individual
What campus are you from?
Daytona Beach
Authors' Class Standing
Max Zuieback, Senior
Lead Presenter's Name
Max Zuieback
Faculty Mentor Name
Flavio Antonio Coimbra Mendonca
Abstract
The Human Factors Analysis and Classification System (HFACS) is an accident investigation framework designed to identify both the direct actions of frontline personnel and the organizational conditions that contribute to accidents. It examines human error at four levels: unsafe acts of operators, preconditions for unsafe acts, unsafe supervision, and organizational influences. By tracing factors across these tiers, investigators can reveal how deeper systemic weaknesses allow errors to result in failures in the cockpit. This study applies HFACS to American Airlines Flight 1420, which crashed during a landing at Little Rock National Airport in 1999. The flight crew attempted to land in severe thunderstorms after a long day of flying, and the aircraft overran the runway, resulting in fatalities and injuries. While the pilots decision to proceed with the approach in hazardous weather represented a surface level unsafe act, HFACS highlights additional contributing conditions. Pilot fatigue, poor crew resource management, and stress from time pressure created preconditions for error. Inadequate supervisory emphasis on weather avoidance and runway overrun risks further compounded the problem. At the organizational level, scheduling practices, insufficient training for severe-weather operations and equipment, and a culture that prioritized on-time performance over safety. Applying HFACS to Flight 1420 demonstrates that aviation accidents rarely result from isolated mistakes by a flight crew but they often reflect latent conditions originated in organizational issues and poor safety culture. Recognizing and addressing these factors is essential to developing safety recommendations that prevent future accidents.
Did this research project receive funding support from the Office of Undergraduate Research.
No
HFACS Framework Applied to American Airlines Flight 1420
The Human Factors Analysis and Classification System (HFACS) is an accident investigation framework designed to identify both the direct actions of frontline personnel and the organizational conditions that contribute to accidents. It examines human error at four levels: unsafe acts of operators, preconditions for unsafe acts, unsafe supervision, and organizational influences. By tracing factors across these tiers, investigators can reveal how deeper systemic weaknesses allow errors to result in failures in the cockpit. This study applies HFACS to American Airlines Flight 1420, which crashed during a landing at Little Rock National Airport in 1999. The flight crew attempted to land in severe thunderstorms after a long day of flying, and the aircraft overran the runway, resulting in fatalities and injuries. While the pilots decision to proceed with the approach in hazardous weather represented a surface level unsafe act, HFACS highlights additional contributing conditions. Pilot fatigue, poor crew resource management, and stress from time pressure created preconditions for error. Inadequate supervisory emphasis on weather avoidance and runway overrun risks further compounded the problem. At the organizational level, scheduling practices, insufficient training for severe-weather operations and equipment, and a culture that prioritized on-time performance over safety. Applying HFACS to Flight 1420 demonstrates that aviation accidents rarely result from isolated mistakes by a flight crew but they often reflect latent conditions originated in organizational issues and poor safety culture. Recognizing and addressing these factors is essential to developing safety recommendations that prevent future accidents.