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, moments 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.
Runway collision caused by taking the wrong taxiing route (red instead of green), as control room had not given clear instructions. The accident occurred in thick fog.

Pilot error (sometimes called cockpit error) is a decision, action or inaction by a pilot of an aircraft determined to be a cause or contributing factor in an accident or incident. Pilot error can be a mistake, oversight, lapse in judgment, or failure to exercise due diligence by pilots during the performance of their duties.

A broader view of how human factors fit into a system is now considered standard practice by accident investigators when examining the chain of events that led to an accident.[1][2]

Description[edit]

Usually in an accident caused by pilot error, the pilot in command (captain) is seen[by whom?] as making an error unintentionally. However, an intentional disregard for a standard operating procedure (or warning) is still considered[by whom?] pilot error, even if the pilot's actions justified criminal charges.

The pilot may be a factor even during adverse weather conditions if the investigating body deems that the pilot did not exercise due diligence. The responsibility for the accident in such a case would depend upon whether the pilot could reasonably know of the danger and whether he or she took reasonable steps to avoid the weather problem. Flying into a hurricane (for other than legitimate research purposes) would be considered pilot error; flying into a microburst would not be considered pilot error if it was not detectable by the pilot, or in the time before this hazard was understood. Some weather phenomena (such as clear-air turbulence or mountain waves) are difficult to avoid, especially if the aircraft involved is the first aircraft to encounter the phenomenon in a certain area at a certain time.

Placing pilot error as a cause of an aviation accident has often been controversial. For example, the NTSB ruled that the crash of American Airlines Flight 587 was because of the failure of the rudder, which was caused by "unnecessary and excessive rudder pedal inputs" on the part of the co-pilot who was operating the aircraft at the time. Attorneys for the co-pilot, who was killed in the crash, argue that American Airlines' pilots had never been properly trained concerning extreme rudder inputs. The attorneys also claimed that the rudder failure was actually caused by a flaw in the design of the Airbus A300 aircraft and that the co-pilot's rudder inputs should not have caused the catastrophic rudder failure that led to the accident that killed 265 people.

Modern accident investigators attempt to avoid the words "pilot error", as the scope of their work is to determine the cause of an accident, rather than apportion blame. Furthermore, any attempt to blame pilots does not consider that they are part of a broader system, which in turn may be at fault for their fatigue, work pressure or lack of training.[2] ICAO and its member states therefore adopted the Reason Model in 1993 in an effort to better understanding the role of human factors in aviation accidents.[3]

Notable examples[edit]

One of the most famous incidents of an aircraft disaster attributed to pilot error was the night time crash of Eastern Air Lines Flight 401 near Miami, Florida on December 29, 1972. The captain, first officer, and flight engineer had become fixated on a faulty landing gear light and had failed to realize that the flight controls had been bumped by one of the crew 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 on the ground visible 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 out of 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.[4] For scheduled air transport, pilot error typically accounts for just over half of worldwide accidents with a known cause.[5]

  • 24 December 1958 – BOAC Bristol Britannia 312, registration G-AOVD, crashed as a result of a controlled flight into terrain, (CFIT), near Winkton, England while on a test flight. The crash was caused by a combination of bad weather and a failure on the part of both pilots to read the altimeter correctly. The First Officer and 2 other people survived.
  • 3 January 1961 - Aero Flight 311 crashed near Kvevlax, Finland. All twenty-five occupants were killed in the crash, the worst in Finnish history. An investigation later determined that both pilots were intoxicated during the flight, and may have been interrupted by a passenger at the time of the crash.
  • 29 December 1972 - Eastern Air Lines Flight 401 crashed into the Florida Everglades after the flight crew failed to notice the deactivation of the plane's autopilot, having been distracted by their own attempts to solve a problem with the landing gear. Out of 163 occupants, 75 survived the crash.
  • 27 March 1977 – the Tenerife disaster; a senior KLM pilot failed to hear, understand or follow tower instructions, causing two Boeing 747s to collide on the runway at Tenerife; 583 people were killed in the worst-ever air disaster.
  • 28 December 1978 – United Airlines Flight 173; a flight simulator instructor Captain allowed his Douglas DC-8 to run out of fuel while investigating a landing gear problem. United Airlines subsequently changed their policy to disallow "simulator instructor time" in calculating a pilot's "total flight time". It was thought that a contributory factor to the accident is that an instructor can control the amount of fuel in simulator training so that it never runs out.
  • 19 February 1985 – above the Pacific Ocean the crew of China Airlines Flight 006 lost control of their Boeing 747SP after the No. 4 engine flamed out. The aircraft fell 10,000 feet in twenty seconds and lost a total of 30,000 feet in two-and-a-half minutes before control was regained. There were no fatalities but the aircraft was badly damaged.
  • 28 August 1988 – the Ramstein airshow disaster; a member of an Italian aerobatic team misjudged a manoeuvre, causing a mid-air collision. Three pilots and 67 spectators on the ground were killed.
  • 31 August 1988 – Delta Air Lines Flight 1141 crashed on takeoff after the crew forgot to deploy the flaps for increased lift. Of the 108 crew and passengers on board, fourteen were killed.
  • 8 January 1989 – in the Kegworth air disaster, a fan blade broke off in the left engine of a new Boeing 737-400, but the pilots mistakenly shut down the right engine. The left engine eventually failed completely and the crew could not restart the right engine before the aircraft crashed. Instrumentation on the 737-400 was different from earlier models, but no flight simulator for the new model was available in Britain.
  • 3 September 1989 – The crew of Varig Flight 254 made a series of mistakes so that their Boeing 737 ran out of fuel hundreds of miles off-course above the Amazon jungle. Thirteen died in the ensuing crash-landing.
  • 23 March 1994 – Aeroflot Flight 593 crashed on its way to Hong Kong. The captain, Yaroslav Kudrinsky, invited his two children into the cockpit, and permitted them to sit at the controls, against airline regulations. His fifteen-year-old son, Eldar Kudrinsky, accidentally disconnected the autopilot, causing the plane to bank to the right before diving. The co-pilot brought up the plane too far, causing it to stall and start a flat spin. The pilots recovered the plane but it crashed into a forest, killing all 75 people on board.
  • June 24 1994 - B-52 crashes in Fairchild Air Force Base. The crash was largely attributed to the personality and behavior of the pilot in command and delayed reactions to the earlier incidents involving this pilot. After past histories, Mark McGeehan, a USAF squadron commander, refused to allow any of his squadron members to fly with that pilot unless he (McGeehan) was also on the aircraft. McGeehan's attempts to save the plane immediately before the crash were not successful. This crash is now used in military and civilian aviation environments as a case study in teaching crew resource management.
  • 30 June 1994 - Airbus Industrie Flight 129, a certification test flight of the Airbus 330-300, crashed at Toulouse-Blagnac Airport. While simulating an engine-out emergency just after takeoff with an extreme center of gravity location, the pilots chose improper manual settings which rendered the autopilot incapable of keeping the plane in the air, and by the time the PIC regained manual control, it was too late. The aircraft was destroyed, killing the flight crew, a test engineer, and four passengers which inclded Airbus and airline customer VIPs. The investigative board concluded the PIC was overworked from earlier flight testing that day, and was unable to devote sufficient time to the preflight briefing. As a result, Airbus had to revise the engine-out emergency procedures.
  • 12 October 1997 – Singer John Denver died when his newly-bought Rutan Long-EZ home-built aircraft crashed into the Pacific Ocean off Pacific Grove, California. The NTSB indicated that Denver lost control of the aircraft while attempting to manipulate the fuel selector handle, which had been placed in a hard-to-reach position by the aircraft's builder. The NTSB cited his unfamiliarity with the aircraft's design as a cause of the crash.
  • 31 August 1999 – 65 people died after Lineas Aéreas Privadas Argentinas (LAPA) flight 3142 crashed after an attempted take-off with the flaps retracted.
  • 12 November 2001 – American Airlines Flight 587 encountered heavy turbulence and the co-pilot over-applied the rudder pedal, turning the Airbus A300 side to side. Due to the excessive stress, the rudder failed. The A300 spun and hit a residential area, crushing 5 houses and killing 265. Contributing factors included wake turbulence and pilot training.
  • 24 November 2001 – Crossair Flight 3597 crashed into a forest on approach to runway 28 at Zurich Airport. This was caused by Captain Lutz descending below the minimum safe altitude of 2400 feet on approach to runway 28 at Zurich.
  • 26 February 2004 – a Beech 200 carrying Macedonian President Boris Trajkovski crashed, killing Trajkovski and eight other passengers. The crash investigation ruled that the accident was caused by "procedural mistakes by the crew" during the landing approach.
  • 3 January 2004 – Flash Airlines Flight 604 dived into the Red Sea shortly after take off. All 148 people were killed. The captain had encountered vertigo, his control column was slanted to the right, and the captain did not notice. The 737 banked until it was unable to stay in the air. It is Egypt's worst air disaster.
  • 14 August 2005 – the pilots of Helios Airways Flight 522 lost consciousness, most likely due to hypoxia caused by failure to switch the cabin pressurization to "Auto" during the pre-flight preparations. The Boeing 737-300 crashed after running out of fuel, killing all on board.
  • 3 May 2006 – Armavia Flight 967 performed a CFIT, killing all on board, after the pilot lost spatial awareness during a simultaneous turn and climb.
  • 27 August 2006 – Comair Flight 191 operating a Bombardier CRJ-100ER aircraft, crashed while taking off from Lexington's Blue Grass Airport. 49 of the 50 on board, including all 47 passengers, were killed.
  • 1 January 2007 – Adam Air Flight 574; The crew's preoccupation with a malfunction of the inertial reference system diverted their attention from the flight instruments and allowed the increasing descent and bank angle to go unnoticed. Appearing to have become spatially disoriented, the pilots did not detect and appropriately arrest the descent soon enough to prevent loss of control. This caused the aircraft to impact the water at high speed and a steep angle and disintegrate, killing all 102 people on board.[6]
  • 12 February 2009 - Colgan Air Flight 3407 flying as Continental Connection entered a stall and crashed in to a house in Clarence Center, NY 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 in the plane died, along with one person inside the house.
  • 22 May 2010 - Air India Express Flight 812; overshot the runway at Mangalore Airport killing 158 people. The plane touched down 610 metres from the usual touchdown point after a steep descent. CVR recordings showed that the Brit-Serb captain of the aircraft was sleeping and woke up just minutes before landing. His lack of alertness made the plane land very fast and steep and it ran off the end of the tabletop runway.
  • 28 July 2010 – Airblue Flight 202 crashed into the Margalla Hills due to the pilot going the wrong way, killing all 152 occupants aboard.
  • 20 June 2011 - RusAir Flight 9605 crashed onto a motorway while on final approach to Petrozavodsk Airport in western Russia, after the intoxicated navigator encouraged the captain to land in heavy fog. Forty-three people died in the crash, while only five survived.

See also[edit]

References[edit]

4. “Multiaxis Thrust Vectoring Flight Control Vs Catastrophic Failure Prevention”, Reports to U.S. Dept. of Transportation/FAA, Technical Center, ACD-210, FAA X88/0/6FA/921000/4104/T1706D, FAA Res. Benjamin Gal-Or, No: 94-G-24, CFDA, No. 20.108, Dec. 26, 1994

  1. ^ "Human Behavior" (pdf). Federal Aviation Administration. 9 Apr 2012. Retrieved 11 Jun 2013. 
  2. ^ a b Rural and Regional Affairs and Transport References Committee (May 2013). "Aviation Accident Investigations" (pdf). Government of Australia. 
  3. ^ Investigating Human Error: Incidents, Accidents, and Complex Systems. Ashgate Publishing, Ltd. 2004. ISBN 0754641228. 
  4. ^ 2005 Joseph T. Nall Report
  5. ^ PlaneCrashInfo.com accident statistics
  6. ^ http://www.dephub.go.id/knkt/ntsc_aviation/baru/Final_Report_PK-KKW_Release.pdf Aircraft Accident Investigation Report of Indonesian's National Transportation Safety Committee