Pilot error


Historically, the term pilot error has been used to describe 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. Errors are intentional actions that fail to achieve their intended outcomes. 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." Hence the definition of the "pilot error" does not include deliberate crash.
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.
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.

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. The International Civil Aviation Organization, 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 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." 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."

Errors

The term "error" is defined as any action or inaction leading to deviation from team or organizational intentions. 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. 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. The three steps are decision-making, goal-setting, and strategy-selection errors, all of which were highly related to primary accidents. 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)

involves the effective detection and response to internal or external factors that have the potential to degrade the safety of an aircraft's operations. Methods of teaching TEM stress replicability, or reliability of performance across recurring situations. TEM aims to prepare crews with the "coordinative and cognitive ability to handle both routine and unforeseen surprises and anomalies." 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, implementation of crew resource management, cockpit task management, 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 and ground proximity warning systems. 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. Observers on flights which are being audited typically observe the following:
LOSA was developed to assist crew resource management practices in reducing human error in complex flight operations. 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.

Crew resource management (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." 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:
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."

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. The applications of CRM has been developed in a series of generations:
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.

Cockpit task management (CTM)

Cockpit task management is the "management level activity pilots perform as they initiate, monitor, prioritize, and terminate cockpit tasks." A 'task' is defined as a process performed to achieve a goal. 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. 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.

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. The objectives of checklists include "memory recall, standardization and regulation of processes or methodologies." 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. 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 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. 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, 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 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. For scheduled air transport, pilot error typically accounts for just over half of worldwide accidents with a known cause.