{"title":"印尼航空事故调查报告中飞行员的先决条件和错误。","authors":"Inne Yuliawati, Budi Sampurna, Tjhin Wiguna, Imam Subekti, Aria Kekalih, Widura Imam Mustopo, Hervita Diatri, Wawan Mulyawan","doi":"10.3357/AMHP.6674.2025","DOIUrl":null,"url":null,"abstract":"<p><strong>Introduction: </strong>Human factors are responsible for 80% of accidents and 50% of serious incidents. The Human Factor Analysis and Classification System allows the identification of contributing factors, including pilot preconditions, as the imminent layer prior to errors. This study aimed to investigate the association of pilot preconditions and errors to accidents and serious incidents from 2007-2024 in Indonesia.</p><p><strong>Methods: </strong>This was a cross-sectional study design with secondary data from the investigation reports published by the National Transport Safety Committee (NTSC) from 2007-2024 in Indonesia, downloaded from the NTSC website, August 12-31, 2024. The study focused on pilot-error-related investigation reports, analyzing preconditions and errors. Internal validation was conducted with the NTSC investigators. Statistical analysis using nonparametric tests was carried out to assess the association between preconditions, errors, and incident severity (Accidents and Serious Incidents).</p><p><strong>Results: </strong>A total of 245 investigation reports were downloaded, amounting to 253 aircraft, with 8 aircraft involved in near collisions, and 186 pilot-error-related investigations selected as subject analysis. The study found that pilots with Adverse Mental States had a 3.87 times higher risk [95% confidence interval (CI) = 1.77-8.47] for accidents, while pilots with Physical Mental Limitation had a 3.35 times higher risk (95% CI = 1.50-7.45). In addition, pilots with Skill-Based Errors had a 3.07 times higher risk (95% CI = 1.38-6.83) for accidents.</p><p><strong>Discussion: </strong>Aviation accidents and serious incidents are caused by multiple contributing factors, and the complexity of human factors emphasizes the need for a multifaceted approach to mitigating pilot error. Yuliawati I, Sampurna B, Wiguna T, Subekti I, Kekalih A, Mustopo WI, Diatri H, Mulyawan W. Pilot preconditions and errors identified in indonesian aviation accident investigation reports. Aerosp Med Hum Perform. 2025; 96(10):911-918.</p>","PeriodicalId":7463,"journal":{"name":"Aerospace medicine and human performance","volume":"96 10","pages":"911-918"},"PeriodicalIF":0.9000,"publicationDate":"2025-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":"0","resultStr":"{\"title\":\"Pilot Preconditions and Errors Identified in Indonesian Aviation Accident Investigation Reports.\",\"authors\":\"Inne Yuliawati, Budi Sampurna, Tjhin Wiguna, Imam Subekti, Aria Kekalih, Widura Imam Mustopo, Hervita Diatri, Wawan Mulyawan\",\"doi\":\"10.3357/AMHP.6674.2025\",\"DOIUrl\":null,\"url\":null,\"abstract\":\"<p><strong>Introduction: </strong>Human factors are responsible for 80% of accidents and 50% of serious incidents. The Human Factor Analysis and Classification System allows the identification of contributing factors, including pilot preconditions, as the imminent layer prior to errors. This study aimed to investigate the association of pilot preconditions and errors to accidents and serious incidents from 2007-2024 in Indonesia.</p><p><strong>Methods: </strong>This was a cross-sectional study design with secondary data from the investigation reports published by the National Transport Safety Committee (NTSC) from 2007-2024 in Indonesia, downloaded from the NTSC website, August 12-31, 2024. The study focused on pilot-error-related investigation reports, analyzing preconditions and errors. Internal validation was conducted with the NTSC investigators. Statistical analysis using nonparametric tests was carried out to assess the association between preconditions, errors, and incident severity (Accidents and Serious Incidents).</p><p><strong>Results: </strong>A total of 245 investigation reports were downloaded, amounting to 253 aircraft, with 8 aircraft involved in near collisions, and 186 pilot-error-related investigations selected as subject analysis. The study found that pilots with Adverse Mental States had a 3.87 times higher risk [95% confidence interval (CI) = 1.77-8.47] for accidents, while pilots with Physical Mental Limitation had a 3.35 times higher risk (95% CI = 1.50-7.45). In addition, pilots with Skill-Based Errors had a 3.07 times higher risk (95% CI = 1.38-6.83) for accidents.</p><p><strong>Discussion: </strong>Aviation accidents and serious incidents are caused by multiple contributing factors, and the complexity of human factors emphasizes the need for a multifaceted approach to mitigating pilot error. Yuliawati I, Sampurna B, Wiguna T, Subekti I, Kekalih A, Mustopo WI, Diatri H, Mulyawan W. Pilot preconditions and errors identified in indonesian aviation accident investigation reports. 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引用次数: 0
摘要
导读:80%的事故和50%的严重事故是人为因素造成的。人为因素分析和分类系统允许识别影响因素,包括飞行员先决条件,作为错误之前的迫在眉睫的层。本研究旨在调查2007-2024年印度尼西亚飞行员先决条件和错误与事故和严重事件的关系。方法:这是一项横断面研究设计,次要数据来自印度尼西亚国家运输安全委员会(NTSC)发布的2007-2024年调查报告,该报告于2024年8月12日至31日从NTSC网站下载。这项研究的重点是与飞行员错误相关的调查报告,分析了前提条件和错误。与NTSC调查人员进行了内部验证。使用非参数检验进行统计分析,以评估前提条件、错误和事件严重程度(事故和严重事件)之间的关联。结果:共下载调查报告245份,涉及飞机253架,其中近碰撞事故8架,选取飞行员失误相关调查186份作为分析对象。研究发现,精神状态不良的飞行员发生事故的风险高出3.87倍[95%可信区间(CI) = 1.77-8.47],而身体精神限制的飞行员发生事故的风险高出3.35倍(95% CI = 1.50-7.45)。此外,有技能错误的飞行员发生事故的风险高出3.07倍(95% CI = 1.38-6.83)。讨论:航空事故和严重事件是由多种因素引起的,人为因素的复杂性强调了需要采取多方面的方法来减轻飞行员的错误。Yuliawati I, Sampurna B, Wiguna T, Subekti I, Kekalih A, Mustopo WI, Diatri H, Mulyawan W.印度尼西亚航空事故调查报告中飞行员的先决条件和错误。航空航天Med Hum Perform. 2025;96(10): 911 - 918。
Pilot Preconditions and Errors Identified in Indonesian Aviation Accident Investigation Reports.
Introduction: Human factors are responsible for 80% of accidents and 50% of serious incidents. The Human Factor Analysis and Classification System allows the identification of contributing factors, including pilot preconditions, as the imminent layer prior to errors. This study aimed to investigate the association of pilot preconditions and errors to accidents and serious incidents from 2007-2024 in Indonesia.
Methods: This was a cross-sectional study design with secondary data from the investigation reports published by the National Transport Safety Committee (NTSC) from 2007-2024 in Indonesia, downloaded from the NTSC website, August 12-31, 2024. The study focused on pilot-error-related investigation reports, analyzing preconditions and errors. Internal validation was conducted with the NTSC investigators. Statistical analysis using nonparametric tests was carried out to assess the association between preconditions, errors, and incident severity (Accidents and Serious Incidents).
Results: A total of 245 investigation reports were downloaded, amounting to 253 aircraft, with 8 aircraft involved in near collisions, and 186 pilot-error-related investigations selected as subject analysis. The study found that pilots with Adverse Mental States had a 3.87 times higher risk [95% confidence interval (CI) = 1.77-8.47] for accidents, while pilots with Physical Mental Limitation had a 3.35 times higher risk (95% CI = 1.50-7.45). In addition, pilots with Skill-Based Errors had a 3.07 times higher risk (95% CI = 1.38-6.83) for accidents.
Discussion: Aviation accidents and serious incidents are caused by multiple contributing factors, and the complexity of human factors emphasizes the need for a multifaceted approach to mitigating pilot error. Yuliawati I, Sampurna B, Wiguna T, Subekti I, Kekalih A, Mustopo WI, Diatri H, Mulyawan W. Pilot preconditions and errors identified in indonesian aviation accident investigation reports. Aerosp Med Hum Perform. 2025; 96(10):911-918.
期刊介绍:
The peer-reviewed monthly journal, Aerospace Medicine and Human Performance (AMHP), formerly Aviation, Space, and Environmental Medicine, provides contact with physicians, life scientists, bioengineers, and medical specialists working in both basic medical research and in its clinical applications. It is the most used and cited journal in its field. It is distributed to more than 80 nations.