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Aircraft accidents are generally the end result of a number of latent conditions arising in the organizational and managerial sectors. These conditions frequently permit or even motivate the unsafe acts by the flight crew. The Human Factors Analysis and Classification System (HFACS) is a system safety tool for the investigation and analysis of underlying human causal factors in aircraft accidents. Using the HFACS framework, four researchers classified the human factors identified by the Brazilian Aeronautical Accidents Investigation and Prevention Center (CENIPA) during the investigation of a mishap(PR-AFA) that happened in Brazil in 2014. CENIPA argued that errors and violations by both pilots contributed to the accident. Results of this study indicate that inappropriate decision making by upper-level management had an adverse effect on the performance of the PR-AFA pilots. Most importantly, safety strategies to mitigate unsafe acts by crew members should receive significant attention from the highest managerial levels of the organization.


This paper was accepted for publication at the International Symposium on Aviation 2017

Mendonca, F. A., Huang, C., & Keller, J. (2017). A Case Study Using the Human Factors Analysis and Classification System Framework. 19th International Symposium on Aviation Psychology, 113-118.