The Development of a Scenario-based Human-machine-environment-procedure (HMEP) the Classification Scheme for the Root Cause Analysis of Aviation Accidents

Abstract

The current study analyzed the root causes of 22 helicopter accidents/incidents that occurred between 1998 and 2019. Each root cause was coded using three commonly used classification models in aviation: HFACS, ATSB, and IATA. The objective was to identify recurring factors for better targeting of future prevention strategies. Since none of the existing models could summarize the root causes of 22 occurrences effectively, a scenario-based human-machine-environment- procedure (HMEP) classification scheme was proposed. This scheme utilised organizational influences, people management, technical failure, procedure and document, and environment as the first-layer subcategories. The HMEP scheme was applied to the analysis and coding of 4 helicopter accidents in the USA, as reported by the NTSB. The HMEP scheme revealed that NTSB had identified a significantly greater number of root causes in the areas of manufacturer design, manufacturing and documentation. Overall, HMEP can be used to guide the data collection during accident investigation and subsequently to aggregate aviation accidents to derive recurring factors and efficiently compare accident patterns.

Speaker

Prof. Chia-Fen Chi received her PhD in Industrial Engineering from State University of New York at Buffalo and joined National Taiwan University of Science and Technology in 1990. She serves as the President of the Ergonomics Society of Taiwan from 2003 to 2005 and was a visiting professor at the Hong Kong University of Science and Technology in 2016. From 2008 to 2015, she held various positions including Department Chair, Associated Dean, Dean of International Affairs, and the Director of the Center for teaching & learning.  Since 2009, she has been an editorial board member for the International Journal of Industrial Ergonomics, and since 2015, for Applied Ergonomics. Additionally, she served as the Vice Chairwoman for the Aviation Safety Council from 2016 to 2019 and has been a board member of the Taiwan Transportation Safety Board and the Consumer Protection Committee since 2019 and 2022, respectively. Prof. Chi’s research interests include Accident Analysis and visual Fatigue. Some of her recent publication titles include: 

• Classification Scheme for Root Cause and Failure Modes and Effects Analysis (FMEA) of Passenger Vehicle Recalls. 
• The development of a safety management system (SMS) framework based on root cause analysis of disabling accidents.