Cognitive failure analysis for aircraft accident investigation

The present studies were undertaken to investigate the applicability of an information processing approach to human failure in the aircraft cockpit. Using data obtained from official aircraft accident investigation reports, a database of accidents and incidents involving New Zealand civil aircraft between 1982 and 1991 was compiled. In the first study, reports were coded into one of three error stages proposed by Nagel (1988) and for the presence of any of 61 specific errors noted by Gerbert and Kemmler (1986). The importance of decisional factors in fatal crashes was noted. Principal components analysis suggested the presence of five different varieties of human failure. In the second study, a more detailed error taxonomy derived from the work of Rasmussen (1982) was applied to the data. Goal selection errors emerged as the most frequent kind of cognitive error in fatal accidents. Aircraft accident reports can be a useful source of information about cognitive failures if probed with an appropriate, theoretically-based, analysis of information processing errors. Such an approach could provide the accident investigators with a useful tool, and lead to a more complete understanding of human error in aviation.