Case Studies


USS Fitzgerald

The factors that contributed to the collision of USS Fitzgerald and ACX Crystal can be linked to a poor human performance environment. A significant amount of sailors were undertrained, important equipment either needed maintenance or was broken, the ship was short-staffed, and sailors lacked proper sleep.

USS McCain

The main contributing factors to the USS McCain collision with the Alnic MC was poor control system design coupled with inefficient system training. New systems were installed on the ship’s bridge to make the helm station easier, but ended up causing confusion and stress leading to many critical mistakes.


2016 Canadian Pacific Railway Collision

Human errors were reported to be the main factors in the August 2016 collision. The final report deemed that a critical warning signal was missed due to operator fatigue and distraction. This warning was signaling the train to stop for an oncoming train.

2008 Chatsworth Metrolink Collision

Fatigue, distraction, and poor communication were the main causes in the deadliest train collision in California history. It was concluded that the train’s engineer lacked adequate sleep between shifts and was distracted while operating the train causing them to miss a critical red stop signal. The conductor also failed to report the red signal to the engineer.


Air France Flight 447

In 2008, a flight from Rio de Janeiro to Paris fell out of the sky killing everyone aboard. After reviewing the plane’s black box and audio recorder, the underlying cause was poor control interface design. While the captain was taking his rest period, the co-pilots became confused by the errors that began to sound. Improper action was taken due to a misinterpretation of the error. The signal was not properly communicated and as a result, the co-pilots had to guess what corrective actions to take. By the time the captain came to help and the real problem was identified, it was too late. This is a perfect case of why interface design needs to be focused around the user’s needs while accounting for environmental conditions.

Boeing 737 Max Crashes

Rapid creation and production coupled with the low amount of training required for the Boeing 737 Max were the key factors in the crashes. The design process was hasty and restricted. Pilots only received a 2.5 hour computer course on the new plane controls until they were certified. The article also reveals that Boeing knew about the failure that caused confusing alarms and what lead to the crashes. They posted a notice to pilots but did not give sufficient details.

Flight Experience

The study concludes that first officers were more likely to have a safety incident during a missed approach while captains were less likely. Captains with a middle range of flight hours are more likely to have a safety incident than less experienced captains. Overconfidence with own ability is a huge factor in human error.