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Analysis of Incident Studies


We reviewed studies of Aviation Safety Reporting System (ASRS) incident reports, including one we conducted ourselves (see ASRS Incident Report Analysis Page for more information). ASRS has a database of over 150,000 incident reports submitted anonymously by pilots, air traffic controllers and others directly involved with aircraft operations. In addition to data on the class of aircraft involved in the incident and the composition of the flightcrew (if known), ASRS reports contain a narrative section in which the reporter describes the incident in his or her own words.

In each of the incident studies we reviewed, the investigators selected a set of incident reports from the larger ASRS database based on study-specific criteria, then reviewed the narratives for information identifying and/or describing automation-related issues. We reviewed the investigators' summaries and conclusions in search of evidence for the flight deck automation issues identified earlier in our study.

The strengths we assigned to this evidence were based on the percentage of reviewed reports citing the problem suggested by the issue statement of one of the flight deck automation issues. Where no exact percentages were given and, instead, words like 'some' or 'most' were used, we assigned strengths conservatively. We used the following table to assign strengths to incident study evidence.

Strength % Of Reviewed Reports Citing Problem






50-74% (or 'most')




1-24% (or 'some')


We found evidence in 6 of the incident studies we reviewed, including our own. The incident studies are listed alphabetically by author and include links to the bibliographic information and evidence found in the report. Evidence from our own study is detailed on a separate page (see ASRS Incident Report Analysis Page for more information).

Investigator(s) Short Description of Incident Study
Degani, A., & Heymann, M. An analysis of an altitude deviation incident involving an autopilot. EVIDENCE
Eldredge, D., Mangold, S., & Dodd, R.S. An analysis of FMS-related ASRS incident reports EVIDENCE
McElhatton, J., Buchanan, P., & Drew, C. An analysis of ASRS incident reports to identify causes and contributors to altitude devation incidents during SID and STAR procedures. EVIDENCE
Mosier, K.L., Skitka, L.J., & Korte, K.J. An analysis of ASRS incident reports to illustrate errors as a result of over-reliance on automated aids EVIDENCE
Palmer, E.A., Hutchins, E.L., Ritter, R.D., & VanCleemput, I. An analysis of ASRS incident reports to examine breakdowns in the normally error-tolerant environment EVIDENCE

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  Last update: 20 September 2007 Flight Deck Automation Issues Website  
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