APPLICATION OF HFACS-HFIX FRAMEWORK IN NTSC’S FINDINGS AND RECOMMENDATIONS: WAMENA AIR ACCIDENTS’ CASE STUDY

Abstract

Wamena airport experienced accidents in 2002, 2008, 2009, 2013, 2015, and 2016. All accidents were cargo flights and in approach and landing flight phases. As the Swiss Cheese concept, accident happened when errors penetrated safety defenses’ layers in straight line. Structuring NTSC’s investigations, under HFACS framework to understand the human factor failures type and HFIX strategy to close the failures by applying the recommendations, need to be done in air accident investigation. Eleven aviation experts and practitioners were interviewed in this study, to validate the framework. There were layers without any failures in accident 2008, 2013, and 2016. Accident in 2016 has no recommendation due operators’ safety actions were considered relevant to block failures. Accidents in 2002, 2009, 2013, and 2015 have failure in a layer which intervened by two or more recommendations. There were failures remain open in accident 2002, 2009, 2013, and 2016. Repetitive failure, error or violation of repetitive accidents in 2002, 2009, 2013, 2015, and 2016 is un-stabilized approach and has not been blocked with effective interventions. HFACS and HFIX are useful to framework the accident investigation, preventing similar accident happened in the future.