Extending HFACS Beyond the Organizational Boundary: A State Safety Governance and Oversight Analysis of the VoePass Flight 2283 Accident
Main Article Content
Abstract
Purpose - This study examines the VoePass Flight 2283 accident using the Human Factors Analysis and Classification System (HFACS) and proposes State Safety Governance and Oversight (SSGO) as a fifth analytical level to examine how operational, supervisory, organizational, and State-level conditions collectively influenced the accident.
Methodology - A qualitative case study using directed content analysis was conducted based primarily on evidence documented in the CENIPA final investigation report. Contributing factors were independently coded and classified through consensus across the four traditional HFACS levels and the proposed SSGO level, comprising five categories: State safety governance, capability and resources, certification and regulatory control, surveillance and risk management, and safety intervention and resolution.
Findings/conclusions - The analysis identified unsafe acts associated with icing operations, aircraft-performance management, and procedural execution, together with supervisory and organizational deficiencies involving maintenance control, safety culture, discrepancy reporting, training, operational risk management, and Safety Management System implementation. The proposed SSGO level identified State-level influences related to surveillance, regulatory intervention, and the sustained resolution of known safety deficiencies. Overall, the findings demonstrate that the accident is best understood as the outcome of interacting system-level conditions rather than isolated frontline errors.
Originality/value - This study extends HFACS by introducing State Safety Governance and Oversight (SSGO) as a fifth analytical level, providing a structured approach for examining how State safety oversight may shape organizational safety performance without assuming direct causality. The proposed framework offers a foundation for future applications and empirical validation across aviation accidents and regulatory systems.
Article Details
References
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