Analyzing Air Traffic Control Failures In Aviation Incidents And Accidents Through The HFACS Framework
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Abstract
Aviation safety depends heavily on precise interaction between pilots and Air Traffic Control (ATC), yet failures within that interaction remain a recurring contributing factor in civil aviation accidents and incidents. This study aims to identify and analyze patterns of ATC-related failure across a set of historically significant aviation accidents and incidents, and to derive implications for global aviation safety improvement. A qualitative literature review design was employed, drawing on official investigation reports, safety databases, and peer-reviewed journal articles concerning five representative events—Tenerife (1977), Zagreb (1976), Uberlingen (2002), Linate (2001), and Jakarta Halim (2016)—synthesized through directed content analysis guided by the Human Factors Analysis and Classification System (HFACS) and Reason's Swiss Cheese Model. The findings reveal that communication breakdowns, non-standard phraseology, controller work overload, limitations in surveillance technology, and weak inter-unit coordination constitute recurring causal patterns behind ATC-related accidents/incidents. The study concludes that enhancing aviation safety requires stricter phraseology standardization, strengthened Crew/Team Resource Management training for controllers, and sustained investment in surface radar and conflict-alert technologies.
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References
Bongo, M. F., & Seva, R. R. (2022). Effect of fatigue in air traffic controllers’ workload, situation awareness, and control strategy. The International Journal of Aerospace Psychology, 32(1), 1–23. https://doi.org/10.1080/24721840.2021.1896951
Federal Aviation Administration / Scientific Expert Panel on Air Traffic Controller Safety, Work Hours, and Health (Rosekind, M. R., Flynn-Evans, E. E., & Czeisler, C. A.). (2024). Assessing fatigue risk in FAA air traffic operations. Washington, DC: U.S. Department of Transportation. https://www.faa.gov/newsroom/media/Fatigue_Report.pdf
International Civil Aviation Organization. (2016). Annex 13 to the Convention on International Civil Aviation: Aircraft accident and incident investigation (11th ed.). Montreal: ICAO.
International Civil Aviation Organization. (2024). Global Runway Safety Action Plan (2nd ed.). Montreal: ICAO. https://www.icao.int/global-runway-safety-action-plan
Lyu, T., Song, W., & Du, K. (2019). Human factors analysis of air traffic safety based on HFACS-BN model. Applied Sciences, 9(23), 5049. https://doi.org/10.3390/app9235049
Muecklich, N., Sikora, I., Paraskevas, A., & Padhra, A. (2023). The role of human factors in aviation ground operation-related accidents/incidents: A human error analysis approach. Transportation Engineering, 13, Article 100184. https://doi.org/10.1016/j.treng.2023.100184
Reason, J. (1990). Human error. Cambridge, UK: Cambridge University Press.
SKYbrary Aviation Safety / EUROCONTROL. (2025). Runway incursion. Retrieved from https://skybrary.aero/articles/runway-incursion
Wiegmann, D. A., & Shappell, S. A. (2003). A human error approach to aviation accident analysis: The human factors analysis and classification system. Aldershot, UK: Ashgate.
Yan, Y., Boufous, S., & Molesworth, B. R. C. (2025). Speaking of human factors: An interview study on the causes and prevention of runway incursions with aviation professionals. Safety Science, 190, Article 106913. https://doi.org/10.1016/j.ssci.2025.106913
Yin, R. K. (2018). Case study research and applications: Design and methods (6th ed.). Thousand Oaks, CA: SAGE Publications.
Zhang, J., Chen, Z., Liu, W., Ding, P., & Wu, Q. (2021). A field study of work type influence on air traffic controllers’ fatigue based on data-driven PERCLOS detection. International Journal of Environmental Research and Public Health, 18(22), 11937. https://doi.org/10.3390/ijerph182211937