Jul 2026· International Journal of Health Engineering and Technology· 0 citations· 12 references
Abstract
Aviation safety depends heavily on precise interaction between pilots and Air Traffic Control (ATC), yet failures within that interaction remain a recurring contributing factor in civil aviation accidents and incidents. This study aims to identify and analyze patterns of ATC-related failure across a set of historically significant aviation accidents and incidents, and to derive implications for global aviation safety improvement. A qualitative literature review design was employed, drawing on official investigation reports, safety databases, and peer-reviewed journal articles concerning five representative events—Tenerife (1977), Zagreb (1976), Uberlingen (2002), Linate (2001), and Jakarta Halim (2016)—synthesized through directed content analysis guided by the Human Factors Analysis and Classification System (HFACS) and Reason's Swiss Cheese Model. The findings reveal that communication breakdowns, non-standard phraseology, controller work overload, limitations in surveillance technology, and weak inter-unit coordination constitute recurring causal patterns behind ATC-related accidents/incidents. The study concludes that enhancing aviation safety requires stricter phraseology standardization, strengthened Crew/Team Resource Management training for controllers, and sustained investment in surface radar and conflict-alert technologies.
This study analyzes the contribution of legal aspects and human factors to civil aviation accidents and incidents associated with Air Traffic Control (ATC) services. Utilizing a qualitative descriptive literature review methodology, this research conducts a comparative evaluation of the Halim Perdanakusuma runway collision accident (2016) and the Austin-Bergstrom near-miss incident (2023). The juridical framework is anchored in Indonesian Aviation Law No. 1 of 2009 and International Civil Aviation Organization (ICAO) standards, while systemic analysis applies the SHELL model and HFACS taxonomy. The results indicate that expectation bias and operational deviations from standardized radio-telephony phraseology are the primary drivers of cognitive and procedural failures. Weak supervisory monitoring and the absence of integrated surface surveillance technology further compromised the systemic defenses in both cases. In conclusion, runway accidents and incidents do not result from isolated operator errors but stem from interactive mismatches within the sociotechnical system. Enforcing legal compliance with standard safety procedures and accelerating the deployment of surface detection radar are critical mitigation strategies to prevent future occurrences.
Freshal Fitran, Elfi Amir, Rany Adiliawijaya et al.· International Journal of Hea...· 0 citations
Aviation Safety is highly dependent on effective communication between Air Traffic Controllers (ATCs) and pilots. Communication is a vital component of the Air Traffic Services (ATS) system, serving to prevent collisions, regulate air traffic flow, and provide essential safety information. However, data from the International Civil Aviation Organization (ICAO) and Indonesia's National Transportation Safety Committee (KNKT) indicate that approximately 60–70% of aviation incidents are caused by human error, with Communication Breakdown being one of the most significant contributing factors. In Indonesia, the rapid increase in air traffic following the COVID-19 pandemic has heightened the risk of miscommunication, particularly during peak traffic periods and emergency situations. This study aims to comprehensively analyze the factors contributing to Communication Breakdown, its impact on Aviation Safety, and evidence-based mitigation strategies identified in the literature. The study employed a literature review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) approach. A total of 10 nationally accredited SINTA 3–6 journals published between 2018 and 2025, along with KNKT reports and ICAO documents, were analyzed thematically. The findings identified four dominant factors contributing to Communication Breakdown: the use of non-standard Phraseology, English language proficiency below ICAO Level 4, ATC workload and fatigue, and technical factors such as frequency interference and stuck microphone. The consequences of miscommunication include loss of separation, runway incursion, near miss incidents, and the potential for fatal accidents. Recommended mitigation strategies include strengthening ICAO English Proficiency training, implementing Controller–Pilot Data Link Communications (CPDLC)/Data Link technology, enforcing readback-hearback procedures, adopting Crew Resource Management (CRM) and Threat and Error Management (TEM), and improving fatigue risk management for ATCs. This study is expected to serve as a reference for AirNav Indonesia and aviation education institutions in enhancing communication standards to support Aviation Safety in Indonesia.
Rany Adiliawijaya Putriekapuja, Elfi Amir, Faktor Manusia et al.· Jurnal Ilmiah Dan Karya Maha...· 0 citations
Flight safety is greatly influenced by the effectiveness of communication between pilots and Air Traffic Controllers (ATC). In many aircraft accidents and incidents, communication failures, readback/hearback errors, the use of non-standard phraseology, and limited situational awareness are significant contributing factors. This research aims to analyze the literature related to the relationship between pilot-ATC communication and aircraft accident and incident incidents, especially in the context of Air Traffic Services Safety Investigation. The method used was literature review with stages of identification, selection, analysis, and synthesis of literature from investigation reports, scientific articles, and international aviation safety documents. The results of the study show that unclear communication can trigger runway incursion, loss of separation, clearance errors, and delayed decision-making. Case studies such as the Tenerife Airport Disaster show that a combination of miscommunication, operational pressures, weather, and technological limitations can develop into fatal accidents. The conclusion of this study emphasizes the importance of standardization of phraseology, improving human factors training, implementing readback/hearback discipline, and strengthening safety support systems in ATS operations.
Human factors remain one of the leading contributors to aviation accidents despite continuous advancements in aircraft technology and safety regulations. This study examined the critical role of human factors in aviation accident prevention, focusing on Crew Resource Management (CRM), Training and Competency Development, and Safety Culture among Aircraft Maintenance Technology (AMT) students, licensed aircraft mechanics, and on-the-job training (OJT) trainees at Indiana Aerospace University during the Academic Year 2025–2026. An explanatory sequential mixed-method research design was employed, integrating quantitative survey data with qualitative interview responses to provide a comprehensive understanding of maintenance-related human factors. A total of 90 respondents participated in the quantitative phase, while 10 participants were purposively selected for the qualitative inquiry. Descriptive statistics, including frequency, percentage, weighted mean, and ranking, were utilized to analyze quantitative data, whereas thematic analysis was applied to qualitative responses. The findings revealed that respondents strongly agreed on the critical importance of CRM, Training and Competency Development, and Safety Culture in preventing aviation accidents. Teamwork, communication, situational awareness, competency-based training, and organizational commitment to safety were consistently identified as essential elements for minimizing maintenance-related errors. However, the study also identified persistent challenges, including communication breakdowns, insufficient emphasis on human factors education, limited practical exposure, inadequate maintenance resources, ineffective shift turnovers, and unclear task allocation. These issues indicate the need for stronger integration of technical and non-technical competencies within aviation education and maintenance organizations. Based on the findings, an action plan emphasizing continuous human factors training, standardized communication protocols, simulation-based learning, and the promotion of a proactive safety culture was developed. The study contributes empirical evidence that supports curriculum enhancement, organizational safety initiatives, and evidence-based strategies for reducing maintenance-related human errors and strengthening aviation safety.
Brian Robinson, Lance Frederic Arcosa, Khazim Joseph Cagigas et al.· Journal of Advanced Studies...· 0 citations
Low-altitude aviation accidents can become fatal when pilots have little time or altitude to recover after an abnormal event. Fatal outcomes, however, are rarely explained by altitude alone: they often depend on how human, aircraft, environmental, and operational factors combine within the accident sequence. This study asks whether the structure of these documented factor combinations helps explain injury severity in U.S. low-altitude aviation accidents. The data comprise 11,639 low-altitude accidents with completed Findings investigations, drawn from the National Transportation Safety Board (NTSB) Aviation Accident/Incident Data System (AVALL) for 2013-2024; throughout, "Findings" denotes the NTSB's investigator-coded causal and contributing factors. The method represents Findings as a co-occurrence network that links factor types documented in the same investigation. The global network is constructed from a broader base of 23,847 completed-investigation accidents and is used only to define the co-occurrence structure; it is not the analytical sample. From this network, five accident-level measures describing the breadth and structure of each accident's documented failure pattern are added to a 43-covariate multinomial logit severity model. The five measures significantly improve model fit (LR(15) = 236.2, p < 10-6). The strongest fatal-severity associations are found for factor diversity, the number of distinct factor types involved (odds ratio OR = 1.46 per standard deviation, 95 % CI 1.31-1.64), and multi-source spread, the extent to which those factors span broader co-occurrence groups (OR = 1.37, 95 % CI 1.25-1.51). The multi-source-spread association is strong for fixed-wing aircraft (OR = 1.66) but weaker and not statistically significant for helicopters and agricultural Part 137 operations. We interpret these results as evidence that, among completed investigations of conventional low-altitude aviation accidents, fatal outcomes are associated with broader documented failure configurations, whereas some specialized operations may follow narrower, operation-specific fatality pathways. Because Findings are coded after investigation, the framework is a retrospective safety-review tool rather than a real-time warning or causal-prediction method.
Yang Cao, Tianlin Liu, Y. Zhou et al.· Accident Analysis and Preven...· 0 citations
The oil and gas industry is recognized as one of the highest-risk industrial sectors due to its complex operations, hazardous technologies, and intensive interactions among human, technical, and organizational factors. Despite the implementation of occupational safety management systems, fatal workplace accidents continue to occur, indicating that conventional investigations focusing solely on human error are insufficient to identify the underlying causes of incidents. This study aimed to identify patterns of human and organizational failures contributing to fatal workplace accidents at PT X during 2023 using the Human Factors Analysis and Classification System (HFACS). A descriptive-analytical research design with a retrospective approach was employed. The analysis focused on three fatal accident cases documented in 2023 using accident investigation reports, incident records, and occupational safety performance data. Each accident was systematically classified into four HFACS levels: unsafe acts, preconditions for unsafe acts, supervisory factors, and organizational influences. The findings revealed that all fatal incidents involved causal factors across the four HFACS levels. Organizational culture, operational processes, resource management, inadequate supervision, tools and technology, communication, coordination, and planning were identified as dominant latent conditions across all cases. At the operational level, decision errors and routine violations consistently emerged as the primary active failures directly contributing to fatal accidents. These results demonstrate that workplace fatalities are primarily driven by systemic organizational weaknesses rather than isolated worker errors. Therefore, strengthening safety culture, improving supervisory effectiveness, enhancing competency management, and reinforcing risk-based operational planning are essential strategies for preventing future fatal accidents and improving sustainable safety performance in the oil and gas industry.
