Date of Award
Master of Science (MS)
Wrong surface events are a serious and ongoing risk to aviation safety in the United States National Airspace System. A wrong surface event occurs when an aircraft lands, departs or attempts to land or depart from a surface other than the intended landing or takeoff, also including aircraft landing at the wrong airport. This research examined the contextual factors that contributed to human error ultimately leading to wrong surface events, assessed the efficacy of technology that can be used to prevent, and aviation professional’s awareness of wrong surface events in order to determine prevention strategies that can reduce occurrences in the NAS. Four NTSB reports were reviewed to identify context that influences a pilot’s actions in wrong surface events. Next, flight deck and air traffic control tower based technologies were examined for their ability to detect and alert the conditions in the four event reports. Finally, eleven aviation professionals were interviewed to assess their awareness and knowledge of risks, strategies, historical events, and terminology related to wrong surface events. The results identified numerous recurring contextual factors in wrong surface events. While technology intended to prevent wrong surface events is improving, numerous shortfalls were identified that inhibit the system’s ability to effectively prevent such occurrences. Additionally, results showed an overall lack of awareness among pilots and a pilot training department of wrong surface events and their associated risks, suggesting that efforts to prevent wrong surface events through training are ineffective. The results give opportunities for human error mitigation strategies to be employed to reduce occurrences of wrong surface events.
Bowers, William, "Applying Human Error Framework To Explore Prevention Strategies For Wrong Surface Events" (2023). Theses and Dissertations. 5233.