Is this project an undergraduate, graduate, or faculty project?
Undergraduate
Project Type
group
Campus
Daytona Beach
Authors' Class Standing
Ashley Perez-Galvan, Senior
Lead Presenter's Name
Ashley Perez-Galvan
Lead Presenter's College
DB College of Aviation
Faculty Mentor Name
Dr. Flavio Antonio Coimbra Mendonca
Abstract
Applying the HFACS Framework: A Case Study of Air Florida Flight 90 Abstract This study applies the Human Factors Analysis and Classification System (HFACS), a widely used safety framework for identifying human and organizational contributors to accidents to examine the crash of Air Florida Flight 90 crash on January 13, 1982. The accident occurred shortly after takeoff from Washington National Airport during severe winter weather, when the aircraft failed to gain sufficient lift and impacted a bridge before entering the Potomac River. The goal this analysis is to understand how multiple layers of human and organizational factors contributed to this accident. The findings indicatethat unsafe acts, including improper deicing decisions, failure to adhere to procedures, and continuation of the takeoff despite abnormal aircraft performance, played a major role in the crash. These actions were influenced by preconditions such as adverse weather, operational pressure due to delays, poor communication between crew members, and limited experience with winter operations. At a broader level, organizational influences, including inadequate training programs for cold-weather operations, limited emphasis on standardization and procedural compliance, and operational pressures associated with maintaining schedules, further shaped the conditions that contributed to the accident. At higher levels of the HFACS framework, issues related to inadequate supervision and lack of proper training further contributed to the accident sequence. Overall, this study demonstrates that the Air Florida Flight 90 accident did not occur because of a single error but rather emerged from a chain of interconnected contributing factors across multiple levels of the organization. By applying HFACS, the analysis moves beyond attributing the event to individual actions and instead reveals how failures across preconditions, supervision, and organizational influences aligned. This system-level understanding provides valuable insight into how safety can be improved through stronger training, more effective communication, enhanced oversight, and consistent adherence to procedures.
Did this research project receive funding support (Spark, SURF, Research Abroad, Student Internal Grants, Collaborative, Climbing, or Ignite Grants) from the Office of Undergraduate Research?
No
Included in
Aviation Safety and Security Commons, Human Factors Psychology Commons, Management and Operations Commons
Applying the HFACS Framework: A Case Study of Air Florida Flight 90
Applying the HFACS Framework: A Case Study of Air Florida Flight 90 Abstract This study applies the Human Factors Analysis and Classification System (HFACS), a widely used safety framework for identifying human and organizational contributors to accidents to examine the crash of Air Florida Flight 90 crash on January 13, 1982. The accident occurred shortly after takeoff from Washington National Airport during severe winter weather, when the aircraft failed to gain sufficient lift and impacted a bridge before entering the Potomac River. The goal this analysis is to understand how multiple layers of human and organizational factors contributed to this accident. The findings indicatethat unsafe acts, including improper deicing decisions, failure to adhere to procedures, and continuation of the takeoff despite abnormal aircraft performance, played a major role in the crash. These actions were influenced by preconditions such as adverse weather, operational pressure due to delays, poor communication between crew members, and limited experience with winter operations. At a broader level, organizational influences, including inadequate training programs for cold-weather operations, limited emphasis on standardization and procedural compliance, and operational pressures associated with maintaining schedules, further shaped the conditions that contributed to the accident. At higher levels of the HFACS framework, issues related to inadequate supervision and lack of proper training further contributed to the accident sequence. Overall, this study demonstrates that the Air Florida Flight 90 accident did not occur because of a single error but rather emerged from a chain of interconnected contributing factors across multiple levels of the organization. By applying HFACS, the analysis moves beyond attributing the event to individual actions and instead reveals how failures across preconditions, supervision, and organizational influences aligned. This system-level understanding provides valuable insight into how safety can be improved through stronger training, more effective communication, enhanced oversight, and consistent adherence to procedures.