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A causal analysis of aviation accidents that involved pilot error is presented. The analysis employs a top-down methodology that investigates the relationship between pilot errors and other causal factors with accidents. The Human Factors Analysis and Classification System (HFACS) framework is utilized to produce a comprehensive causal analysis of accident groups. This analysis will compare and evaluate causal factor patterns for both accidents induced by pilot errors and those where pilot error was a contributor but not the initiating event. Pilot induced accidents are those initiated by an inappropriate action of the aircrew. That is, the National transportation Safety Board (NTSB) report cited pilot error first within its analysis defining accident causes, factors, and findings. Pilot contributed accidents are those that are initiated by some other causal factor (weather, aircraft failure, etc.) and the pilot’s inappropriate action played a part in the outcome.

This paper presents a top-down methodology for causal analysis of fatal aviation accidents. The methodology incorporates a three tiered hierarchical approach to analyze accident causes and factors. These include looking at the big picture or “profile” of accident categories, followed by a detailed analysis that “fingerprints” each profile. Finally, an in-depth analysis is performed for each fingerprint which produces a “DNA” sequence breakdown for each accident category. The paper includes analysis results of National Transportation Safety Board (NTSB) accidents from 1990-1996. Key areas are identified which most significantly impact current accident rates. This includes a ranking by accident type as well as identifying focus areas for future research.