Pilot error

300px|thumb|[[1994 Fairchild Air Force Base B-52 crash, caused by pilot Arthur Holland flying the aircraft beyond its operational limits. Here the aircraft is seen in an unrecoverable bank, a split second before the crash. This accident is now used in military and civilian aviation environments as a case study in teaching crew resource management.]]

thumb|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.]]

thumb|Map of the [[2001 Linate Airport runway collision 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.]]

thumb|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.]]

thumb|The "three-pointer" design altimeter is one of the most prone to being misread by pilots (a cause of the [[United Airlines Flight 389|UA 389 and G-AOVD crashes).]]

In aviation, pilot error generally refers to an action or decision made by a pilot that is a substantial contributing factor leading to an aviation accident. It also includes a pilot's failure to make a correct decision or take proper action. Errors are intentional actions that fail to achieve their intended outcomes. The Chicago Convention defines the term "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." Hence the definition of "pilot error" does not include deliberate crashing (and such crashes are not classified as accidents).

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. 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.

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. 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.

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." 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.

Threats

The term "threat" is defined as any event "external to flight crew's influence which can increase the operational complexity of a flight." 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." 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. 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. 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.

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. TEM aims to prepare crews with the "coordinative and cognitive ability to handle both routine and unforeseen surprises and anomalies." 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). 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. 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. 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: 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.

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. A 'task' is defined as a process performed to achieve a goal (i.e. fly to a waypoint, descend to a desired altitude). The objectives of checklists include "memory recall, standardization and regulation of processes or methodologies." 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. For scheduled air transport, pilot error typically accounts for just over half of worldwide accidents with a known cause.

7 March 2007 – Garuda Indonesia Flight 200: poor crew resource management and the failure to extend the flaps led the aircraft to land at an "unimaginable" speed and run off the end of the runway after landing. Of the 140 occupants, 22 were killed.
17 July 2007 – TAM Airlines Flight 3054: the thrust reverser on the right engine of the Airbus A320 was jammed. Although both crew members were aware, the captain used an outdated braking procedure, and the aircraft overshot the runway and crashed into a building, killing all 187 people on board, as well as 12 people on the ground.
20 August 2008 – The crew of Spanair Flight 5022 failed to deploy the MD-82's flaps and slats. The flight crashed after takeoff, killing 154 out of the 172 passengers and crew on board.
12 February 2009 – Colgan Air Flight 3407 (flying as Continental Connection) entered a stall and crashed into a house in Clarence Center, New York, due to lack of situational awareness of air speed by the captain and first officer and the captain's improper reaction to the plane's stick-shaker stall warning system. All 49 people on board the plane died, as well as one person inside the house.
1 June 2009 – Air France Flight 447 entered a stall and crashed into the Atlantic Ocean following pitot tube failures and improper control inputs by the first officer. All 216 passengers and twelve crew members died.
10 April 2010 – 2010 Polish Air Force Tu-154 crash: during a descent towards Russia's Smolensk North Airport, the flight crew of the Polish presidential jet ignored automatic warnings and attempted a risky landing in heavy fog. The Tupolev Tu-154M descended too low and crashed into a nearby forest; all of the occupants were killed, including Polish president Lech Kaczynski, his wife Maria Kaczynska, and numerous government and military officials.
12 May 2010 – Afriqiyah Airways Flight 771 The aircraft crashed about short of Runway 09, outside the perimeter of Tripoli International Airport, killing all but one of the 104 people on board. The sole survivor was a 9-year-old boy named Ruben Van Assouw. On 28 February 2013, the Libyan Civil Aviation Authority announced that the crash was caused by pilot error. Factors that contributed to the crash were lacking/insufficient crew resource management, sensory illusions, and the first officer's inputs to the aircraft side stick; fatigue could also have played a role in the accident. The final report cited the following causes: the pilots' lack of a common action plan during the approach, the final approach being continued below the Minimum Decision Altitude without ground visual reference being acquired; the inappropriate application of flight control inputs during the go-around and after the Terrain Awareness and Warning System had been activated; and the flight crew's failure to monitor and control the flight path.
22 May 2010 – Air India Express Flight 812 overshot the runway at Mangalore Airport, killing 158 people. The plane touched down from the usual touchdown point after a steep descent. CVR recordings showed that the captain had been sleeping and had woken up just minutes before the landing. His lack of alertness made the plane land very quickly and steeply and it ran off the end of the tabletop runway.
28 July 2010 – The captain of Airblue Flight 202 became confused with the heading knob and thought that he had carried out the correct action to turn the plane. However, due to his failure to pull the heading knob, the turn was not executed. The Airbus A321 went astray and slammed into the Margalla Hills, killing all 152 people on board.
20 June 2011 – RusAir Flight 9605 crashed onto a motorway while on its final approach to Petrozavodsk Airport in western Russia, after the intoxicated navigator encouraged the captain to land in heavy fog. Only five of the 52 people on board the plane survived the crash.
6 July 2013 – Asiana Airlines Flight 214 tail struck the seawall short of runway 28L at San Francisco International Airport. Of the 307 passengers and crew, three people died and 187 were injured when the aircraft slid down the runway. Investigators said the accident was caused by the Captain misreading the runway, leading to an incident.
23 July 2014 – TransAsia Airways Flight 222 brushed trees and crashed into six houses in a residential area in Xixi Village, Penghu Island, Taiwan. Of the 58 people on board the flight, only ten people survived the crash. The captain was overconfident with his skill and intentionally descended and rolled the plane to the left. Crew members did not realize that they were at a dangerously low altitude and the plane was about to impact terrain until two seconds before the crash.
28 December 2014 – Indonesia AirAsia Flight 8501 crashed into the Java Sea as a result of an aerodynamic stall due to pilot error. The aircraft exceeded the climb rate, way beyond its operational limits. All 155 passengers and 7 crew members on board were killed.
6 February 2015 – TransAsia Airways Flight 235: one of the ATR 72's engines experienced a flameout. As airplanes are able to fly on one engine alone, the pilot then shut down one of the engines. However, he accidentally shut off the engine that was functioning correctly and left the plane powerless, at which point he unsuccessfully tried to restart both engines. The plane then clipped a bridge and plummeted into the Keelung river as the pilot tried to avoid city terrain, killing 43 of the 58 on board.

Causes of pilot error

Threats

Decision making

Threat and error management (TEM)

Line operations safety audit (LOSA)

See also

References