Human Factors in Aviation: Understanding What Happens Before the Error

By Jahmal Bethel

Aviation has evolved dramatically over the past several decades. Aircraft are more reliable, technology is more capable, and modern systems provide levels of redundancy and protection that earlier generations could not have imagined.

What has not changed is the importance of the human element.

Every aviation operation relies on the interaction between people, aircraft, procedures, technology, and the environment in which work occurs. When these elements align, the system performs well. When they drift out of alignment, risk increases.

This is why the term human error—on its own—does not tell us enough. It may describe the action closest to an event, but it does not explain the conditions that allowed the event to develop.

Looking Beyond the Immediate Action

When something goes wrong, the final action is often the easiest part to identify:

• A procedure was missed.

• A decision came too late.

• Information was misunderstood.

• A task was not completed as expected.

These facts matter, but stopping there leaves the most important part of the investigation unfinished.

Human performance does not occur in isolation. Workload, training, supervision, communication, procedures, available resources, and operating conditions all influence how people make decisions and perform their work.

Recent aviation safety research reinforces this broader view. A 2023 study on HFACS and aviation safety management highlighted the industry’s shift away from focusing solely on frontline failures and toward identifying systemic conditions and latent factors that may exist elsewhere within an organization.

The visible error may be only the last link in a much longer chain.

If a step is missed, the analysis should not automatically end with the person who missed it. The clarity of the procedure, workload, interruptions, training, information available, and working conditions may all be relevant.

The same principle applies to operational decision‑making. Understanding what information was available, what pressures existed, and whether warning signs were present often provides more useful insight than simply identifying the decision that ultimately proved unsuccessful.

This broader view does not remove individual accountability. Accountability and understanding serve different purposes—and if the objective is preventing recurrence, an organization needs both.

Using HFACS to Understand the Larger System

The Human Factors Analysis and Classification System (HFACS) offers a structured way to examine the relationships within the aviation system.

Originally developed from aviation accident analysis, HFACS provides a framework for examining active failures as well as conditions that may exist beyond the immediate action, including preconditions, supervision, and organizational influences. Current research continues to use HFACS to explore how frontline actions relate to broader systemic factors.

This matters because recurring problems rarely remain confined to one individual.

• A procedural deviation may indicate a process that is unclear or outdated.

• A poor decision may reflect workload, time pressure, or incomplete information.

• Repeated errors may signal weaknesses in training, communication, supervision, or organizational controls.

The FAA’s current human‑factors initiatives take a similarly comprehensive approach. Its Aviation Safety human‑factors program addresses aircraft systems, maintenance, operations, procedures, human performance, policy, guidance, and continued airworthiness—rather than treating human error as an isolated issue.

The purpose of human‑factors analysis is not to shift responsibility. It is to understand how the system was functioning when the event occurred.

Recognizing Patterns Before They Become Events

A single event may appear isolated. Several similar events can tell a different story.

Recurring procedural deviations, communication breakdowns, workload concerns, supervision issues, or informal workarounds may indicate that something broader is developing within an operation.

This is where human‑factors analysis moves beyond investigation and becomes a tool for prevention.

When organizations examine information collectively rather than treating each occurrence as unrelated, patterns emerge that may be difficult to recognize one event at a time. This creates an opportunity to act before those conditions contribute to something more serious.

Safety culture plays a role as well. A 2026 FAA review emphasized that a positive safety culture is essential for managing risk and highlighted evidence‑based approaches for improving organizational performance.

Experience also teaches us to pay attention to conditions that gradually become accepted. A workaround may begin as an exception. A deviation may occur without consequence. Repeated exposure can make an undesirable practice appear less risky simply because nothing serious has happened yet.

The absence of an accident does not mean the condition is safe.

Recognizing that distinction is a core part of proactive safety management.

Technology Changes the Risk, Not the Need for Human‑Factors Awareness

Modern technology has reduced many risks that earlier generations had to manage differently. But technology does not remove people from the system.

People still maintain aircraft, interpret technical information, supervise operations, troubleshoot problems, manage competing priorities, and make decisions when circumstances do not follow the expected plan.

As technology becomes more sophisticated, the nature of human interaction changes as well.

Automation may reduce workload in one area while increasing monitoring demands in another. More information can improve decision‑making, but only when that information is relevant, timely, understood, and properly prioritized.

Current FAA research reflects these concerns. A 2026 human‑factors methodology addressing safety‑critical information examines workload, situation awareness, decision‑making, information relevance, timing, and operational context as factors that influence performance and risk.

The lesson is not that people are the weak link. That description is too simple.

People are part of the system, and their performance is shaped by the system around them.

Improved technology does not make human factors less important—it changes the conditions under which people perform.

Understanding Why Improves the System

When an aviation event occurs, determining what happened is necessary. The greater value comes from understanding why it happened and what conditions made it possible.

HFACS provides one structured method for examining those conditions. Its purpose is not to remove responsibility from individuals, but to give investigators and organizations a more complete view of the system surrounding the event.

An effective investigation should do more than explain the past. It should leave the organization with a clearer understanding of its risk and better information for preventing recurrence.

Finding the error matters. Understanding what made it possible is what improves the system.

References

Beckel, J., Yetter, C., & Worthington, K. K. (2026). A Targeted Review of Safety Culture Interventions: Tools and Insights for Aviation Regulators. Federal Aviation Administration, Office of Aerospace Medicine, Report DOT/FAA/AM‑26/05.

Chan, W. T.-K., & Li, W.-C. (2023). Development of effective human factors interventions for aviation safety management. Frontiers in Public Health, 11, 1144921.

Sanders, C. S. (2026). Prioritizing Safety‑Critical Information in the National Airspace System: A Four‑Phased Human Factors Methodology and Its Future Applications. Federal Aviation Administration, Office of Aerospace Medicine, Report DOT/FAA/AM‑26/07.

Wiegmann, D. A., & Shappell, S. A. (2001). Human error analysis of commercial aviation accidents: Application of the Human Factors Analysis and Classification System (HFACS). Aviation, Space, and Environmental Medicine, 1006–1016.