The Human Factor Analysis of Airline Accidents Within Last 50 Years

ABSTRACT
Each year, several passengers and aircraft crew members perish in plane accidents. Of
course, accidents cannot be fully avoided. However, with the appropriate precautions in
place, the likelihood of accidents may be lowered. Thus, how can we select the
appropriate course of action? Of course, it is essential to have a broad understanding of
the elements that contribute to the disaster. Because we cannot establish the path to a
solution if we do not know precisely what we are focused on. We may be unwilling to
examine our errors as human beings. However, we can stay as far away as possible from
the next aircraft catastrophe with thorough accident investigations.
ICAO has performed several research on aviation accidents to date. Most accidents,
particularly in air transport, are caused by human mistakes. Regrettably, reports on
human error are few despite the high incidence of incidents involving human mistakes.
Due to the possibility that those who can be examined had perished in the accident.
Which is often the case. The research remains inconclusive, given that the pilot, who is
the study's primary subject, died in most incidents caused by human error.
Many precautions can be taken and ways can be determined in order to avoid accidents
on highways, especially plane accidents. However, the most fundamental aspect for
implementing these remedies is to investigate the basis of the issue, namely the human
component. In its simplest form, thorough investigations and human factor studies
conducted after an aircraft crash might provide insight into the incident. This section is
critical. Additionally, the effects of environmental and psychological factors on persons
must be recognised.
Additionally, the human factor investigator on accident investigation committees should
be a specialist in analytical methodologies and equipped with a good inspection checklist
and technological equipment to perform the study. After the investigation is complete and
the exact reasons for the disaster are identified, the most critical event component is that
the findings be communicated with all pilots. The facts are not concealed to prevent
similar accidents and errors from occurring in the future. As long as errors and omissions
remain concealed, the same sort of accident will always recur. The objective is not to
penalise or criticise individuals but to minimise accident rates. The emphasis of this
research is on X. Whenever feasible, detailed information about this topic will be
provided. Additionally, the Y model will be discussed concerning this issue, and readers
will be educated on the need of analysing the human component.

Some abbreviations are used in this article. The explanation of these abbreviations is
given below.

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 CRM: Crew Resource Management
 FAA: Federal Aviation Authority
 IFR: Instrument Flight Rules
 ILS: Instrument Landing System
 HFACS: Human Factors Analysis and Classification System
 SD: Spatial Disorientation
 VOR: Vertical Omni-Directional Radar
 VFR: Visual Flight Rules

 5M: Man, Machine, Management, Medium, Mission

1. Introduction
Since the middle of the twentieth century, rapid developments in aviation technology have
been experienced. The Second World War led to the rapid growth of the aviation and space
industry. Parallel to this, the importance of aviation in the military and transportation has
increased day by day. Today, it has become one of the most important sectors.
Despite the aircraft accidents that have occurred since the first years of aviation (Picture 1.1),
people's trust in air transportation is quite high compared to land transportation. Statistics
confirm that this trust is justified. Eight hundred nineteen people lost their lives in 2180
aviation accidents in the USA in 1990, and this figure constitutes only 3% of those who died
in accidents on highways (Ewing, 2004). Despite this low rate, dozens of people lose their
lives in a plane crash that may have occurred due to a simple mistake. This causes more
serious studies and measures to be taken on the subject. It is possible to reduce this rate even
more with the measures taken.

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Aircraft accidents can only be prevented if the causes are known. Causes can also be revealed
as a result of a good accident investigation. Five main factors cause aircraft accidents and
crashes. These factors, known as the 5M formula, are Man, Machine, Management,
Medium, and Mission. The most important among these factors is humans. Based on the idea
that "people make mistakes", the human element is the weakest link in the chain. When the
human factor was mentioned, only the pilot came to mind in the past. However, today, other
people in the system are considered to have the potential to play a primary role in accidents
with their mistakes, personal weaknesses and inadequacies. Therefore, the pilot and other
crew members, air traffic controllers, managers, engineers, maintainers, etc. In-flight safety,
the elements of the human factor are considered (Bibel & Hedges, 2018).

Researches on the human factor, which has a share of 70-80% in accidents, and the measures
taken are insufficient. Accident investigation reports usually tell clearly and in detail what
happened and when. However, explanations of How and Why accidents occur are often kept
very short. When there is no tangible evidence to explain the accidents, researchers and
authorities prefer to blame the pilot directly and choose the easiest way. However, revealing
the 'Why' and 'How' with detailed and scientific research will enable both the real causes of
the event to be known and the probability of the same type of accidents to be reduced (ICAO
Circular, 1993).

When the concept of the "human factor" first emerged in 1969, it was echoed in the world
media as "the first attempt to uncover the human errors that cause plane crashes".
Nevertheless, until the 1977 accident, when two Boeing 747s collided on the runway, killing
583 people, aeroplane manufacturers, operators, and even pilots resisted the role of the human

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factor in plane crashes. With this event, the aviation world began to focus on the issue and
take steps to understand the problem (Bibel & Hedges, 2018).
 
Institutions and people involved in flight show an understandable resistance to human factor
studies. This resistance is due to the naturally occurring defence mechanism. Especially in the
face of severe consequences such as plane crashes, people seek to be blamed in society, and
heavy penalties are envisaged. However, in recent years, the understanding of finding and
uncovering a criminal (usually a pilot) after accidents has been replaced by a chain of
mistakes (collective mistakes). In this approach, the chain of mistakes that can be said to be
the fault of person A and reveal the causes of the same event is not ignored. This is how
today's modern accident and crime investigation/prevention systematic works.
2. Some Essential Definitions
An accident is defined as unplanned and undesirable events resulting from completely
accidental or unknown causes, resulting in damage or injury (Editorial, 2021). On the other
hand, unlike an accident, an aircraft incident is an event that is related to the operation of the
aircraft and affects or may affect operational safety. As a result, an incident related to the
operation of the aircraft that, if not corrected, could affect safety; is not an accident. Incident
does not result in serious injury to a person or serious damage to aircraft.

Aircraft Accident and incident; death or serious injury to a person from being struck by any
part of the aircraft in or around the aircraft during the period from boarding to disembarkation
for flight; These are the events that result in structural damage, loss or inaccessibility of the
aircraft (ICAO Circular, 1993).

2.1 Factors Causing the Pilot's Mistake

 Factors Related to the Senses
We can examine the factors related to the senses in six parts:
Visual Errors
Visual misconceptions are quite normal and have happened to every person. However,
making these mistakes by the pilot in the wrong place at the wrong time can cost many lives.
The main misconceptions that can happen to pilots are:
Perception Errors Related to Vision: These types of perceptual errors are usually caused by
the wrong perception of sequential and geometric shape arrangements. E.g; A wide runway is
perceived as being higher than a narrow runway. This causes the pilot to misjudge the
descent.
Auto-Kinetic Errors: It can be explained by the illusion that a fixed light moves according to
the observer. Auto kinetic movement: It has been reported to occur under night flight
conditions, including stars, ground lights, lights in the cockpit. The pilot's perception of an
stationary light as moving can cause significant problems, especially when there is no
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reference point on the ground. Channeling a star or ground light during flight can cause loss
of direction and bearing.
Deceptive and Imaginary Horizons: The pilot must fly in cloudy air as well. In such cases
there are sometimes times when a cloud cluster is considered the horizon. If the clouds are not
parallel to the horizon, it often becomes impossible to maintain level flight by sight. In such
situations, flight instruments are the pilot's best and reliable friends and life savers. A careful
pilot uses flight instruments for horizon reference and altitude. Many aircraft crashes have
occurred while the pilot has attempted to find a visible reference for landing after making an
instrument approach. The plane crash that took place in Diyarbakır in 2003, in which many
passengers and all crew members lost their lives, is a sad example of this.
Errors in Semicircular Channel Excitation: If a pilot leans forward or turns his head left
and right while maneuvering the aircraft, he will lose his orientation. In this case, dizziness
and nausea are felt. For this reason, it is very important for the pilot to adapt to the maneuver
of the aircraft and not to move his head too much.
Geographic Misdirection: Almost every pilot has been disoriented and headed in the wrong
direction. In bad weather and visibility conditions, the frequency of such incidents is higher.
Not using a map in flight, short-term carelessness, finding similar landmarks in different
places, changing from instrument flight conditions to visual flight conditions cause the
direction to be confused.
Vertigo because of flicker of light: The introduction of a light that normally comes directly
into the eye and another flicker of light between the eye can cause disorientation or vertigo.
An example of this is the fact that the sunlight reflected from the propeller of the airplane
waiting on the runway for takeoff causes nausea in the pilots. The pilot is often asked to
choose between vague or incomplete stimuli. It is not surprising that the pilot made an
erroneous assessment because of distant or similar vague visual stimuli. Most visual illusions
can be corrected by cross-checking or rechecking and relying on flight instruments (Aviation
Psychology, 2003).
2.1.1 Sensory Errors
Perception is the concepts that the impressions determined by the sensory organs leave on the
person. The person evaluates the information obtained through his senses within himself.
Perception is a phenomenon that does not only have physical dimensions, but also includes
the physiological and psychological characteristics of human beings. Throughout his life, a
person continues his life by evaluating his inner emotional reactions as well as thousands of
external stimuli (King, 2018).
These reactions have ceased to be a problem in our daily life and have turned into a habit.
However, learning and comprehending meaningful patterns based on knowledge and skills is
not easy. A pilot's responses to grasping stimuli must be organized and turn into meaningful
patterns. Otherwise, the understanding of the event becomes very complicated. Incorrect
perceptions also cause erroneous responses. Stimulants carry various environmental
characteristics together; they are not simple and obvious. E.g; The pilot is under the influence

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of many stimuli such as interpreting the data during the flight, feeling the position of the
aircraft, establishing a radio connection, controlling the flight instruments and so on.
Otherwise, flight is not just command control. Misperception of one of the direct or indirect
reasons affecting the flight, if not noticed, drags the pilot towards the continuation of the
chain of errors.
Two important perceptions in aviation; perception of objects and events and space perception.
Giving the right response in flight occurs when the pilot correctly recognizes the objects and
events around him. Whether the object seen in the distance is an airplane or a bird, whether
the lamps are runway lighting or streetlights, etc. Misperceptions on these issues greatly affect
flight safety. Evaluations gained through experience are important in perceiving details.
Skilled and experienced pilots can accurately perceive details that inexperienced pilots cannot
notice. E.g; short and muffled speeches or speeches from different radios at the same time can
be defined as sounds that are correctly perceived by an experienced pilot, but
incomprehensible to a novice pilot (King, 2018).
The three-dimensional spatial view, the distance of objects, and the relationships between
objects in the sky must also be correctly perceived by the pilot. If the pilot misunderstands the
spatial position, speed, direction, position of the aircraft he is using, and the situation and
distance of the surrounding objects, this will adversely affect flight safety. Misconceptions lie
behind the main causes of many aircraft accidents and crashes. Misjudgement of instruments,
misjudgement of altitude, distance, descent, and approach speeds, misunderstanding of
written or verbal communication, etc. misconceptions are the types of errors that lead the pilot
to react incorrectly (Aviation Psychology, 2003).
Noise
Acute acoustic trauma: Hearing loss due to high-intensity sound trauma, acoustic traumas
caused by cannons and firearms are examples of these. Chronic sound trauma of the inner ear;
It is hearing loss that occurs because of long exposure to a certain loud sound. Hearing loss
that occurs for a long time in people working in noisy places is an example of this type. It is a
well-known fact that permanent changes in hearing threshold occur when exposed to high-
intensity noise continuously for 15 years in daily life (Nicholson, 2017).
Permanent hearing loss due to the high noise load in aviation is of particular importance. The
negative effects of the flight environment on the hearing threshold have been shown in many
studies due to the excessive noise created by modern technology high-performance aircraft
and other environmental noises. It has been determined that helicopters produce more than
120 dB of noise. Increasing the number of blades causes excessive noise due to both the
increase in blade-related noise and the increase in body vibration. The noise load that
helicopter pilots are exposed to is quite high since helicopters have weaker insulation
compared to other aircraft and transmit the noise to the inner ear via vibration.
Noise negatively affects the communication between the pilot and the ground by revealing
non-hearing pathologies such as changes in blood pressure and fatigue. Thus, flight safety is
deteriorated to some extent. According to the internationally accepted ISO Standard 1999
values, 87.5 dB noise is the maximum value given over 8 hours a day, 40 hours a week or
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2000 hours a year. If these values are exceeded, it means that hearing impairment is within the
risk dimensions (Nicholson, 2017).
2.2 What is Aviation Pathology?
Aviation pathology is the use of traumatic pathology principles in the flight safety service.
Aviation Pathology is a comprehensive study investigating the relationship of survivors'
medical history and autopsy findings with environmental factors, other structural or non-
structural errors in the aircraft, and appropriate or inappropriate use of equipment so that a
complete analysis of the accident can be made (Martinussen & Hunter, 2017).
The purpose of accident and crash investigations is to determine all factors related to human,
material and environment that directly or indirectly contribute to the accident and to prevent
the recurrence of similar accidents by eliminating the causes of the accident. Every accident
and accident investigation adds to our experience in taking corrective action. Appropriate use
of these experiences also reduces the potential for accidents. Pathologists personally conduct a
great deal of research both at the crime scene and on the remains. These pathologists have
significant experience in the specific issues of aviation pathology. While base flight
physicians encounter only a few accidents during their entire tenure, flight pathologists
participate in numerous accident and accident investigations at different bases.
In fatal accident and accident investigations, the contribution of the pathologist and the
medical member of the aircraft accident and accident investigation committee constitutes a
very meaningful part of the whole research. A complete medical review evaluates the
physical, physiological and psychological aspects of human factors and the role of disruptions
in the human-aircraft interaction. Since careful forensic investigations can reveal a significant
disease in terms of air sickness, it is thought that accidents that were described as "pilot error"
or "undetermined causes" in the past may be due to a disease. The medical investigation of
aircraft accidents has five purposes:
(1) Identification of Victims: This is necessary for identification of the deceased person's
closest relatives and for other bureaucratic procedures. Compensation, insurance, inheritance,
debts and closing the military personnel file will be made according to this diagnosis. If there
is a suspicious death, there may be signs of homicide or suicide or the remains of the saboteur
on the body. There may even be deliberate tampering of the corpse for security or other
reasons.
(2) Reconstruction of the accident: By examining the distribution of the accident remains
and analyzing the wounds of each victim, the accident can be constructed immediately before,
during and after the accident. By designing how it happened, it can be determined why the
accident happened and who or what caused it.
(3) Identification of Major and Minor Medical Causes Leading to the Accident: It will
help to explain the accident if it is understood by the autopsy of the crew that there is a pre-
existing or coincidentally found disease. Also, for pharmaceuticals or occupational
substances, chemical analyzes should be routinely performed on passengers and crew.

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(4) Investigation of the Relationship between the Structure and Design of the Aircraft
and the Accident and Death: The information obtained here may be useful in the design of
new airplanes. This information can be used by planners of both military and civilian
companies.
(5) Collection and Preparation of Learning Materials: Information gathered from accident
and accident research is used in the training of pilots, flight crew, accident investigators and
aerospace physicians, and in statistical studies (Martinussen & Hunter, 2017).

3. The Formation of the Factors Causing the Accident and the 5M Model
There are five factors that affect the realization of aircraft accidents. Explanation of 5M
Formula/Model; It is Man (Human), Machine, Management, Medium, Mission. The figure
describes the relationship between these factors.
The most important factor in this relationship is people. Because human nature makes
mistakes. In all units of aviation, the operation is carried out with the initiative of people.
There are people who work in many positions in aviation, from pilots to cabin crew, from air
traffic controllers to maintenance personnel, from managers to security guards. Even in a
single flight operation, all these employees have a duty. A single mistake of one of these
officials can cause chain errors and accidents. The effect of the human factor on aircraft
accidents in aviation is the most difficult factor to control due to the limits and limits of
human beings (Brochu, 2014).

Figure 1

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3.1 Human/Man Factor
When aircraft were produced and used, some problems were experienced due to technical
errors. These technical reasons have brought accidents. Over time, developments in aircraft
maintenance and engineering have reduced the rate of these accidents. However, the increase
in human-induced accident rates has been remarkable since the mentioned dates (National
Transportation Safety Board & National Transportation Safety Board, 2014). As a result of
the research, it turns out that, even if the reason is technical, it is people who direct it. The fact
that there are errors in these directions makes the accident inevitable. All processes, including
the applications to be made in possible emergencies, are under the control of people. This
situation reveals the importance of the human factor underlying the causes of the accident.
In addition, humanity (Man Factor), seeing, hearing, fatigue, distraction, eating, resting,
forgetting, etc. It has some features such as These are the traits that make people human.
These features constitute the limits of human nature. These limits directly affect our
performance during operation. People need to be aware of their limits and recognize these
factors.
3.2 Machine
As time progresses in the aviation industry, there are developments in aircraft maintenance
and engineering. Although progress has been made, it is necessary to ensure that aircraft are
always airworthy. For this reason, aircraft maintenance, repair and renewal operations
maintain their importance. Because to be able to perform a safe flight, first of all, the
maintenance of the aircraft must be applied completely. Otherwise, malfunctions may occur
and may lead to accidents.
3.3 Management
It is also the management's responsibility to ensure safety and prevent accidents. In order to
ensure safety, it is necessary to create a comfortable environment for the employees, manage
the resources of the teams correctly, and keep the motivation at the highest level. The
decrease in the motivation of the employees can cause a chain of mistakes that lead to wrong
flight planning. Even the decrease in the motivation of a single person can lead us to the same
result.
Because management is only as strong as the weakest link in the chain. For this reason, it is
very important to have a safe culture in it. Safety culture means that everyone involved in the
organization is aware of the risks of their work, understands safety, can cope with emerging
safety problems, and reports emerging safety problems. This perception can only be given to
the employees by the management.
3.4 Medium
The medium is also of great importance for flight safety. According to the literature, human
factors are examined under two headings: natural environment and human environment. They
are environments that consist of conditions such as land structure and weather conditions.
This natural environment consists of events (storms, hail, lightning, etc.) outside human
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control. A person can stay away from the relevant environment only by making predictions
about these natural events. In this way, it is possible to avoid possible dangers. Humane
environment; environments such as education and communication. This medium is formed
because of human and human activities. Both environments can create risks and cause
accidents.
3.5 Mission
Employees in the aviation industry are responsible for completing their duties completely and
on time. It is important to fulfil the task on time in aviation, not interrupting the flight
operation. For this reason, employees need to master their duties. Because mistakes made
during the operation or not fulfilling the tasks on time can affect all processes and disrupt the
entire operation.

4. Some 5M Model Relationships

4.1 Man-Machine-Medium Relationship
A machine is designed, built, and operated by man. So, a malfunction of the machine is
human error. Likewise, a man may not eliminate or avoid a known environmental hazard.
Therefore, this situation can also be considered human error rather than environmental
factors. There are differences in the percentages of accidents attributed to human error in
different countries for these reasons. Humans have a structure that can easily adapt to
anything. Therefore, it can compensate for many shortcomings in the design and manufacture
of the aircraft. As the capabilities of the human and the quality of the aircraft match, the level
of safety to be achieved will be higher (Seedhouse et al., 2019).
On the contrary, the larger the gap, the higher the probability of making mistakes. For
example, turning off a faulty switch may be possible if the aircraft is not suitable for use or if
the flight cabin is not properly designed. In this case, the importance of ergonomics emerges.

4.2 Reasons for Human Factor to Cause Accident

Some coordination problems may occur by aviation workers such as pilots, cabin crew, air
traffic controls, maintenance personnel. This situation causes the formation of human-induced
errors. The mistakes that occurred during the studies again highlight the importance of
interpersonal communication. In aviation maintenance, the importance of communication has
come to the fore in maintenance communities. The care community has been active in this
area, measuring achievements in teaching and improving communication.

During the 1980s and 1990s, a significant number of maintenance-related aviation accidents
occurred. As a result of these events, Transport Canada (the department within the
Government of Canada responsible for developing regulations, policies and services for
road, rail, sea, and air transport in Canada) initiated a study to identify twelve human factors
that degrade human performance.
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 One of the Maintenance Resource Management (MRM) training programs was developed by
Gordon Dupont for Transport Canada and introduced the “Dirty Dozen”, twelve potential
problem areas in human factors (Seedhouse et al., 2019).
According to a study, each of these twelve mentioned factors has different reflections. Based
on the reflections, a study was conducted on how effective each factor was on the accidents.
This research includes the examination of eleven fatal accidents according to relevant factors
(“Human Performance in Controlled Flight into Terrain”, 2020). The study analyses the
related shortcomings against two separate models, the Dupont “Dirty Dozen” and the Pilot
Competencies Model. While all crashes have identifiable factors from both models, some
crashes include shortcomings in nearly all pilot qualifications with many of the factors.

Figure 2

Twelve factors that affect flight safety and cause an accident are as follows:

1. Lack of communication 5. Complacency 9. Lack of knowledge

2. Distraction 6. Lack of teamwork 10. Fatigue
3. Lack of resources 7. Pressure 11. Lack of assertiveness
4. Stress 8. Lack of awareness 12. Norms

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4.3 Lack of communication
Communication is a two-way process that allows communication from one place to another.
The "thing" conveyed is a message, a signal, a meaning, etc. can happen. In order to provide
communication between people, it is necessary to make coding such as mimics, pictures,
words. It is possible to think of a flight permit as a code used for communication in the
aviation industry. The main purpose of communication is to increase interaction between
people. However, for this, people in communication need to understand each other.
Otherwise, serious problems may arise. These problems arising from the lack of
communication can result in aircraft accidents (Wiener, 1977).

Managers, pilots, cabin crew, maintenance-repair workers, air traffic controllers.

Miscommunication between people can also create problems. These misunderstandings can
be language-based problems or cultural differences. There are misunderstandings caused by
sound similarity under language-based accidents. Although a common language and alphabet
are used in aviation to eliminate these misunderstandings, sometimes even this cannot prevent
communication. The lack of communication-based on cultural differences is because people
grow up in very different places. E.g., During an emergency, expressing the event very
politely due to cultural differences may prevent the other pilot from understanding the
seriousness. This can cause failure to intervene correctly at the right time and cause an
accident.

Especially the lack of communication between the tower and the pilot makes the accident
inevitable. According to the literature, only verbal communication creates an obstacle for
people to understand each other correctly. For this reason, taking and repeating the instruction
is carried out during the speeches. Another situation in which the lack of communication in
aviation is experienced frequently occurs during shift changes. Failure to provide accurate
information about completed, incomplete or partially completed tasks during shift changes is
among the reasons that may cause problems. There is a possibility that these errors, which
may adversely affect safety and result from lack of communication, may lead to an accident.

According to the literature, when the accidents that have taken place in the last 20 years are
investigated, it has been determined that most of them are caused by a lack of communication.
Correct communication remains important to ensure safety and security in the aviation
industry (Wiener, 1977).

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4.4 Complacency

As people gain knowledge about a subject and constantly work on it, they find comfort. This
situation causes self-confidence to become dangerous. The sense of competence that comes
with self-confidence can lead to wrong conclusions in some cases. We come across this
situation more often, especially during continuous work. Repeated routine checks can distract
an employee and take critical action. For ınstance, Since a cabin crew performs the same
checks every time he gets on a plane, he has memorized the check items. With the sense of
self-confidence of doing the same job all the time, it does not need to use a checklist. A
simple check performed hundreds of times without fault-finding may be insignificant and
therefore a skipped check. This means that some things may be overlooked during the control.
Missing a very important malfunction during pre-flight checks can lead to many problems
((Bucchianico et al., 2019). When we look at it from a different perspective, it has been
observed that employees who lack self-confidence are also open to making mistakes.
Individuals with low motivation and even fear making mistakes may be more likely to make
mistakes.

4.5 Lack of Information

The consequences of lack of information in the aviation world can lead to disasters.
Technology varies according to aircraft types, and new technologies designed for the same
aircraft type pose a great risk for employees. In particular, lack of knowledge about new
technological developments prevents the correct implementation of the necessary applications
in possible emergencies. In order to avoid these risks, training should be a priority. Unless the
training received on a subject is applied, or over time, it may become dull. Airline companies
need to overcome the lack of information that this will bring. Today, the pieces of training
given to aviation sector employees are repeated at regular intervals under the name of
refresher training. Thus, it is ensured that employees are informed about all regulations and
procedures applied in common emergencies. At the same time, it aims to get up-to-date
information about innovations within the scope of the constantly held refresher pieces of
training.
As in all areas of aviation, it is necessary to have the right knowledge in maintenance and
repair and apply it correctly. A wrong maintenance activity caused by a lack of knowledge
can cause various malfunctions and, as a result, accidents (Bucchianico et al., 2019).

4.6 Distraction
Distraction can disrupt all industries, including aviation. Various factors can cause distraction.
These can be caused by external factors as well as mental reasons. A noise that will disrupt
work is among the external factors. Here, a distracting technological device can also be a
mobile phone. According to the literature, texting on a mobile phone is defined as a source of

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distraction and interruption. Distracting devices such as cell phones are thought to reduce
cognitive capacity, potentially reducing the processing of relevant information.
As a result, people who use mobile phones while working face confusion or forget the
information in their memory. It is possible to give an example of the distraction of an
employee who has financial concerns for mental reasons. The performance of employees who
are exposed to one or more of these effects may decrease, and people may become open to
making wrong decisions (Seedhouse et al., 2019, p. 13).
The employee needs to realize that he or she is distracted. After realizing this, there are
several steps to consider when resuming the interrupted procedure. The procedures must be
followed by starting a few steps back and adhering to the checklist. Otherwise, an item that
needs to be implemented will likely be skipped. In addition, the high workload and long hours
of work can cause mental clutter. In this case, the lack of healthy controls may cause
disruptions in the use of existing resources.

4.7 Lack of Teamwork

All areas of the aviation industry are about teamwork. However, this means that the human
factor is also at the forefront. Personality conflicts, poor communication, coordination, and
compromising consensus leave people prone to making mistakes. This factor can also be
eroded by individuals not establishing their roles correctly. Making sure that the role
distribution among human factors is made correctly minimizes the possibility of risk that may
arise in teamwork (Dhillion, 2017, p. 157). In other words, it is important to correctly
distribute the tasks among the individuals who will participate in teamwork. At this point, the
team leader has a great responsibility. The leader must ensure cooperation within the
framework of justice and respect among the individuals in the team by making the right
sharing.
According to the Shel model, accidents occur due to erroneous interactions with other people.
Because a single weak link in teamwork can lead to a deficiency, these deficiencies may
appear as accidents at the end of the operation in aviation. It is important to communicate
clearly and adequately for teamwork. When we say crew in aviation, only cabin and cockpit
crews in the plane come to mind. However, the team; includes everyone working for an
operation, from technical maintenance personnel to apron workers, from controllers to ground
workers. At the same time, ensuring team integrity brings many advantages. E.g., Sharing
knowledge, skills and expertise among pilots is very important. In an emergency, the captain
will have the opportunity to assess the problem and make sound decisions by allowing the co-
pilot to fly the aircraft. (Krause, 2003, p. 455). There are also some disadvantages brought by
teamwork. These appear as a lack of teamwork.
Equality between individuals is very important to maintain team integrity. The pressure that
people in the team create on each other can cause low motivation. On the other hand,
individuals who feel under pressure may also be shy about expressing their own opinions.
This situation may cause delays in preventing an emerging danger.

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4.8 Fatigue
Fatigue is shown as an important human factor in all kinds of aviation accidents. Fatigue can
be mental, physical and emotional. Fatigue can cause difficulty in making decisions,
weakening of cognitive skills, loss of reasoning ability, and loss of awareness. Along with all
these, loss of mental abilities, loss of speed and power, and balance disorder also occur. Being
unable to react as a result of these effects due to extreme fatigue is called “Fatique”. It is very
important for the individual to be aware that he is under these influences and that this is
effective in the decision-making process. Otherwise, there will be a high probability of
causing accidents by making mistakes. In order to raise this awareness, airline companies
regularly provide trainings.
Performance drops due to stress and fatigue can increase the risk of making mistakes and
negatively affect flight safety. Work among team members is carried out based on division of
labor. Teams share the necessary information to be used in the decision-making process.
A wrong decision made by one of the members due to fatigue may lead to other wrong
decisions by other members. Furthermore, tired people tend to be unhappy and aggressive.
This variable psychological state that the person experiences in himself can cause difficulty in
the decision-making process, intra-team conflicts and being open to mistakes. These
negativities that we have mentioned will cause damage to the safety culture. The injury of the
safety culture, on the other hand, paves the way for the disruption of flight operations and the
increase in accident rates (Bucchianico et al., 2019).
For businesses with shift work, such as airline companies, it should be a priority to ensure that
the distribution of tasks is equal. It is important to prepare a monthly flight plan, paying
attention to the limits, especially for flight personnel. Otherwise, it is inevitable that
employees with a heavy workload will be more likely to make mistakes with fatigue.

4.9 Lack of Resource

Lack of resources can prevent employees from completing their work. Because it causes a
lack of supply and support. In case of a lack of resources, the ability of the person to
demonstrate his/her ability and fulfil the task at hand may be jeopardized. Similarly, low-
quality products can affect safety. That is why it is so important to have the right tools for the
task. In the case of products, this need not necessarily mean equipment. The important thing is
to write the technical documentation and manuals correctly and preserve the revisions made in
them (Seedhouse et al., 2019, p. 14).

4.10 Pressure
Aviation is an industry with tight schedules, and operating under a tight schedule inevitably
means working under pressure. Many factors, including the pilot, cabin crew, manager and
passenger, can pressure the person. However, the problems that a person experiences in his
private life can also pressure him. When working under high pressure is noticed, the superiors

15
need to take various measures regarding it. Sometimes this can be achieved by distributing
tasks fairly, and sometimes by eliminating the situation that creates the stress factor.
It is possible to say that employees in airline companies are exposed to serious pressure.
Because, in addition to their problems, they have to work at an intense pace. In particular,
flight personnel feel this pressure when their monthly flight schedules are hectic. To not
disrupt the aviation operation, the works must be carried out in a limited time.
According to the literature, people who work under pressure are prone to error. However, they
have also proven to be more effective and productive under pressure. Whatever the case, time
pressure needs to be brought under control. Because only in this way is it possible to ensure
flight safety by preventing mistakes. Besides employees, businesses and operators can also be
exposed to pressure. When we consider the aviation industry, it is hard not to notice how

much pressure is put on airlines by factors such as financial problems, changes in cost rates,
and busy flight schedules.

4.11 Lack of Assertiveness

It is a term that describes the ability to express ideas and beliefs positively and productively.
Assertiveness should not be confused with aggression, and sometimes there is a fine line
between the two. As with others, lack of self-confidence also plays an important role in
human factors. It has been proven that many accidents occur for this reason (Seedhouse et al.,

16
2019, p. 14). The person must be sure that he knows the truth and be persistent in expressing
it. The necessity of teamwork in aviation is defined in this way.
Various factors cause employees to avoid being persistent. It is common for the co-pilots to
shy away from the captain pilot in the cockpit, and the cabin crews are afraid of the cabin
chief in the cabin. It has been observed that people hesitate to share even a piece of
information they are sure of when they are in this shy state. However, it should not be
forgotten that this situation can lead to many fatal accidents.
4.12 Stress
The fact that aviation starts with flying an aircraft causes stress to always be at the forefront.
For the operation to be carried out without interruption, the employees have to do the right
planning to make a profit. Everyone, including managers, is exposed to stress factors.
However, some factors cause and increase stress. These; It is divided into three physical,
psychological, and physiological.
It can be caused by physical factors, temperature, noise, lighting. There may be psychological
factors, financial concerns, family problems, health problems. On the other hand,
physiological factors can be given as examples of fatigue, insomnia, and hunger. For flight
personnel, conflicting schedules, excessive alcohol use and smoking can be included in the
list of stressors. Because each of them can cause a decrease in performance, and as a result,
increase the stress on the individual.
Being exposed to excessive stress causes dissatisfaction and, as a result, a lack of perception.
After that, distraction is inevitable. Looking at it from another angle, people with a lot of
decision-making responsibility, such as pilots, are likely to be under constant stress. People
who are under this influence must first be aware of it. Otherwise, they cannot manage stress
and become prone to making mistakes. This can lead to undesirable accidents and events.

4.13 Lack of Awareness

Aviation is an industry with tight schedules and operating under a tight schedule inevitably
means working under pressure. Many factors, including the pilot, cabin crew, manager, and
passenger, can put pressure on the person. However, the problems that a person experiences in
his private life can also put pressure on him. When the situation of working under high
pressure is noticed, the superiors need to take various measures regarding it. Sometimes this
can be achieved by making the distribution of tasks fairly, and sometimes by eliminating the
situation that creates the stress factor.

5. The Importance of CRM and CRM

17
In the aviation community and many other high-tech career fields, motor skills and the ability
to communicate clearly are essential. Airlines apply a training set to help employees gain
these skills. They prepare these training sets specifically for each field and plan them as
programs for employees.

Education in the aviation sector always continues. Employees are ensured to retake the
training they received at regular intervals, in other words, to renew their training. These
refresher trainings are applied whether the skills are used. For example, among the trainings
that a cabin crew should receive, there is also emergency safety rules training. In these
trainings, cabin crew learn the movements and procedures to be followed in a possible
abnormal situation. Employees receive these trainings theoretically and practically. However,
abnormal condition is not always encountered on everyone's flight. For this reason, since this
information is not reflected in real life, it may remain in the air. On the other hand, a flight
attendant is expected to perform the application completely in an emergency, which may
happen only once in his life. In short, it is necessary to keep all the information given in the
training in the aviation sector fresh, whether it is used or not.

The importance of education in the aviation sector has come to the fore even more with the
recognition of the effect of human factors on accidents. Along with this, Crew Resource
Management trainings came to the fore in airlines. The care industry, on the other hand,
aimed to respond to the need for systemic solutions by focusing primarily on developing
awareness-level training programs. The needs and needs of the cockpit and then the crew, in
terms of maintenance, have been determined.

5.1 What Is CRM?

Team Resource Management has been around for more than two decades. However, aviation
is still some misunderstanding for what the term entails. The aim of Team Resource
Management is a reliable management system that makes the most of all available tools such
as equipment people to increase operational activities in the aviation industry. CRM includes
a wide range of knowledge and skills, including cognitive and interpersonal skills (Weintrit &
Neumann, 2011, p. 16).

Generally, aviation training is considered in conjunction with the technical skills required to
fly an aircraft. These are map reading, reading, and interpreting the weather, calculating the
weight and balance, and maintaining the controls properly. However, other skills are also
valuable (Weintrit & Neumann, 2020). These skills were previously handled as CRM (Crew
Resource Management) Cockpit Resource Management. This area includes getting along with
crew members, knowing when and how to defend oneself effectively in critical situations, and
maintaining situational awareness. Over time, it was concluded that these factors are
important for the cockpit and all aviation employees. CRM (Crew Resource Management)
was named Crew Resource Management.

18
As a result of studies on the causes of civil aircraft accidents in general, it has been
determined that some human factors contribute to mishaps. These; preoccupation with minor
mechanical irregularities, inadequate leadership and monitoring, failure to delegate tasks and
assign responsibilities, failure to set priorities, failure to communicate intentions and plans,
failure to use available data, and insufficient monitoring of other crew members in the cockpit
(Martinussen and Hunter, 2009, p. 109).

CRM training is a way of optimizing the human-machine relationship and addressing the
interpersonal activities accompanying them. These activities include team building,
maintenance, knowledge transfer, problem-solving, decision making, situational awareness.
In 1980, the first CRM training course was implemented by United Airlines, concerned with
evaluating the performance of its team members and team members. Today, CRM is essential
for all airlines and aviation schools and reduces human errors and prevents any incidents,
accidents, and collisions (Weintrit & Neumann, 2020).

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 6. Accident Investigations Caused by Human
Error Tenerife Airport Disaster

In this section, the titles of A Qualitative Research on the Investigation of the Tenerife
Airplane Accident in the Framework of Human Factors in Aviation and the Determination of
the Human Factors Affecting the Process of Aircraft Accidents will be discussed.
6. 1. A Human Factor Investigation of Tenerife Airplane Crash in Aviation
The plane crash that killed the most people occurred in 1977 in Tenerife when two planes
collided. The image of the horrific accident is in Picture-5. As a result of this accident, 583
people died. The fact that very experienced pilots were using the planes could not prevent the
accident, and two giant Boeing 747s collided. This review will analyse the human factors that
negatively affect safety in plane crashes on the "Tenerife Airplane Crash Case".

Figure 3

6.2. History of The Tenerife Airplane Crash

On Sunday, March 27, 1971, a bomb planted by a terrorist group exploded at Gran Canaria
International Airport. After the second bomb threat was received, the airport was closed to

20
traffic. Planes planned to land at Gran Canaria International Airport were diverted to Los
Rodeos Airport in Tenerife in the Canary Islands (Cookson, 2009, p. 22.8).

Los Rodeos Airport has a single runway and a single taxiway. At the same time, the airport is
at the top of the island. For this reason, meteorological conditions tend to vary. The airport is
often in the fog of fog. The height of the airport is high enough to normalize the circulating of
clouds on the runway.
This situation may lead to a decrease in visibility and delays in landing and take-off of
aircraft. However, in Tenerife, there is not much problem in this sense. Because this is a
small, quiet airport not used to heavy traffic, where a few small planes come and go a day.
Due to the planes diverted from Gran Canaria Airport, Tenerife Los Rodeos Airport is
experiencing the busiest day in its history. This density makes the job of controllers more and
more difficult. The landing of many planes caused a complete mess. Planes parked in
taxiways. For this reason, the controllers started to direct the departing planes on the single
runway of the airport to bring them to the correct position.

Pan Am Flight 1736, departing overnight from Los Angeles, made a stop in New York and is
waiting for take-off in Tenerife. Passengers and flight crew who have been on the road for a
long time want to reach their destination, Las Palmas, as soon as possible. Boeing 747-121
type aircraft has 396 people, 380 of which are passengers and 16 are crew members. When
Las Palmas Airport opens, the Pan Am crew and aircraft are ready for take-off. However,
KLM is getting fuel and blocking the runway road. There are approximately 30 minutes to
complete the fuel purchase (Ziomek, 2020).
KLM flight 4805 from Amsterdam is waiting for taking off. There are 248 people on the
Boeing 747-206B type aircraft, of which 234 are passengers, and 14 are crew members. KLM
requested permission to take off after fueling was finished.
Meanwhile, fog covered the whole place and made the visibility almost non-existent. After
KLM requested take-off clearance after fueling, Pan Am requested take-off clearance.
Controllers direct the planes to the runway simultaneously to accelerate the take-off of both
KLM and Pan Am, allowing the two giant Boeing 747s to take off simultaneously.

21
Pan Am will get on the runway and taxi after KLM and exit C3 to get behind it again
(Ziomek, 2020). KLM must turn 180 degrees at the end of the runway and notify when it is
ready to take off. The images of KLM, which has made its turn after take-off, and Pan Am on
the runway heading to exit C3 are shown in Figure-6.

Figure 4

Meteorological conditions make the situation more difficult, and visibility has decreased to
300 meters. Meanwhile, the controller informs the KLM flight crew about what to do after
take-off. This speech is also heard in the Pan Am cockpit. After the conversation, the
controller commands the KLM to wait for take-off; I will call you. Pan Am, simultaneously
taxiing on the runway, reports the situation over the radio. The controller asks Pan Am to
inform him when he leaves the runway. However, they see the KLM plane coming towards
them at that moment. Pan Am Captain Pilot Victor Grubbs tried to get off the track quickly by
giving the engines full throttle. KLM Captain Pilot Jacob Veldhuyzen Van Zanten tried to
take off without crashing but was unsuccessful. KLM crashed into Pan Am while attempting
to take off, cutting the upper floor of the Pan Am plane in half. The KLM aircraft drifted
about 300 meters on the runway. A loud explosion was heard in Tenerife. However, no one
can see what happened because of the fog. Radio communication of Air Traffic Controllers
(HTK, Air Traffic Control-ATC) with both planes was lost. Figure 5 showed the location of
KLM and Pan Am aircraft when they collided on the runway.
As a result, the cockpit crew on the Pan Am aircraft survived. Three hundred thirty-five
people died: 61 survived. There were no survivors from the KLM plane. Two hundred forty-
eight passengers and all crew were killed. A total of 583 people lost their lives in this
accident.

22
As a result of the Tenerife disaster, which is called the deadliest plane crash in aviation
history, 583 people lost their lives. Thereupon, KLM paid a total of 110 million dollars
compensation to the relatives of the people who lost their lives. While KLM continues to
operate even today, the Pan Am company was never able to recover after the accident and was
shuttered in 1991.
After the accident, many allegations were made. The most serious of these was undoubtedly
that the control tower was watching the match at the time of the accident. However, these
claims were never proven, and research revealed factors such as the disruption of radio
conversations, the KLM captain pilot's mixing of real life and simulation, known as the
training syndrome, adverse weather conditions and the airport's lack of necessary equipment.

23
6.3 Investigation of the Accident in the Framework of Human Factors
Human factors are at the forefront in this accident, which was realized by the combination of
many factors and the formation of a chain of errors. Additional factors that develop outside of
human behavior also have some effect on the course of events. It is accepted that human error
and additional factors also interact with each other. For this reason, Tenerife Plane Crash will
be examined under the headings of “Man”, “Machine” and “Medium” within the framework
of human factors (Wiener, 1977).
6.3.1 Lack of communication
1 minute and 23 seconds before the crash, the KLM aircraft made a 180-degree turn for
takeoff. He stated that he was ready for take-off and that they were waiting for take-off
clearance. However, it has expressed this as an ATC Clearance request. ATC Clearence (air
traffic controller clearance) contains information about the route that the aircraft should fly
from after departure to the destination airport. The controller then gives information about
what to do after takeoff. In the approval they receive from the air traffic controller, the word
takeoff is mentioned, and the captain pilot accepts it as having received the take-off clearance.

24
The captain pilot wants to take off as soon as possible due to the time pressure he is in (the
concern about the expiry of the working hours is examined in detail under the heading of
pressure). That is, it is the takeoff instruction the pilot expects to hear from the air traffic
controller. The use of the word "takeoff" during the speech made the pilot think that he had
received the instruction he was waiting for. In other words, the pilot is inclined to do the
instruction he expects to hear, not what he hears, and he has done it. This communication ror
resulted from expectation-based misinterpretation (Wiener, 1977). Confirming by repeating
the controller's ATC Clearance, the KLM co-pilot says, "We are now at takeoff" (Cushing,
1997, p. 10). Tower; wait for takeoff. I will let you know (“Stand by for takeoff. I will call
you”) (Cushing, 1997, p. 10). As can be understood from the conversations, the KLM pilot
announced that he was ready for take-off, while the controller told them to wait for take-off.
Meanwhile, Pan Am reports that they are on the runway, saying that we are still taxiing. The
tower, on the other hand, asks them to give information when they get off the runway. These
conversations are assumed to be heard in the KLM cockpit, as they use the same radio

frequency. However, simultaneous tower and Pan Am conversations caused a high-pitched

25
sound in the KLM cockpit and the conversations were not heard. After that, the KLM plane
taking off crashed into the Pan Am plane taxiing on the runway while trying to take off. These
last few minutes of conversations are shown in Figure-6 as they were recorded.

Figure 5

The tower allowed Pan Am aircraft to take to the runway after the KLM aircraft to speed up
the operation. The aim is for the Pan Am aircraft to taxi on the runway, arriving at the take-off
position immediately after the KLM aircraft takes off. The Pan Am aircraft must turn off the
runway from the C3 taxiway. However, they had a communication problem while the
controller was directing the aircraft to the third exit. The fact that the controllers' mother
tongue is Spanish made it difficult for them to get along with the Pan Am captains. This is one
of the language-based problems of the lack of communication. In particular, the accents of
people whose mother tongue is different when speaking English can prevent them from being
understood (Seedhouse et al., 2019).
Also, since the accident at Tenerife Los Rodeos Airport was on Sunday, two officers were on
duty at the Control Tower. They are trying to control the intensity they encounter for the first
time. There is also a football match played that day. The controllers in the tower tried to
follow the match among this intensity. This is an indication that the minds of the controllers
can be messy (Seedhouse et al., 2019).
6.3.2 Lack of Teamwork, Self-Confidence, Lack of Self-Confidence
As seen in the conversations in Table-3, the controller's wait for take-off instruction was not
heard in the KLM cockpit. However, the controller's instruction to Pan Am to report when
you leave the runway and Pan Am's statement that we will report when we are done was
heard in the KLM cockpit. In fact, these conversations are an indication that there is a Pan Am
plane on the runway. However, KLM Captain Pilot Van Zanten almost ignores these
conversations under time pressure. Van Zanten is a self-confident pilot who is aware of his
success. Unfortunately, having a high sense of self-confidence sometimes causes a feeling of
extreme comfort. With a sense of self-confidence, the KLM Captain Pilot tended to see what
he wanted to happen, not what is.
People may not be able to make the right decisions under the influence of some factors. For
this reason, possible mistakes can be prevented if other pilots or flight engineers in the cockpit
give their opinions. Communication in the cockpit must be strong, and teamwork must be
prioritized. However, it is not easy to even express the possibility that what he did to an
experienced trainer, in short, the star of the company captain like Van Zanten, might be
wrong. A captain in the Van Zanten position is unlikely to be opposed by the co-pilot or flight
engineer. This is an indication of the lack of teamwork in the cockpit. When people cannot
express their thoughts freely, everything is left to the decision of one person. This can cause
an accident to be inevitable due to one person's fault.

26
The part of the last conversation between the tower and Pan Am, which was reflected in the
KLM cockpit, created a question mark in the mind of the flight engineer. Pan Am not off the
track? He asks. After the captain pilot said he was out, the flight engineer could not say
anything. The flight engineer is the most junior member in the KLM cockpit. An experienced
pilot like Van Zanten was not likely to give a warning again. This is a sign of a lack of self-
confidence. Even if it was possible, he could not be insistent on an important issue such as an
aeroplane on the runway and could not prevent the accident. Audio recordings of the last
conversations in the KLM cockpit are shown in Figure 6.

6.3.4 Pressure and Lack of Awareness

KLM Pilots are concerned about flight hours, which puts them under pressure. It is almost
time to expire, which may cause an operational disruption that may lead to the cancellation of
the flight. Passengers in Las Palmas have waited for about six hours at the terminal.
According to the planned operation, after the KLM flight arrives in Las Palmas, it will take
the waiting passengers and make it to Amsterdam. If the flight from La Palmas to Amsterdam
is cancelled, it will be a very difficult option for all passengers to find accommodation for the
night. Considering the airline, this situation is seen as a serious financial loss. Captain Van
Zanten decides to take advantage of the time they wait in Los Rodeos and buy enough fuel to
return to Amsterdam to reduce his loss and allow minimum ground time in Las Palmas. Thus,
they want to manage time well and reduce the waiting time in Las Palmas to 15-20 minutes.
However, when Las Palmas Airport opens to air traffic, the fuel purchase is not finished yet.
Van Zanten's decision to buy fuel to save time brought about a further loss of time
(Fitzgerald, 2010). So much so that the Pan Am plane, which could not pass by it, could not
reach the runway for take-off.
6.3.5 Working hour
The time pressure that the constraint creates on him leads to a lack of awareness. The audio
recordings show that the experienced pilot gives gas for take-off without obtaining permission
yet. Upon the warning of the co-pilot, Van Zanten realizes what he has done and cuts off the
gas. Van Zanten wanted to prevent the accident by flying over the Pan Am plane before the
collision. For this reason, the plane's noise was lifted as much as possible, and even the
plane's tail rubbed the ground. However, this effort could not prevent the accident. However,
if it were not for the non-essential fueling before take-off, it would be possible to take off
without crashing into the Pan Am aircraft. KLM bought the 55,000 litres of fuel it needed to
buy in Las Palmas while waiting in Los Rodeos to save time. Due to the excess fuel, the
weight of the aircraft increased. For this reason, the take-off distance of the aircraft has also
increased. We can say that this is one of the side factors that brought the accident.
Controllers at Los Rodeos Airport are not used to such heavy traffic. Almost 50 planes took
off in a few hours. Moreover, it is very difficult to control many aircraft at an airport without
ground radar. It is inevitable for controllers to feel under pressure when faced with a more
intense operation than they have ever managed before (Fitzgerald, 2010).

27
6.3.6 Stress, Fatigue and Lack of Knowledge
Stress and its impact on human and organizational behaviour were the main factors in the
Tenerife collision. The problems faced by KLM crews include delays caused by terrorists at
the destination airport, difficult and uncertain weather conditions, and stringent flight duty
time limits that are coming to an end.
Spanish controllers in the tower have to deal with aircraft much larger than normal and
heavier than normal traffic volumes. In addition, the controllers try to manage the operation
correctly with a less familiar second language, English. As such, the importance of normally
unfamiliar topics disrupts cognitive processes, reducing alertness and judgment. Jobs that
become complex for people in particular directly impact performance. Along with many other
factors, this factor is also present in Tenerife. Deciding to buy fuel to buy time, the KLM
captain did not consider the possibility that Pan Am was still on the way. It removes the
uncertainty presented by the engineer and decides ahead of time. However, choosing a better
option, such as waiting for a few more seconds in response to a fast take-off, maybe a choice
that could save the lives of 583 people (Mccreary, Pollard, Stevenson, & Wilson, 1998, p. 24).
In addition, Pan Am pilots, who have been waiting with their passengers for a long time, are
now impatient to reach the destination square. Pan Am crews faced environmental conditions
such as fog at the airport. However, they have been working for 11 hours, although they are
not approaching the limits of their tenure. After Las Palmas Airport was opened to air traffic,
they had to wait for the fueling of the KLM plane to take off. They are unnecessarily delayed
by KLM aircraft. This situation has been a source of stress for the cockpit crew, who want to
get their passengers to their destination as soon as possible. In particular, the prolongation of
fuel intake increased the tension. This is a side factor that affects normal behaviour. Because
the combination of minor nervous disorders can accumulate at the end of the day and become
a source of stress (Mccreary et al., 1998, p. 24-25).
Pilots, landing, taking off, and taxiing at an airport do not get much attention. This lack of
information, especially the dense fog that reduces the visibility to almost nothing, makes it
difficult for the pilots to find their way in an unfamiliar place. It would not be wrong to say
that Pan Am pilots, who have communication problems with the tower and difficulty finding
the taxiway on the runway, are under intense stress. For the cockpit crew, who have been
working for long hours, fatigue is among the factors that gradually emerge.
6.3.7 Norms
KLM Captain Pilot, Jacob Veldhuyzen Van Zanten, 50, flew 11,700 hours. He is an
experienced pilot with a flight time of 1545 with a Boeing 747 aircraft type. Van Zanten, the
advertising face of KLM, also serves as Head of KLM Flight Training Department and
Instructor Pilot. Captain Van Zanten is healthy during the flight, and he has no problems with
vision and hearing. He was on duty for 9 hours and 21 minutes at the time of the accident.
Looking at this last six-month flight log of the captain, it is seen that he spends most of his
time in the simulation. Although the simulators successfully provide a real flight experience,
28
tower communication is limited. Van Zanten has been simulating take-off for months without
tower clearance. This means that there is no obstacle for a pilot to be ready and wait for flight
once he has mastered the necessary controls. This habit, which he had acquired for a long
time in simulation, has become an acquired useless norm for the experienced pilot. In this
accident, the captain pilot had the useless norm that it was, was to take off without obtaining a
take-off permit, as it does every day in training (Air Line Pilots Association, 1978, p. 4).
Under normal circumstances, he is an experienced pilot who would not make the fatal mistake
of taking off without the tower's permission. However, the time pressure on him caused him
to make the wrong decision. The captain pilot's impulsive behaviour on take-off caused a lack
of awareness. Thus, it has become inevitable for a vital mistake to occur on this subject,
which would never be overlooked under normal circumstances.

6.3.8 Machine
KLM pilots say that they are taking off, thinking they have received permission. However, the
tower does not understand this due to a communication error. The controller then tells them to
wait for take-off, but this instruction is not heard in the KLM cockpit. Because the tower and
the Pan Am pilot warned at the same frequency simultaneously. KLM uses the same
frequency as the Pan Am pilot reported continuing to taxi.
For this reason, only the OK command is heard in the KLM cockpit, instead of the tower
saying OK, wait for take-off, I will call you. The warning that Pan Am is taxiing on the
runway and that the tower must wait for take-off is only heard in the cockpit as a sizzling
sound. This situation, which is one of the most important factors that cause the lack of
communication and brings the accident, is due to the radio frequency's inability to transmit
more than one voice simultaneously.
6.3.9 Lack of Resources
This small airport in Tenerife has no ground radar to track planes. It is very difficult for
controllers to operate without ground radar in very busy situations. As I mentioned before,
Los Rodeos airport has several planes land and take off every day. Moreover, these are
usually small jet planes. The controllers, who had to work harder than usual, also suffered
from the lack of ground radar. Visibility at the airport, under heavy fog, is almost non-
existent. This situation creates a serious problem for the tower, which provides control only
by radio communication.
6.4.0 Lack of Information
It's not uncommon for a Boeing 747 to arrive in Los Rodeos. For controllers, steering these
large planes is something they have not experienced before. Small planes can easily turn from
exit C3. As a result, the controller diverted the Pan Am aircraft to the C3 taxiway, an exit
from which it was impossible to turn. The image of the table we mentioned on the runway is
shown in Figure-10. Realizing that this turn would not be possible, Pan Am pilots crossed the

29
C3 road and headed for C4. The collision occurred as the Pan Am aircraft was about to reach
the C4 taxiway.

6.4.1 Medium
Those located at Los Rodeos Airport.
 An air observation tower located approximately 400 meters southwest of the approach
end of runway 30

 Another tower located approximately 200 meters northeast of the approach end of
runway 12

 a sight transmissometer located approximately 70 meters south of runway 30 approach

(Electronic instrument that continuously records atmospheric transport between two fixed
points (“Meteorological Dictionary”, 2021))

 Barometric pressure, temperature, and dew point value logger

 Teletype for route weather information

 Visibility is reported by the tower controller when the approach to the service runway is
visible. Otherwise, this is done by an observer in the weather observation stage.

 Runway visual range should be reported (Final Report and Comments of The Netherlands
Aviation Safety Board of The Investigation Into the Accident With The Collision of KLM
Flight 4805, Boeing 747-206B, PH-BUF and Pan American Flight 1736 [ICAO], 1979).

Meteorological conditions and cloud types in Tenerife vary. The airport is 2073 feet above sea
level, on the seafront at 2000 feet above ground level. Due to the height level, there are clouds
several floors above. That is, the fog situation in Tenerife exhibits very different
characteristics from the normal fog. For pilots, cloud density causes changes in visibility.
These conditions can cause pilots to have difficulties in determining the appropriate viewing
distance for take-off and landing. The Tenerife Plane Crash also took place in a very high-

30
density cloud. While both planes are on the runway at the same time, the airport is under
heavy fog and visibility is almost zero. The tower cannot see the runway and planes due to
fog.
Due to the absence of ground radar, the controllers had no choice but to rely on radio contact.
For this reason, no one was able to see the moment of the accident. The first indication that
something is wrong with the controllers is the sound of two successive explosions (Air Line
Pilots Association, 1978, p. 8). The fog did not only cause the two planes not to see each other
on the runway and the tower not to see the runway. The ever-decreasing visibility also caused
Pan Am pilots to find it difficult to find the turn they needed to take off. After hearing the
explosion, the teams went to the runway for help.
However, it was not immediately clear that the KLM plane was also involved in the accident,
again due to the low visibility. There were no survivors from the KLM aircraft, which went
undetected as it drifted away after the collision. Los Rodeos Airport in Tenerife was not
designed to accommodate large numbers of aircraft. There is not enough parking space for the
large number of planes diverted to this small airport. For this reason, the planes have become
parked on the taxiway. This is another factor that complicates the work of controllers. The
presence of too many aircraft at the airport compared to normal times caused the parking
problem and the aircraft had to park on the only taxiway of the airport.
In addition, measurement equipment for runway visual range (Runway Visual Range-RVR) is
not available at the airport. The controllers were therefore unable to provide accurate visibility
information to the pilots. In addition to all these conditions, the runway lights do not work on
the day of the accident.
7. Analysis of Tenerife Plane Crash
7.1.1 Measurement Models of the Human Factor in Aviation
To understand human factors, some research models are needed during the analysis. These
models allow us to understand, step by step, the effects of humans on aviation. In this title, the
SHEL model, the Swiss Cheese model and the HFACTS model will be examined.
7.1.1.1 SHEL Model
The concept of SHEL is used by the International Civil Aviation Organization (ICAO), and its
name is derived from the initials of this word. It was first established in 1972 by Prof.
Invented by Elwyn Edwards and developed by Captain Frank Hawkins in 1975. The SHEL
model, which consists of the initials of its name, has four components. In this model, which
consists of different components of aviation, the relationship of human with other components
is examined.
At the same time, human is one of these components and is at the center of the SHEL model.
Thus, the interaction of human with other components is emphasized by considering them
separately. Because people can be adversely affected by many reasons during work. These
negative effects also cause a decrease in human performance. Decreased performance and
making mistakes can cause accidents and incidents. As seen in Figure 7, the SHEL model
31
emphasizes the importance of the human factor in aviation by putting people in the center. To
ensure the harmony between the components, it is necessary to know the characteristics,
performance, and limits of the human being.
As shown in Figure 7, the SHEL model consists of the following components:

 S- Software: Software (documents, procedures, training, systems, etc.)

 H- Hardware: Hardware (machines, tools, equipment, etc.)

 E- Environment: Environment (lighting, etc.)

 L- Liveware: Human (technician, manager, etc.)

32
According to the literature, human-software, human-hardware, human-environment, human-
human interactions are shown in the SHEL model.

1. Human – Hardware (L – H)
This interaction has come to the fore when designing systems for human machine use. Seat
design to suit the sitting characteristics of the human body, screens suitable for the user's
sensory and information processing characteristics, and controls with appropriate gestures are
some of these. In particular, the human-equipment relationship was prioritized during the
cockpit design. As a result of these new designs, there has been a decrease in accident rates.

33
The relationship between human and hardware components is becoming an important
research topic for the human factor in aviation.
2. Human – Software (L – S)
This interaction includes humans and their non-physical aspects. Systems such as procedures,
guide and checklist layout, computer programs are some of them. Problems in the human-
software relationship are usually more less concrete and, as a result, more difficult to analyze.
It is possible to show the misinterpretation of checklists as an example (CAA, 2013, p. 1-4).
3. Human – Environment (L – E)
Human-environment is one of the oldest interactions. All the measures taken in the early days
of aviation were aimed at adapting people to the environment. For this reason, some materials
such as helmets, flight suits, oxygen masks have been designed for use during flight.
However, later the trend changed to suit the environment to man. Today, new challenges arise
such as radiation hazards and problems associated with disrupted biological rhythms,
especially at ozone concentrations and high flight levels. The increase and continuous practice
of east-west travel results in people experiencing sleep disorders and withdrawal problems.
Since illusions and disorientation form the basis of many aviation accidents, the human-
environment relationship gains importance (CAA, 2013, p. 1- 5).

4. Human – Human (L – L)
This component deals with the interaction of people with people. It is important for people to
be fit for flight physiologically and psychologically to ensure safety. Because, any distraction,
perception disorder or emotional state that may be experienced during the flight can prevent
people from correctly perceiving what is happening around them. According to the literature,
human-human interaction is mostly at the source of situations that pose a risk to flight safety
(Erdem, 2018, p. 21). In this context, it is important for flight personnel to provide in-team
coordination.

7.1.1.1.1 HFACS Model

Swiss Cheese needed improvement as its model was only used for post-accident inspections.
The HFACS Model has been developed to meet this need. The HFACS Model was first
developed in 2000 by Dr. Scott Shappell and Dr. Doug Wiegman was introduced as the
“Human Factors Analysis and Classification System”. The basis of the model is based on the
Swiss Cheese Model. Shappell and Wiegman define human factors with 4 levels of error: first
level unsafe acts, second level unsafe acts, the third level unsafe management, fourth level
organizational effects (“The Industrial Training Levy (Air Transport and Travel) Order 1970
(Amendment) Order 1971,” 1971).
The HFACS Model is helpful in measuring people's performance and limits, especially in
forming survey questions of research. This model considers the causes of accidents in a
34
systematic order. Thus, it tries to determine which element has how much share in the chain
of errors. Shappell and Wiegman analyze and classify human factors in 4 levels and 19
categories. Thus, it is aimed to find the main causes of accidents. The four levels we have
mentioned are Manual factors are unsafe management, unsafe situations, and actions that
prepare unsafe situations. From the order of levels shown in Figure-8, the first two are
concerned with the management of institutions, and the other two dealing with people.
We can say that aviation accidents occur due to many reasons. Because accidents are usually
caused by the inability of people to manage the mechanical, technical, or meteorological
problems that arise. Accordingly, the main cause of plane crashes often leads us to pilot error.
This has never been a correct perception. In accidents that occur because of a combination of
many reasons, these reasons can often seem meaningless when considered alone. It may even
make us think that it does not have the qualifications to be the cause of an accident.
However, when we look at the whole picture and consider all causes as a link in the chain, it
can be clearly seen how insignificant situations have a great impact on the accident. In aircraft
accidents that occur, either there is a problem in the aircraft design, there is a mistake in the
production, or a misuse was made by the pilot, or a mistake was made in the maintenance of
the aircraft. Along with all these, trusting people is the most important requirement. However,
it is not possible to ignore the great impact of human factors on plane crashes.

Figure 6

35
7. Unsafe Behaviors
Before moving on to the concept of unsafe behavior, “What is safety?” need to answer the
question. Wiegmann & Shappell (2016) defines this concept as follows.
Safety is one of the most important issues in aviation. In the most basic sense, safety means
no accident. A safe air traffic flow is achieved by avoiding collisions between airplanes and
airplanes, and between airplanes and obstacles, vehicles, and people. The rules, which have
been constantly changing and developed because of the important experiences gained in the
history of world aviation for many years, are also mostly related to safety (Uslu, 2011: 56).
unsafe behavior; are examined under two main headings, namely errors and violations. Errors
are unintentionally causing an accident, damage or undesired event without the pilot or cabin
crew being aware of it. Violations, on the other hand, are characterized as the team's ignoring
of the problem despite being aware of the problem or acting as it suits them. Shappell and
Wiegmann (2000) emphasized that while mistakes are considered legal, that is, in accordance
with the rules, violations are breaking the law. Errors and violations are also divided into
various classes (Shappell & Wiegmann) As can be seen, errors are examined in 3 separate
classes, and violations are examined in 2 separate classes.
Decision errors: It can be evaluated as the inability of the pilot or cabin crew to solve a
problem. According to Shappell and Wiegmann (2001), decision errors can be called honest
mistakes. It is also considered as misinterpretation of information, making inappropriate
decisions, or incomplete or poor implementation of procedures (Shappell & Wiegmann, 2001:
1009). Berry (2010) explains decision errors as follows; It is to cause unsafe behavior by
making a wrong choice in the face of the situation encountered. It can also be described as the
fact that a planned behavior works as planned, but the plan is wrong in the face of the
situation encountered (Berry, 2010: 16).
Talent mistakes: It can be defined as constantly experienced situations or mistakes made in
situations that do not require thought. Errors such as failure to scan screens, skipped checklist
item, incorrect or inappropriate use of flight controls are examples of this error group
(Shappell & Cristy et al., 2007: 230). Contrary to mistakes, the decision is not about thought
but rather about talent. Insufficient control of the lever or stick or scanning the indicators
quickly requires skill. Sometimes, pilots may not have the necessary skills in these matters,
many conditions such as the pilot's mood or physiological condition on that day are effective.
It also covers situations such as the inability to pay full attention to the flight.
Detection errors: Decision errors and skill errors make up the majority of accidents, but
these errors, which are generally in the background, are also very important. At night, in bad
weather conditions, or in cases of incomplete or insufficient information, it becomes difficult
for pilots to perceive and manage the flight, and this pushes them to make perception mistakes
(Shappell & Wiegmann, 2001: 1010). Violations: Violations can be divided into many
classes. However, it is basically examined in two classes as routine and unusual violations. If
these two types of violations will be explained on the example; Driving at 60 km/h in a 50
km/h speed limit is considered a routine violation. However, it is unusual to drive at 120 km/h

36
in a 50 km/h speed limit. Therefore, it can be said that routine violations occur as a habit in
people because of the connivance of the laws or administrators.
8. Swiss Cheese Model
There are several human factors that contributed to the Tenerife accident. However, we can
qualify as side factors; Technical and meteorological factors were also examined. The
succession of all these factors caused the accident by creating a chain of errors. For this
reason, Tenerife will be examined within the framework of the Swiss Cheese Model.
Technological developments lost their impact on preventing accidents towards the end of the
1990s and reached normal levels. The Swiss Cheese Model based on Reason's idea of
accident causation has been the biggest step taken to investigate organisational effects in
accidents (Wiegmann & Shappell, 2016)

The Swiss cheese model of accident causation is used as the principle behind layered security
as it is used in-depth in risk analysis and risk management, and computer security and
defence, including aviation safety, engineering, health, emergency services organisations.
World aviation authorities have accepted it. At the same time, HFACS is based on Reason's
Swiss Cheese Model.

Reason has described various layers and the holes on these layers, namely pathogens. In the
model, pathogens represented errors, missing or non-working elements. While apparent
causes are expressed as the apparent causes of the accident, implicit causes express the
invisible causes behind the apparent cause of an accident. The overlapping of holes causes
disasters to occur. In most of accidents, a layer can stop the accident that may occur. Holes
may appear, disappear, or change in size. This change depends on the mental and physical
structure of the system or organisation.

Even though we think that apparent reasons cause accidents, hidden errors may extend to
organisational effects behind the accidents. According to Reason, although there are visible
errors in all cases, they are often not detected or overlooked. This raises the biggest problem
in Reason's work itself. Thus, it has ceased to be a model for pre-accident analysis and has
become a limited model for post-accident investigation. Therefore, the dangers underlying
this model suggest that more work is needed.

 Example for Swiss Cheese Model

Birgen Air Accident, 1996

Apparent Cause: The plane entered the Stall, and the crew did not respond properly.

Implicit Reasons: Unsafe Behavior Background: Hierarchy and Lack of Education

37
Unsafe Management: Inadequate training planning and lack of awareness of Human Factors.

Organisational Factors: Hierarchy is accepted in the company culture, lack of training

department, lack of a quality system to measure training deficiencies.

Although the cause of the accident is thought to be due to the plane entering the Stall and the
crew not responding to this situation, there are invisible reasons for this error. The formation
of errors is likened to an iceberg. Known and seen errors are at the top; Errors that can cause
great disasters are under the water in the invisible part. For this Reason, accidents should be
carefully examined, and implicit causes should not be ignored.

8.1 Factors Causing Tenerife Plane Crash with Swiss Cheese Model Evaluation.
1. Diverting the planes that will land at Las Palmas Airport to Tenerife Los Rodeos Airport
due to the bomb threat
2. Los Rodeos Airport is small and inadequate. For this reason, non-standard and potentially
dangerous maneuvers are made.
3. Low windblown clouds change visibility in Tenerife
4. KLM aircraft, refueling, delay for departure of other aircraft and itself
5. Pan Am cockpit crew having trouble finding the turn to use to exit the runway (Airport had
no signs at taxiway exits. Visibility was poor and pilots were unfamiliar with the airport. It
was difficult to communicate with the controller to understand instructions. This was due to
the controller's Spanish accent in English speaking)
6. Pan Am aircraft failing to turn from exit C3 to which it was steered (C3 Taxiway had two
148-degree turns and was a difficult maneuver for a Boeing 747. Pan Am aircraft, which
passed the C3 exit related to the reason, headed for the C4 exit and a collision occurred at the
specified location)

38
7. When the KLM pilot wanted to express that he was ready for take-off and that they were
waiting for take-off clearance, he expressed this as an ATC Clearance request (After receiving
ATC Clearance permission, the captain took off thinking that he had received a take-off
permit)
8. The KLM Co-Pilot says we are taking off now when the plane starts to move, but the tower
from which the plane is taking off does not understand
9. Two important messages are not heard in the KLM cockpit, as the Control Tower and Pan
Am are conducting simultaneous radio communications. (The content of these two messages
is the tower's wait for departure instruction and Pan Am's information that we are still taxiing
on the runway)
10. KLM captain takes off without permission from the control tower
11. The KLM captain did not take the flight engineer seriously and the subsequent
conversations about the possibility of Pan Am being on the runway. (Based on these
conversations, the flight engineer thought that the Pan Am plane was likely to be on the
runway and warned about this. However, the KLM captain pilot did not heed the flight
engineer's warning on this matter.)
The Tenerife Plane Crash was a combination of many factors. When the accident report is
examined by focusing on human factor problems, it is seen that many human factors cause the
accident. This accident was the first step in the start of team resource management training.
The importance of the human factor in aviation has been emphasized once again. Even if the
captain is the pilot, it is possible to make a wrong decision when the human factor comes into
play. The accident also changed the common language. After this accident, it was decided not
to use the word "takeoff" in the speeches made by the controllers outside the take-off
clearance.

9. Boeing 737 Max: Indonesia 2018 Lion Air Crash

The majority of aviation accidents are caused by a combination of factors. In other words,
aviation accidents occur as a consequence of a complex interaction of factors. Production
processes, maintenance operations, human factors, climatic circumstances, certification
controls, and runway condition are examples of these influences. Consecutive accidents
involving the same aircraft type, on the other hand, are unmistakably noticeable. These
successive disasters include two B-737 Max commercial passenger jet crashes in Indonesia on
October 29, 2018, and Ethiopia on March 10, 2019. These mishaps are explored in this paper
in terms of certification methods from a piloting and engineering standpoint.
On October 29, 2018, a Boeing B-737 Max plane crashed in Indonesia, causing 189 deaths.
After about 4 months, another B-737 Max plane crashed on March 10, 2019, this time in
Ethiopia, and 157 people lost their lives in this accident. B-737 Max accidents, with a total
loss of life of 346 people, are among the most remarkable accidents in the history of the

39
 International Civil Aviation Organization (ICAO), which was established with the Chicago
Convention in December 1944.
ICAO is the top organization of aviation authorities under the United Nations and is
considered one of the most successful sub-organizations of the United Nations. ICAO
publishes important documents for international standards and practices in order to increase
flight and ground safety in accordance with aviation rules. One of the most important of these
documents is the "International Standards and Recommended Practices" (SARP) standards.
The purpose of distributing the said documents to the relevant institutions and organizations is
to try to make aviation, which has become a growing and multi-layered discipline, as safe as
possible at the global level.
However, there are opinions on many platforms that applications such as SARP are
insufficient in adapting new technologies to aircraft and that these applications should be
made on a digital basis. The basis of these views is the transition from the rule-based
certification process to the risk-based certification process, especially in the adaptation of new
systems to aircraft, and the implementation of digital-oriented applications. Likewise, it is
stated that the safety surveillance speed and capabilities of aviation authorities in different
units of the same organization may be insufficient in supervising new technologies adapted to
aircraft, and this is a risk for flight and ground safety.

At this stage, it would be appropriate to focus on the concept of airworthiness. Airworthiness,

by definition, is the ability of an aircraft to operate in a certain configuration during its life
cycle, with limitations and without posing risks other than those accepted for the flight crew,
ground crew, passengers, other aircraft, and the residential area over which it is flying. the
ability to initiate, maintain, and terminate. Airworthiness certification, on the other hand, is a
systematic process applied to determine the airworthiness of an aircraft under defined
operating conditions and documented by the certification authority. Airworthiness
certification is handled in two different processes as “initial” and “continuous airworthiness”.
In general, within the scope of the controls, the certification process can be handled on two
different fronts: "rule-based" and "risk-based".

40

Şekil 1. Uçuş Safhaları [13]

Conclusion
The human factor has an important role in all sectors. In particular, people working in the
aviation industry had to get out of their normal comfort zones. In aviation, people must keep
their limits under control and ensure safety and security despite all risks. Although
investments have been made in uncrewed aerial vehicles with the developing technology,
aviation history started with humans, and humans are always at the centre of the aviation
industry.
Human errors are inevitable in the aviation industry, where humans play such an active role.
While the accident rates caused by technical reasons have gradually decreased with the
developing technology, the active role of the human in aviation increases the effect of human
errors on accident rates. After accepting that aviation's most important building block is
human, an increase is observed in studies on understanding and analysing human beings. With
the adaptation of humans to physical conditions, research has been done on his resources.
With the creation of models such as SHEL, the components with which humans interact were
determined and analysed on the relationship between them. As a result, it was concluded that
the interaction between aviation industry employees caused errors to occur. Dupont's study
reveals that twelve factors cause people to make mistakes. Factors called Dirty Flat; lack of
communication, self-confidence, lack of knowledge, distraction, lack of teamwork, fatigue,
lack of resources, pressure, lack of self-confidence, stress, lack of awareness, norms. The
effectiveness of these twelve factors, each of which has a different effect on people, in fatal
accidents has been observed.
Determining the limits of people and determining the factor’s affecting people is only one
step towards preventing accidents. The main thing is that people know these factors that they
are under the influence of and become aware of when they are exposed to them. The first step
taken in the light of this awareness was to start giving PBM pieces of training to pilots. These
pieces of training have also started to be given to cabin crews to ensure the safety culture that
has developed over time and has been adopted by airline companies. It was carried out to
determine whether the personnel are aware of the human factors they are exposed to and
determine how effective the PBM training is in preventing plane crashes. In this context,
solution proposals for minimising aircraft accidents have been tried to be determined.
Tenerife Airplane Crash has been analysed within the environmental, human and machine
headings within the scope of dirty dope items. Meteorological conditions and the limits of the
airport were examined under the title of the environment in the Tenerife Airplane Crash,
which includes almost all of the twelve human factors. The visibility range has reached almost
non-existent levels due to fog is seen as one of the triggering reasons for the accident. Under
the human heading, flight personnel, air traffic controllers and maintenance personnel were
examined. In particular, the factors of lack of communication and overconfidence were
41
emphasised. Communication problems between the tower and the cockpit were analysed and
conveyed. It was underlined that the KLM Commander-in-Chief had excessive self-
confidence and that PBM clauses were not applied in the KLM cockpit. This analysis, which
was based on the Swiss Cheese Model, investigated in detail how a fatal aircraft accident
occurred in the event of a chain of errors due to more than one reason. Written document and
document analysis, which is a qualitative research technique, was used for this research. In
this context, accident reports and cockpit sound recordings were examined.
Within the scope of the effect of human factors on aviation accidents, interviews were
conducted with a qualitative data collection method. In this context, interviews were
conducted with 11 cabin crew and nine pilots, all flight personnel, using semi-structured
interview techniques. The collected data were analysed within the scope of determined
environment, human and machine themes. The findings were interpreted based on the codes
determined within the factors causing the accidents. At the same time, these interviews aim to
ensure the reliability and validity of the Tenerife Airplane Crash analysis by using the
environment, human and machine titles used in the Tenerife Airplane Crash analysis codes.
The results obtained by two qualitative data collection methods aimed to answer three
research questions. These are;
• Research Question 1: What factors negatively affect human-related safety in aircraft
accidents?
• Research Question 2: To what extent can a person cause an accident while under the
influence of factors that adversely affect safety?
• Research Question 3: How effective are Crew Resource Management Training in preventing
aircraft accidents?
As a result of this research and analysis carried out within the scope of proposing a solution to
the minimization of aircraft accidents, it has been concluded that the human factor in aviation
and the correct management of these factors are of great importance in preventing errors. In
this context, the importance of the human factor in the realization of aircraft accidents has
been proven. It has been determined through the example of the Tenerife Plane Crash, in
which human beings are exposed to the influence of various factors and form a part of the
chain of errors. The situations in which these factors emerged and how they affected the
employees were analyzed from the interviews. It has been concluded that it is especially
important for flight personnel to be aware that they are under the influence of these factors. In
order to provide this awareness, airlines should carry out PBM training without interruption. It
should be at the forefront to inform the employees about these factors that expose people to
negative effects. However, as a result of the interviews with the flight personnel, it was
concluded that the PBM training was seriously important but insufficient.
For this reason, it is recommended to expand the content of PBM pieces of training. At the
same time, the aviation industry requires all disciplines to work together in the operation
process. It would not be wrong to say that only cockpit and cabin crew benefit from these
pieces of training. It is recommended to expand the scope of PBM training given only to flight

42
personnel. Establishing a training program that includes all employees from management to
operation is necessary. The importance of the interaction between different disciplines can be
shown because communication errors between the tower and the cockpit cause many
accidents. The realization of these recommendations will contribute to the increase in
awareness of human factors and, as a result, the determination of aviation safety and the
minimization of aircraft accidents.

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