Teamwork Turbulence: Lessons for Multi-Team Systems from a Decade of Aviation Accident Reports

Even in 2025, aviation accidents related to ineffective teamwork continue to be reported in the news, highlighting persistent challenges within the industry. Despite decades of aviation safety and team science research, a critical gap remains in understanding one of the most complex aspects of aviation teaming—multi-team systems (MTSs). This work aimed to address this research gap by investigating teamwork breakdowns within the aviation MTS. Through analyzing archival accident reports from the National Transportation Safety Board (NTSB) within the past decade, this research sought to uncover the underlying causal factors that contribute to aviation accidents within the last decade (i.e., 2014-2024) using the Human Factors Analysis and Classification System (HFACS; Wiegmann & Shappell, 2001). However, there is currently no comprehensive error framework specifically designed to analyze MTS-related attributes in aviation. While the HFACS framework does not explicitly focus on MTSs, it does identify teamwork as a personnel factor with the potential to contribute to human error. Therefore, this study explores whether MTS-specific errors can be classified through a proposed theoretical extension of the HFACS framework. Accident reports related to teamwork dysfunction were further analyzed to understand and relate each event to MTS attributes to more comprehensively understand the root of these teamwork breakdowns. Finally, this work uses insights from the analysis to propose theoretical implications to support MTS safety and effectiveness.

Name thesis:degree_name

Doctor of Philosophy

Level thesis:degree_level

Doctoral

Discipline thesis:degree_discipline

Social Sciences

Grantor

Rice University

Year dc:date.issued

2025

Author dc:creator

• Berger, Lila

Advisor dc:contributor.advisor

• Salas, Eduardo

• teamwork
• human error

Statement dc:rights

• Copyright is held by the author, unless otherwise indicated. Permission to reuse, publish, or reproduce the work beyond the bounds of fair use or other exemptions to copyright law must be obtained from the copyright holder.

Language dc:language.iso

eng

Handle dc:identifier.uri

https://hdl.handle.net/1911/118652

OAI identifier oai:identifier

oai:repository.rice.edu:1911/118652