Pilot error

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1994 Fairchild Air Force Base B-52 crash, caused by flying the aircraft beyond its operational limits. Here the aircraft is seen in an unrecoverable bank, a split second before the crash. This incident is now used in military and civilian aviation environments as a case study in teaching crew resource management. FairchildB52Crash.jpg
1994 Fairchild Air Force Base B-52 crash, caused by flying the aircraft beyond its operational limits. Here the aircraft is seen in an unrecoverable bank, a split second before the crash. This incident is now used in military and civilian aviation environments as a case study in teaching crew resource management.
Actual flight path (red) of TWA Flight 3 from departure to crash point (controlled flight into terrain). Blue line shows the nominal Las Vegas course, while green is a typical course from Boulder. The pilot inadvertently used the Boulder outbound course instead of the appropriate Las Vegas course. TWA3.png
Actual flight path (red) of TWA Flight 3 from departure to crash point (controlled flight into terrain). Blue line shows the nominal Las Vegas course, while green is a typical course from Boulder. The pilot inadvertently used the Boulder outbound course instead of the appropriate Las Vegas course.
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Maraba Airport
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Belem Airport
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Departure/destination airports and crash site location of Varig Flight 254 (major navigational error leading to fuel exhaustion). The flight plan was later shown to 21 pilots of major airlines. No fewer than 15 pilots committed the same mistake.
Map of the Linate Airport disaster caused by taking the wrong taxiing route (red instead of green), as control tower had not given clear instructions. The accident occurred in thick fog. Linate Airport disaster map en.gif
Map of the Linate Airport disaster caused by taking the wrong taxiing route (red instead of green), as control tower had not given clear instructions. The accident occurred in thick fog.
The Tenerife airport disaster now serves as a textbook example. Due to several misunderstandings, the KLM flight tried to take off while the Pan Am flight was still on the runway. The airport was accommodating an unusually large number of commercial airliners, resulting in disruption of the normal use of taxiways. Map Tenerife Disaster EN.svg
The Tenerife airport disaster now serves as a textbook example. Due to several misunderstandings, the KLM flight tried to take off while the Pan Am flight was still on the runway. The airport was accommodating an unusually large number of commercial airliners, resulting in disruption of the normal use of taxiways.
The "three-pointer" design altimeter is one of the most prone to being misread by pilots (a cause of the UA 389 and G-AOVD crashes). 3-Pointer Altimeter.svg
The "three-pointer" design altimeter is one of the most prone to being misread by pilots (a cause of the UA 389 and G-AOVD crashes).

Pilot error generally refers to an accident in which an action or decision made by the pilot was the cause or a contributing factor that led to the accident, but also includes the pilot's failure to make a correct decision or take proper action. [2] Errors are intentional actions that fail to achieve their intended outcomes. [3] Chicago Convention defines accident as "An occurrence associated with the operation of an aircraft [...] in which [...] a person is fatally or seriously injured [...] except when the injuries are [...] inflicted by other persons." [4] Hence the definition of the "pilot error" does not include deliberate crash (and such crash is not an accident).

Contents

The causes of pilot error include psychological and physiological human limitations. Various forms of threat and error management have been implemented into pilot training programs to teach crew members how to deal with impending situations that arise throughout the course of a flight. [5]

Accounting for the way human factors influence the actions of pilots is now considered standard practice by accident investigators when examining the chain of events that led to an accident. [5] [6]

Description

Modern accident investigators avoid the words "pilot error", as the scope of their work is to determine the cause of an accident, rather than to apportion blame. Furthermore, any attempt to incriminate the pilots does not consider that they are part of a broader system, which in turn may be accountable for their fatigue, work pressure, or lack of training. [6] The International Civil Aviation Organization (ICAO), and its member states, therefore adopted James Reason's model of causation in 1993 in an effort to better understand the role of human factors in aviation accidents. [7]

Pilot error is nevertheless a major cause of air accidents. In 2004, it was identified as the primary reason for 78.6% of disastrous general aviation (GA) accidents, and as the major cause of 75.5% of GA accidents in the United States. [8] [ better source needed ] There are multiple factors that can cause pilot error; mistakes in the decision-making process can be due to habitual tendencies, biases, as well as a breakdown in the processing of the information coming in. For aircraft pilots, in extreme circumstances these errors are highly likely to result in fatalities. [9]

Causes of pilot error

Pilots work in complex environments and are routinely exposed to high amounts of situational stress in the workplace, inducing pilot error which may result in a threat to flight safety. While aircraft accidents are infrequent, they are highly visible and often involve significant numbers of fatalities. For this reason, research on causal factors and methodologies of mitigating risk associated with pilot error is exhaustive. Pilot error results from physiological and psychological limitations inherent in humans. "Causes of error include fatigue, workload, and fear as well as cognitive overload, poor interpersonal communications, imperfect information processing, and flawed decision making." [10] Throughout the course of every flight, crews are intrinsically subjected to a variety of external threats and commit a range of errors that have the potential to negatively impact the safety of the aircraft. [11]

Threats

The term "threat" is defined as any event "external to flight crew's influence which can increase the operational complexity of a flight." [12] Threats may further be broken down into environmental threats and airline threats. Environmental threats are ultimately out of the hands of crew members and the airline, as they hold no influence on "adverse weather conditions, air traffic control shortcomings, bird strikes, and high terrain." [12] Conversely, airline threats are not manageable by the flight crew, but may be controlled by the airline's management. These threats include "aircraft malfunctions, cabin interruptions, operational pressure, ground/ramp errors/events, cabin events and interruptions, ground maintenance errors, and inadequacies of manuals and charts." [12]

Errors

The term "error" is defined as any action or inaction leading to deviation from team or organizational intentions. [10] Error stems from physiological and psychological human limitations such as illness, medication, stress, alcohol/drug abuse, fatigue, emotion, etc. Error is inevitable in humans and is primarily related to operational and behavioral mishaps. [13] Errors can vary from incorrect altimeter setting and deviations from flight course, to more severe errors such as exceeding maximum structural speeds or forgetting to put down landing or takeoff flaps.

Decision making

Reasons for negative reporting of accidents include staff being too busy, confusing data entry forms, lack of training and less education, lack of feedback to staff on reported data and punitive organizational cultures. [14] Wiegmann and Shappell invented three cognitive models to analyze approximately 4,000 pilot factors associated with more than 2,000 U.S. Navy aviation mishaps. Although the three cognitive models have slight differences in the types of errors, all three lead to the same conclusion: errors in judgment. [15] The three steps are decision-making, goal-setting, and strategy-selection errors, all of which were highly related to primary accidents. [15] For example, on 28 December 2014, AirAsia Flight 8501, which was carrying seven crew members and 155 passengers, crashed into the Java Sea due to several fatal mistakes made by the captain in the poor weather conditions. In this case, the captain chose to exceed the maximum climb rate for a commercial aircraft, which caused a critical stall from which he was unable to recover. [16]

Threat and error management (TEM)

TEM involves the effective detection and response to internal or external factors that have the potential to degrade the safety of an aircraft's operations. [11] Methods of teaching TEM stress replicability, or reliability of performance across recurring situations. [17] TEM aims to prepare crews with the "coordinative and cognitive ability to handle both routine and unforeseen surprises and anomalies." [17] The desired outcome of TEM training is the development of 'resiliency'. Resiliency, in this context, is the ability to recognize and act adaptively to disruptions which may be encountered during flight operations. TEM training occurs in various forms, with varying levels of success. Some of these training methods include data collection using the line operations safety audit (LOSA), implementation of crew resource management (CRM), cockpit task management (CTM), and the integrated use of checklists in both commercial and general aviation. Some other resources built into most modern aircraft that help minimize risk and manage threat and error are airborne collision and avoidance systems (ACAS) and ground proximity warning systems (GPWS). [18] With the consolidation of onboard computer systems and the implementation of proper pilot training, airlines and crew members look to mitigate the inherent risks associated with human factors.

Line operations safety audit (LOSA)

LOSA is a structured observational program designed to collect data for the development and improvement of countermeasures to operational errors. [19] Through the audit process, trained observers are able to collect information regarding the normal procedures, protocol, and decision making processes flight crews undertake when faced with threats and errors during normal operation. This data driven analysis of threat and error management is useful for examining pilot behavior in relation to situational analysis. It provides a basis for further implementation of safety procedures or training to help mitigate errors and risks. [12] Observers on flights which are being audited typically observe the following: [19]

LOSA was developed to assist crew resource management practices in reducing human error in complex flight operations. [12] LOSA produces beneficial data that reveals how many errors or threats are encountered per flight, the number of errors which could have resulted in a serious threat to safety, and correctness of crew action or inaction. This data has proven to be useful in the development of CRM techniques and identification of what issues need to be addressed in training. [12]

Crew resource management (CRM)

CRM is the "effective use of all available resources by individuals and crews to safely and effectively accomplish a mission or task, as well as identifying and managing the conditions that lead to error." [20] CRM training has been integrated and mandatory for most pilot training programs, and has been the accepted standard for developing human factors skills for air crews and airlines. Although there is no universal CRM program, airlines usually customize their training to best suit the needs of the organization. The principles of each program are usually closely aligned. According to the U.S. Navy, there are seven critical CRM skills: [20]

These seven skills comprise the critical foundation for effective aircrew coordination. With the development and use of these core skills, flight crews "highlight the importance of identifying human factors and team dynamics to reduce human errors that lead to aviation mishaps." [20]

Application and effectiveness of CRM

Since the implementation of CRM circa 1979, following the need for increased research on resource management by NASA, the aviation industry has seen tremendous evolution of the application of CRM training procedures. [21] The applications of CRM has been developed in a series of generations:

  • First generation: emphasized individual psychology and testing, where corrections could be made to behavior.
  • Second generation: featured a shift in focus to cockpit group dynamics.
  • Third evolution: diversification of scope and an emphasis on training crews in how they must function both in and out of the cockpit.
  • Fourth generation: CRM integrated procedure into training, allowing organizations to tailor training to their needs.
  • Fifth generation (current): acknowledges that human error is inevitable and provides information to improve safety standards. [22]

Today, CRM is implemented through pilot and crew training sessions, simulations, and through interactions with senior ranked personnel and flight instructors such as briefing and debriefing flights. Although it is difficult to measure the success of CRM programs, studies have been conclusive that there is a correlation between CRM programs and better risk management. [22]

Cockpit task management (CTM)

Multiple sources of information can be taken from one interface here, known as the PFD, or primary flight display from which pilots receive all of the most important data readings Primary Flight Display.svg
Multiple sources of information can be taken from one interface here, known as the PFD, or primary flight display from which pilots receive all of the most important data readings

Cockpit task management (CTM) is the "management level activity pilots perform as they initiate, monitor, prioritize, and terminate cockpit tasks." [23] A 'task' is defined as a process performed to achieve a goal (i.e. fly to a waypoint, descend to a desired altitude). [23] CTM training focuses on teaching crew members how to handle concurrent tasks which compete for their attention. This includes the following processes:

The need for CTM training is a result of the capacity of human attentional facilities and the limitations of working memory. Crew members may devote more mental or physical resources to a particular task which demands priority or requires the immediate safety of the aircraft. [23] CTM has been integrated to pilot training and goes hand in hand with CRM. Some aircraft operating systems have made progress in aiding CTM by combining instrument gauges into one screen. An example of this is a digital attitude indicator, which simultaneously shows the pilot the heading, airspeed, descent or ascent rate and a plethora of other pertinent information. Implementations such as these allow crews to gather multiple sources of information quickly and accurately, which frees up mental capacity to be focused on other, more prominent tasks.

A military pilot reads the pre-flight checklist prior the mission. Checklists ensure that pilots are able to follow operational procedure and aids in memory recall. Running the checklist (14729226029).jpg
A military pilot reads the pre-flight checklist prior the mission. Checklists ensure that pilots are able to follow operational procedure and aids in memory recall.

Checklists

The use of checklists before, during and after flights has established a strong presence in all types of aviation as a means of managing error and reducing the possibility of risk. Checklists are highly regulated and consist of protocols and procedures for the majority of the actions required during a flight. [24] The objectives of checklists include "memory recall, standardization and regulation of processes or methodologies." [24] The use of checklists in aviation has become an industry standard practice, and the completion of checklists from memory is considered a violation of protocol and pilot error. Studies have shown that increased errors in judgement and cognitive function of the brain, along with changes in memory function are a few of the effects of stress and fatigue. [25] Both of these are inevitable human factors encountered in the commercial aviation industry. The use of checklists in emergency situations also contributes to troubleshooting and reverse examining the chain of events which may have led to the particular incident or crash. Apart from checklists issued by regulatory bodies such as the FAA or ICAO, or checklists made by aircraft manufacturers, pilots also have personal qualitative checklists aimed to ensure their fitness and ability to fly the aircraft. An example is the IM SAFE checklist (illness, medication, stress, alcohol, fatigue/food, emotion) and a number of other qualitative assessments which pilots may perform before or during a flight to ensure the safety of the aircraft and passengers. [24] These checklists, along with a number of other redundancies integrated into most modern aircraft operation systems, ensure the pilot remains vigilant, and in turn, aims to reduce the risk of pilot error.

Notable examples

One of the most famous examples of an aircraft disaster that was attributed to pilot error was the night-time crash of Eastern Air Lines Flight 401 near Miami, Florida on 29 December 1972. The captain, first officer, and flight engineer had become fixated on a faulty landing gear light and had failed to realize that one of the crew had accidentally bumped the flight controls, altering the autopilot settings from level flight to a slow descent. Told by ATC to hold over a sparsely populated area away from the airport while they dealt with the problem (with, as a result, very few lights visible on the ground to act as an external reference), the distracted flight crew did not notice the plane losing height and the aircraft eventually struck the ground in the Everglades, killing 101 of the 176 passengers and crew. The subsequent National Transportation Safety Board (NTSB) report on the incident blamed the flight crew for failing to monitor the aircraft's instruments properly. Details of the incident are now frequently used as a case study in training exercises by aircrews and air traffic controllers.

During 2004 in the United States, pilot error was listed as the primary cause of 78.6% of fatal general aviation accidents, and as the primary cause of 75.5% of general aviation accidents overall. [26] For scheduled air transport, pilot error typically accounts for just over half of worldwide accidents with a known cause. [8]

See also

Related Research Articles

Tenerife airport disaster Runway collision at Los Rodeos Airport, Tenerife, 1977-03-27; 583 fatalities

On March 27, 1977, two Boeing 747 passenger jets, operating KLM Flight 4805 and Pan Am Flight 1736, collided on the runway at Los Rodeos Airport on the Spanish island of Tenerife. Resulting in 583 fatalities, the Tenerife airport disaster is the deadliest in aviation history.

Aviation accidents and incidents Aviation occurrence involving serious injury, death, or destruction of aircraft

An aviation accident is defined by the Convention on International Civil Aviation Annex 13 as an occurrence associated with the operation of an aircraft, which takes place from the time any person boards the aircraft with the intention of flight until all such persons have disembarked, and in which a) a person is fatally or seriously injured, b) the aircraft sustains significant damage or structural failure, or c) the aircraft goes missing or becomes completely inaccessible. Annex 13 defines an aviation incident as an occurrence, other than an accident, associated with the operation of an aircraft that affects or could affect the safety of operation.

Aviation safety State in which risks associated with aviation are at an acceptable level

Aviation safety is the study and practice of managing risks in aviation. This includes preventing aviation accidents and incidents through research, educating air travel personnel, passengers and the general public, as well as the design of aircraft and aviation infrastructure. The aviation industry is subject to significant regulation and oversight.

Crew resource management or cockpit resource management (CRM) is a set of training procedures for use in environments where human error can have devastating effects. Used primarily for improving aviation safety, CRM focuses on interpersonal communication, leadership, and decision making in the cockpit of an airliner. Its pioneer is David Beaty, a former Royal Air Force pilot and later a BOAC pilot who wrote his seminal book The Human Factor in Aircraft Accidents first published in 1969. Despite the considerable development of electronic aids since then, many principles he developed continue to prove effective today.

Gulf Air Flight 072 2000 aviation accident

Gulf Air Flight 072 (GF072/GFA072) was a scheduled international passenger flight from Cairo International Airport in Egypt to Bahrain International Airport in Bahrain, operated by Gulf Air. On 23 August 2000 at 19:30 Arabia Standard Time (UTC+3), the Airbus A320 crashed minutes after executing a go-around upon failed attempt to land on Runway 12. The flight crew suffered from spatial disorientation during the go-around and crashed into the shallow waters of the Persian Gulf 5 km from the airport. All 143 people on board the aircraft were killed.

United Airlines Flight 173 1978 aviation accident in Portland, Oregon

United Airlines Flight 173 was a scheduled flight from John F. Kennedy International Airport in New York City to Portland International Airport in Portland, Oregon, with a scheduled stop in Denver, Colorado. On December 28, 1978, the aircraft flying this route ran out of fuel while troubleshooting a landing gear problem and crashed in a suburban Portland neighborhood near NE 157th Avenue and East Burnside Street, killing 10 on board.

One-Two-GO Airlines Flight 269 2007 aviation accident

One-Two-GO Airlines Flight 269 (OG269) was a scheduled domestic passenger flight from Bangkok to Phuket, Thailand. On 16 September 2007, about 15:41 ICT, the McDonnell Douglas MD-82 operating the flight crashed into an embankment beside runway 27 at Phuket International Airport (HKT) bursting into flames upon impact during an attempted go-around after an aborted landing, killing 90 of the 130 persons on board.

Aviastar-TU Flight 1906 2010 aviation accident

Aviastar-TU Airlines Flight 1906 was a Tupolev Tu-204 that crash-landed while attempting to land at Domodedovo airport, Moscow, Russia, in heavy fog on 22 March 2010. The aircraft of Aviastar-TU Airlines was on a ferry flight from Hurghada International Airport, Egypt to Domodedovo. There were no passengers on board and all eight crew survived the accident; four crew members were seriously injured and taken to a hospital, while others suffered minor injuries. The accident was the first hull loss of a Tu-204 and the first hull loss for Aviastar-SP.

In aeronautics, loss of control (LOC) is the unintended departure of an aircraft from controlled flight, and is a significant factor in several aviation accidents worldwide and the leading cause of jet fatalities worldwide. Loss of control may be the result of mechanical failure, external disturbances, aircraft upset conditions, or inappropriate crew actions or responses.

Threat and error management Safety management approach

In aviation safety, threat and error management (TEM) is an overarching safety management approach that assumes that pilots will naturally make mistakes and encounter risky situations during flight operations. Rather than try to avoid these threats and errors, its primary focus is on teaching pilots to manage these issues so they do not impair safety. Its goal is to maintain safety margins by training pilots and flight crews to detect and respond to events that are likely to cause damage (threats) as well as mistakes that are most likely to be made (errors) during flight operations.

Pilot decision making is a process that aviators perform to effectively handle troublesome situations that are encountered. Pilot decision-making is applied in almost every stage of the flight as it considers weather, air spaces, airport conditions, ETA and so forth. During the flight, employers pressure pilots regarding time and fuel restrictions since a pilots’ performance directly affects the company’s revenue and brand image. This pressure often hinders a pilot's decision-making process leading to dangerous situations as 50% to 90% of aviation accidents are the result of pilot error.

Impact of culture on aviation safety

Culture can affect aviation safety through its effect on how the flight crew deals with difficult situations; cultures with lower power distances and higher levels of individuality can result in better aviation safety outcomes. In higher power cultures subordinates are less likely to question their superiors. The crash of Korean Air Flight 801 in 1997 was attributed to the pilot's decision to land despite the junior officer's disagreement, while the crash of Avianca Flight 52 was caused by the failure to communicate critical low-fuel data between pilots and controllers, and by the failure of the controllers to ask the pilots if they were declaring an emergency and assist the pilots in landing the aircraft. The crashes have been blamed on aspects of the national cultures of the crews.

Pilot fatigue

The International Civil Aviation Organization (ICAO) defines fatigue as "A physiological state of reduced mental or physical performance capability resulting from sleep loss or extended wakefulness, circadian phase, or workload." The phenomenon places great risk on the crew and passengers of an airplane because it significantly increases the chance of pilot error. Fatigue is particularly prevalent among pilots because of "unpredictable work hours, long duty periods, circadian disruption, and insufficient sleep". These factors can occur together to produce a combination of sleep deprivation, circadian rhythm effects, and 'time-on task' fatigue. Regulators attempt to mitigate fatigue by limiting the number of hours pilots are allowed to fly over varying periods of time.

Stress in the aviation industry

Stress in the aviation industry is a common phenomenon composed of three sources: physiological stressors, psychological stressors, and environmental stressors. Professional pilots can experience stress in flight, on the ground during work-related activities, and during personal time because of the influence of their occupation. An airline pilot can be an extremely stressful job due to the workload, responsibilities and safety of the thousands of passengers they transport around the world. Chronic levels of stress can negatively impact one's health, job performance and cognitive functioning. Being exposed to stress does not always negatively influence humans because it can motivate people to improve and help them adapt to a new environment. Unfortunate accidents start to occur when a pilot is under excessive stress, as it dramatically affects his or her physical, emotional, and mental conditions. Stress "jeopardizes decision-making relevance and cognitive functioning" and it is a prominent cause of pilot error. Being a pilot is considered a unique job that requires managing high workloads and good psychological and physical health. Unlike the other professional jobs, pilots are considered to be highly affected by stress levels. One study states that 70% of surgeons agreed that stress and fatigue don't impact their performance level, while only 26% of pilots denied that stress influences their performance. Pilots themselves realize how powerful stress can be, and yet many accidents and incidents continues to occur and have occurred, such as Asiana Airlines Flight 214, American Airlines Flight 1420, and Polish Air Force Tu-154.

Pan Am Flight 799 1968 airplane crash

Pan Am Flight 799 was an international cargo flight from Los Angeles International Airport to Cam Ranh Airport in South Vietnam that crashed on December 26, 1968 near Anchorage, Alaska. The aircraft involved was a Boeing 707-321C aircraft operated by Pan American World Airways. All three crew members died in the crash.

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