factors take on more importance.

INSERT FIGURE 1 ABOUT HERE

The last frontier view of human factors is not restricted to the aviation industry (Park

1987). According to Czaja (1997) accident data from a range of industries suggest that

the incidence of human error has risen dramatically in recent years. Hollnagel (1993)

considers the accident record in a range of settings, including nuclear, aerospace and

manufacturing industries. He notes that since the 1960s, there has been a general increase

in the percentage of system accidents attributed to human error. He considers the

3
 This is a pre-publication draft, it may not include changes made prior to publication.
For the final version of this paper, refer to:
Hobbs, A. (2004). Human factors, the last frontier of aviation safety? International Journal of Aviation
Psychology, 14(4), 335–341
possibility that increases in mechanical reliability have made errors more visible, but also

acknowledges that the trend may reflect other factors, such as changes in the focus of

investigations.

The Australian Federal Government has been investigating aircraft accidents since the

Air Navigation Act of 1920 came into force. In the first years after the act, investigations

were conducted by the Department of Defence, however for most of the 20th century

civilian agencies investigated accidents involving civil aircraft. The Australian Transport

Safety Bureau (ATSB) incorporates the former Bureau of Air Safety Investigation, and

maintains civil aviation accident records back to 1921, although aircraft accidents had

occurred in Australia before this date. In order to test the last frontier view, the

contributing factors that were cited in the earliest aircraft accident records were compared

with those in a sample of modern-day accident reports.

Method

Accounts of 100 aircraft accidents that had resulted in death or injury were obtained from

records maintained by the ATSB. The accidents spanned the period from March 1921 to

September 1932 and represented the earliest records maintained by the agency. In each

case a brief narrative summarized the circumstances of the accident and usually referred

to contributing factors.

4
 This is a pre-publication draft, it may not include changes made prior to publication.
For the final version of this paper, refer to:
Hobbs, A. (2004). Human factors, the last frontier of aviation safety? International Journal of Aviation
Psychology, 14(4), 335–341
Contributing factors were placed into six categories following the system used by the

Bureau of Air Safety Investigation until the early 1990s. The factor categories were:

pilot, airframe (including flight controls), engine, terrain, other personnel (personnel

other than flight crew, including passengers and people on the ground), and weather.

Where necessary, more than one factor could be associated with each accident. As a

reliability check, an independent coder also assigned factors to the accidents. Inter-rater

agreement between the primary coder and the check coder was assessed for each

contributing factor using Cohen’s kappa.

Contributing factors for a sample of modern-day accidents were obtained from a

statistical report on fatal aviation accidents in Australia (Bureau of Air Safety

Investigation, 1996). All of the modern-day accidents occurred to aircraft with maximum

takeoff weight less than 5,700 kg (12,540 pounds).

Results

Fifty six of the historical accidents resulted in fatalities, the remaining accidents involved

injuries but no fatalities. Sixteen of the accident reports contained insufficient detail to

identify contributing factors. These cases were excluded, leaving 84 accidents. For five of

the contributing factors, good to excellent levels of inter-rater agreement were obtained

according to guidelines contained in Fleiss (1981). These factors and the corresponding

values of kappa were as follows: pilot (0.75), other personnel (0.81), weather (0.71),

airframe (0.82), engine (0.84). For the terrain factor, kappa was 0.34, indicating a

relatively poor level of inter-rater agreement. Compared to the primary coder, the check

5
 This is a pre-publication draft, it may not include changes made prior to publication.
For the final version of this paper, refer to:
Hobbs, A. (2004). Human factors, the last frontier of aviation safety? International Journal of Aviation
Psychology, 14(4), 335–341
coder identified terrain as a factor in fewer accidents. Given that terrain as an accident

factor was not the focus of this study, this level of disagreement was considered to be

tolerable. With the single exception of terrain, the factor profiles generated by the two

coders were very similar. The results presented from this point forward are those obtained

from the primary coder.

In 57 cases (68%), the narrative referred to pilot factors as having contributed to the

accident. In some cases, the report contained general statements such as “poor judgment”

while in other cases the nature of the pilot’s involvement could be determined more

precisely, such as low flying or attempting to takeoff toward obstructions.

The next most frequent factors, each accounting for 12 (14%) of the accidents, were

engine failures and terrain. Typical terrain factors were animals, vehicles or other

obstructions present in the landing or takeoff area. As previously noted, terrain was the

only factor where the two coders diverged significantly. Weather was a factor in 10

(12%) of the accidents. Australia’s first major airline accident was one of these cases.

The aircraft, with eight people on board, disappeared without trace on a Sydney -

Melbourne flight in May 1931. The inquiry concluded that unexpected headwinds had

contributed to the loss of the aircraft1. Personnel other than the pilot featured in seven

(8%) of the accidents. The earliest accident in the database was considered to be such a

case. It occurred to an Avro 504 near the town of Pithara, Western Australia in March

1921. The report stated “Doubt as to cause, but suspicion of interference by passengers

6
 This is a pre-publication draft, it may not include changes made prior to publication.
For the final version of this paper, refer to:
Hobbs, A. (2004). Human factors, the last frontier of aviation safety? International Journal of Aviation
Psychology, 14(4), 335–341
with pilot”. The pilot and one of the passengers died. Figure 2 presents the contributing

factors involved in the historical accidents alongside the factors assigned to the modern-

day accidents.

INSERT FIGURE 2 ABOUT HERE

Discussion

The results of this study do not support the last frontier view of human factors. In

Australian civil aviation accidents of the 1920s and early 1930s, just as in the present,

pilot factors featured more frequently than aircraft factors. Nevertheless, the mix of

factors is not identical in the two eras. Engine and airframe failures did contribute to a

greater proportion of the historical accidents compared to the modern day ones, however

not to the extent implied by figure 1.

The current findings are consistent with statistical reports from World War 1. According

to Wilmer (1935/1979) of the British aviators who lost their lives in the first year of that

conflict, 90% did so due to “individual deficiencies”, 8% to a defect with their aircraft,

while only 2% were killed by enemy action. Recent research (Jones, 2003) has suggested

that Wilmer’s statistics may understate the percentage of deaths due to enemy action,

nevertheless the importance of the human factor is borne out by other analyses of WW1

losses. Anderson (1918) examined British Naval Aviation training accidents during that

war. He found that less than 1% of accidents were attributed to aircraft defects, whereas

1
Nearly 30 years after its disappearance, the wreckage of the “Southern Cloud” was found in a remote area

7
 This is a pre-publication draft, it may not include changes made prior to publication.
For the final version of this paper, refer to:
Hobbs, A. (2004). Human factors, the last frontier of aviation safety? International Journal of Aviation
Psychology, 14(4), 335–341
91% were associated with pilot factors, most commonly “error of judgment”, but also

“loss of head” and “brain fatigue”. On the German side, the situation was similar. Selz

(1919) analyzed 300 German air force flight school accident reports from the year 1918.

He identified that 66% of the accidents involved factors associated with the individual.

Other factors included terrain in 41% of cases, wind (14%), engine or airframe failures

(10%) and the presence of other aircraft (9%). Early American civil aviation statistics

also indicate that compared with technical failures, human failures were a more common

cause of accidents. The US Department of Commerce (1931) reported that of

approximately 4600 miscellaneous aircraft accidents in the three year period 1928-1930,

57% involved personnel errors, 17% involved power-plant failures, 9% involved airplane

failures, 6% involved terrain and 4% involved weather. It should be noted that in

contrast to the Australian Government and other agencies, the US Department of

Commerce assigned only one “cause” per accident. The percentage of accidents

associated with each causal factor might have been greater had multiple causes been

considered for each accident.

The accident record from WWI to the present suggests that the last frontier view of

human factors is little more than a persistent myth. Nevertheless, it is possible that the

mass-produced aircraft in use from WWI onwards represented mature technologies,

further to the right on figure 1 than we might expect, and that the period in which

airworthiness factors were the prime contributors to accidents had occurred at an earlier

time. Yet this presumed era can only be pushed so far to the left of the graph until we run

of the Snowy Mountains between Sydney and Melbourne.

8
 This is a pre-publication draft, it may not include changes made prior to publication.
For the final version of this paper, refer to:
Hobbs, A. (2004). Human factors, the last frontier of aviation safety? International Journal of Aviation
Psychology, 14(4), 335–341
out of aviation history. Even the earliest authorities on this subject point to a period in the

development of aviation when pilot factors were not as important as airworthiness issues.

Although Anderson (1918) was writing at a time when the history of powered flight

covered a mere 15 years, he noted “In the early days of flying there were necessarily

many accidents, owing firstly and unfortunately to structural weaknesses in the

aeroplanes, and secondly to the fact that pioneer pilots … were unacquainted with many

of the factors governing aerial navigation” (p. 51). If indeed the situation shown at the

left of figure 1 did exist, it appears to have been a brief and steep learning curve in the

first few years of powered flight. Certainly, prior to the outbreak of the Great War in

Europe, mechanical failures and the stalling tendency of early Wright aircraft together

accounted for more than half of the 11 fatal accidents to aircraft of the United States

Army Signal Corps (Grant, 2002).

Finally, it must be acknowledged that a conclusion of “human error” is never an adequate

explanation for an accident. Although the action of a person may be the immediate

precursor of an accident, a mix of task, equipment and environmental factors may also be

involved (Hawkins, 1993). Many of the “pilot errors” considered in this study,

particularly those in historical times, may have reflected wider system deficiencies such

as the handling characteristics of the aircraft, the quality of training, and the challenges of

operating from rudimentary airfields. In addition, while there have been historical cases

of aircraft whose early operational life was plagued by disastrous technological failures

(see Job [1995] for the story of the Comet) these tragic exceptions do not indicate that the

human element was less important then than it is now. Although the nature of aviation

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 This is a pre-publication draft, it may not include changes made prior to publication.
For the final version of this paper, refer to:
Hobbs, A. (2004). Human factors, the last frontier of aviation safety? International Journal of Aviation
Psychology, 14(4), 335–341
changed dramatically over the first 100 years of powered flight, the primary place of

people as determinants of safety remained remarkably constant.

Just as aviation revolutionized the 20th century, technological advances will change the

lives of future generations. If the introduction of such technologies bears any

resemblance to the early years of aviation, we can expect that human performance issues

will be the key to safety and reliability from the beginning.

10
 This is a pre-publication draft, it may not include changes made prior to publication.
For the final version of this paper, refer to:
Hobbs, A. (2004). Human factors, the last frontier of aviation safety? International Journal of Aviation
Psychology, 14(4), 335–341
References

Anderson, G. E. (1918). Aeroplane accidents. Journal of the Royal Navy Medical

Service, 1, 51-68.

Boeing. (2003). Statistical summary of commercial jet aircraft accidents. Seattle WA:

Author.

Bureau of Air Safety Investigation. (1996). Human factors in fatal light aircraft accidents.

Canberra, Australian Capital Territory: Author.

Czaja, S. J. (1997). Systems design and evaluation. In G. Salvendy (Ed.), Handbook of

human factors and ergonomics, (2nd ed., pp. 17-40). New York: John Wiley & Sons.

Fleiss, J. L. (1981). Statistical methods for rates and proportions. New York: Wiley.

Grant, J. (2002). Sacrificed to the gods of progress. The first US military aviation

accidents. Air Enthusiast, Sept-Oct, 16-20.

Hawkins, F. H. (1993). Human factors in flight. Aldershot, UK: Ashgate.

Hollnagel, E. (1993). Human reliability analysis: Context and control. London:

Academic.

11
 This is a pre-publication draft, it may not include changes made prior to publication.
For the final version of this paper, refer to:
Hobbs, A. (2004). Human factors, the last frontier of aviation safety? International Journal of Aviation
Psychology, 14(4), 335–341

International Civil Aviation Organization (1984). Accident prevention manual. Montreal,

Canada: Author.

Job, M. (1995). Air disaster (Vol 1.). Canberra, Australian Capital Territory: Aerospace

Publications.

Jones, D. R. (2003). Theodore Lyster, Isaac Jones and the 90-8-2 statistics in World War

1. [Abstract]. Aviation, Space and Environmental Medicine, April, 474.

Nagel, D. C. (1988). Human error in aviation operations. In E. L. Wiener and D. C. Nagel

(Eds.), Human factors in aviation (pp. 263-303). San Diego: Academic Press.

Park, K.S. (1987). Human reliability: Analysis, prediction and prevention of human

errors. Amsterdam: Elsevier.

Selz, O. (1919). Über den anteil der individuellen eigenschaften der flugzeugführer und

beobachter an fliegerunfällen. Eine psychologische untersuchung auf unfallstatistischer

grundlage. [The role of individual characteristics of pilots and observers in aircraft

accidents. A psychological investigation of accident statistics.] Zeitschrift für

Angewandte Psychologie, 15, 254-296.

12
 This is a pre-publication draft, it may not include changes made prior to publication.
For the final version of this paper, refer to:
Hobbs, A. (2004). Human factors, the last frontier of aviation safety? International Journal of Aviation
Psychology, 14(4), 335–341
U.S. Department of Commerce. (1931). Civil aircraft accident report on miscellaneous

flying for the last six months of 1930. Air Commerce Bulletin, 2, (21), 545-565.

Wilmer, W. H. (1979). The early development of aviation medicine in the United States.

Aviation, Space and Environmental Medicine, May, 459-467. (Originally published in

1935 in The Military Surgeon, 77, 115-135).

Acknowledgements

Russell Sibbison, formerly of the Bureau of Air Safety Investigation, deserves

recognition for preserving the early Australian accident records. He also performed the

independent check coding. I am grateful to Professor Winfried Hacker of the Technical

University of Dresden, who directed me towards the early literature on aircraft accidents.

13
 This is a pre-publication draft, it may not include changes made prior to publication.
For the final version of this paper, refer to:
Hobbs, A. (2004). Human factors, the last frontier of aviation safety? International Journal of Aviation
Psychology, 14(4), 335–341

Human causes
Relative proportion of accident causes

Machine causes

Time

Figure 1. The supposed relative importance of human and machine factors as causes of
accidents throughout the history of aviation (International Civil Aviation Organization,
1984).

14
 This is a pre-publication draft, it may not include changes made prior to publication.
For the final version of this paper, refer to:
Hobbs, A. (2004). Human factors, the last frontier of aviation safety? International Journal of Aviation
Psychology, 14(4), 335–341

Pilot

Weather

Other personnel

Terrain

Engine

Airframe

0 10 20 30 40 50 60 70 80
Percentage of accidents involving factor

Modern-day accidents Historical accidents

Figure 2. Broad contributing factors involved in modern-day and historical accidents in

Australia.

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