What is the general definition of pilot error in aviation?

In aviation, pilot error is generally defined as an action or decision made by a pilot that significantly contributes to an aviation accident. It also encompasses a pilot's failure to take appropriate action or make a correct decision. Errors are considered intentional actions that do not achieve their intended outcomes.

How does the Chicago Convention define an 'accident' in aviation?

According to the Chicago Convention on International Civil Aviation, an 'accident' is defined as an occurrence associated with the operation of an aircraft where a person is fatally or seriously injured, unless the injuries are inflicted by other persons. This definition excludes deliberate acts of crashing, which are not classified as accidents.

Does the definition of pilot error include deliberate crashing of an aircraft?

No, the definition of pilot error, as derived from the Chicago Convention's definition of an accident, does not include deliberate crashing. Such intentional acts are not classified as accidents.

What are the underlying causes of pilot error?

Pilot error stems from the physiological and psychological limitations inherent in humans. These limitations can be exacerbated by factors such as fatigue, workload, fear, cognitive overload, poor interpersonal communications, imperfect information processing, and flawed decision-making processes.

Why do modern accident investigators tend to avoid the term 'pilot error'?

Modern accident investigators often avoid the term 'pilot error' because their focus is on determining the causes of an accident rather than assigning blame. They recognize that pilots operate within a broader system that might contribute to errors through factors like fatigue, work pressure, or inadequate training.

What model of causation did the International Civil Aviation Organization (ICAO) adopt in 1993?

In 1993, the International Civil Aviation Organization (ICAO) and its member states adopted James Reason's model of causation. This model was adopted to better understand the role of human factors in aviation accidents.

What is the statistical significance of pilot error in general aviation accidents?

In 2004, pilot error was identified as the primary reason for 78.6% of disastrous general aviation (GA) accidents and as the major cause for 75.5% of GA accidents in the United States. For scheduled air transport, pilot error typically accounts for just over half of worldwide accidents with a known cause.

What are the two main categories of threats that can lead to pilot error?

Threats in aviation are defined as events external to the flight crew's influence that increase operational complexity. They are categorized into environmental threats, such as adverse weather or air traffic control shortcomings, and airline threats, which include aircraft malfunctions, operational pressure, or ground errors.

Can you provide examples of environmental threats in aviation?

Environmental threats are factors outside the control of the flight crew and airline. Examples include adverse weather conditions, shortcomings in air traffic control, bird strikes, and the presence of high terrain.

What are some examples of airline threats that can contribute to pilot error?

Airline threats are factors that, while not directly manageable by the flight crew, can be influenced by airline management. These include aircraft malfunctions, cabin interruptions, operational pressure, ground or ramp errors, cabin events, ground maintenance errors, and inadequacies in manuals or charts.

How is 'error' defined in the context of aviation safety?

In aviation, an 'error' is defined as any action or inaction by a pilot or crew that leads to a deviation from team or organizational intentions. These errors are often rooted in human limitations and can range from minor deviations to critical mistakes.

What are some common human limitations that lead to pilot errors?

Common human limitations contributing to pilot errors include illness, the effects of medication, stress, alcohol or drug abuse, fatigue, and emotional states. These factors can impair cognitive function and judgment.

What are some specific types of errors pilots might make?

Pilot errors can manifest in various ways, such as setting the altimeter incorrectly, deviating from the flight course, exceeding maximum structural speeds, or forgetting to deploy flaps for takeoff or landing.

What are the three cognitive models developed by Wiegmann and Shappell for analyzing pilot factors?

Wiegmann and Shappell developed three cognitive models to analyze pilot factors in aviation mishaps. While differing slightly in the types of errors they identify, all three models conclude that errors in judgment are a primary cause, specifically citing decision-making, goal-setting, and strategy-selection errors.

What is Threat and Error Management (TEM) in aviation?

Threat and Error Management (TEM) is a systematic approach focused on the effective detection and response to internal or external factors that could compromise flight safety. It aims to equip crews with the ability to handle both routine situations and unexpected events.

What is the primary goal of TEM training for flight crews?

The primary goal of TEM training is to develop 'resilience' in flight crews. Resilience, in this context, refers to the ability to recognize and adapt to disruptions encountered during flight operations, thereby maintaining safety.

What are some methods used in TEM training?

TEM training employs various methods, including data collection through Line Operations Safety Audits (LOSA), implementation of Crew Resource Management (CRM) and Cockpit Task Management (CTM), and the integrated use of checklists. Modern aircraft also feature systems like ACAS and GPWS to aid in threat and error management.

What is a Line Operations Safety Audit (LOSA)?

LOSA is a structured observational program designed to gather data on normal flight crew procedures, protocols, and decision-making when faced with threats and errors. This data helps in developing and improving safety countermeasures and understanding pilot behavior.

What specific elements do LOSA observers typically monitor during flights?

During LOSA audits, observers typically monitor potential threats to safety, how crews address these threats, the errors that arise, how crews manage these errors through actions or inactions, and specific behaviors known to be associated with aviation accidents and incidents.

What is Crew Resource Management (CRM)?

CRM is defined as the effective utilization of all available resources by individuals and crews to safely and effectively accomplish a mission or task, which includes identifying and managing conditions that lead to errors. It is a cornerstone of modern pilot training.

What are the seven critical CRM skills identified by the U.S. Navy?

The seven critical CRM skills are: Decision making, Assertiveness, Mission analysis, Communication, Leadership, Adaptability/flexibility, and Situational awareness. These skills are fundamental for effective aircrew coordination and reducing human errors.

How has CRM training evolved over the generations?

CRM training has evolved through several generations: the first focused on individual psychology, the second on cockpit group dynamics, the third on diversifying scope to include in- and out-of-cockpit functions, the fourth on integrating procedures and tailoring training, and the current fifth generation acknowledges human error as inevitable and focuses on improving safety standards.

What is Cockpit Task Management (CTM)?

CTM refers to the management-level activities pilots undertake to initiate, monitor, prioritize, and terminate cockpit tasks. It focuses on teaching crew members how to effectively handle multiple tasks that compete for their attention during flight.

What are the key processes involved in Cockpit Task Management (CTM)?

The key processes in CTM include task initiation, task monitoring, task prioritization based on safety importance and urgency, resource allocation (human and machine), task interruption for higher priority tasks, task resumption, and task termination.

Why is CTM training necessary for pilots?

CTM training is necessary due to the limitations of human attentional capacity and working memory. Pilots may need to allocate more mental resources to critical tasks, and CTM helps them manage competing demands effectively.

How do modern aircraft systems aid in Cockpit Task Management (CTM)?

Modern aircraft systems aid CTM by consolidating information onto single displays, such as the Primary Flight Display (PFD), which presents multiple critical data readings like heading, airspeed, and altitude. This integration allows crews to quickly gather information, freeing up mental capacity for other tasks.

What is the role and purpose of checklists in aviation?

Checklists are a critical tool in aviation for managing error and reducing risk. They provide a standardized protocol for actions required during flight, serving objectives such as memory recall, standardization, and regulation of processes.

What is the 'IM SAFE' checklist used by pilots?

The 'IM SAFE' checklist is a personal qualitative assessment that pilots may use to ensure their fitness to fly. It stands for Illness, Medication, Stress, Alcohol, Fatigue/Food, and Emotion, helping pilots evaluate their own readiness.

What was the primary cause of the Eastern Air Lines Flight 401 crash in 1972?

The crash of Eastern Air Lines Flight 401 in 1972 was attributed to the flight crew becoming fixated on a faulty landing gear light. This distraction caused them to miss the autopilot disengaging and the aircraft descending into the Everglades, killing 101 people. The NTSB cited the crew's failure to properly monitor the aircraft's instruments.

How did pilot error contribute to the Tenerife airport disaster in 1977?

The Tenerife airport disaster, the deadliest aviation accident in history, occurred when a KLM pilot failed to hear, understand, or follow instructions from the control tower. This led to a collision between two Boeing 747s on the runway, killing 583 people. The airport's congestion and disruptions also played a role.

What was the cause of the Air Florida Flight 90 crash into the Potomac River in 1982?

Air Florida Flight 90 crashed shortly after takeoff from Washington National Airport due to the flight crew's failure to properly employ the aircraft's de-icing system. This resulted in the aircraft losing lift and crashing into the 14th Street Bridge and the Potomac River, killing 74 passengers and crew, plus four motorists.

What pilot error led to the Kegworth air disaster in 1989?

In the Kegworth air disaster, a fan blade failure in the left engine of a Boeing 737-400 led the pilots to mistakenly shut down the right engine. The left engine subsequently failed, and they couldn't restart the right engine before the crash. The instrumentation differences in the new model and lack of simulator training in Britain were contributing factors.

How did pilot error contribute to the crash of Varig Flight 254 in 1989?

Varig Flight 254 ran out of fuel hundreds of miles off course above the Amazon jungle due to a series of navigational mistakes made by the crew. Thirteen people died in the subsequent crash landing.

What was the primary cause of the Aeroflot Flight 593 crash in 1994?

The crash of Aeroflot Flight 593, which killed all 75 people on board, was caused by the captain allowing his children into the cockpit and letting his son sit at the controls. The son accidentally disconnected the autopilot, leading to a loss of control and a flat spin from which the pilots could not recover.

What role did pilot error play in the 1994 Fairchild Air Force Base B-52 crash?

The 1994 Fairchild Air Force Base B-52 crash was largely attributed to the personality and behavior of the pilot in command, Lt Col Arthur "Bud" Holland, and delayed reactions to his past incidents. This accident is now used as a case study in crew resource management training.

What pilot error led to the crash of American Airlines Flight 965 in 1995?

Investigators believe the pilot's unfamiliarity with the Boeing 757-200's technology contributed to the crash of American Airlines Flight 965. The pilots input incorrect coordinates while trying to locate a radio beacon, causing the aircraft to crash into mountains, killing 159 of the 163 people on board.

What was the cause of the Korean Air Flight 801 crash in Guam in 1997?

The crash of Korean Air Flight 801, which killed 228 of the 254 people on board, was caused by the captain's failure to properly conduct a non-precision approach. Pilot fatigue was also cited as a possible contributing factor.

How did pilot error contribute to the crash of China Airlines Flight 676 in 1998?

During an attempted landing in bad weather, the pilots of China Airlines Flight 676 accidentally disengaged the autopilot and failed to notice for 11 seconds. The Airbus A300 entered a stall and crashed into a highway and residential area, killing all 196 people on board and six on the ground.

What was the official cause of John F. Kennedy Jr.'s plane crash in 1999?

The NTSB officially declared that John F. Kennedy Jr.'s plane crash was caused by his failure to maintain control of the aircraft during a night descent over water, resulting from spatial disorientation. He was flying after visual landmarks became obscured and did not hold certification for IFR flight.

What pilot error led to the crash of Singapore Airlines Flight 006 in 2000?

Singapore Airlines Flight 006 collided with construction equipment and caught fire after taking off from the wrong runway. The accident killed 83 of the 179 occupants, caused by the crew's error in selecting the incorrect runway.

What factors contributed to the American Airlines Flight 587 crash in 2001?

The crash of American Airlines Flight 587, which killed 265 people, was caused by the co-pilot over-applying the rudder pedal during turbulence, leading to rudder failure. Contributing factors included wake turbulence and pilot training, specifically how pilots were trained to react to such events.

What pilot error caused the crash of Air China Flight 129 in South Korea in 2002?

The crash of Air China Flight 129, which killed 128 of the 166 people on board, was attributed to the pilot and co-pilot flying too low during their approach to Busan.

What was the cause of the Flash Airlines Flight 604 crash into the Red Sea in 2004?

Flash Airlines Flight 604 crashed shortly after takeoff due to the captain experiencing vertigo and not noticing that his control column was slanted to the right. This caused the Boeing 737 to bank uncontrollably and crash, killing all 148 people on board, though the investigation report was disputed.

How did pilot error contribute to the crash of Helios Airways Flight 522 in 2005?

The pilots of Helios Airways Flight 522 likely lost consciousness due to hypoxia caused by a failure to switch the cabin pressurization to 'Auto' before flight. The Boeing 737-300 crashed after running out of fuel, killing all on board.

What pilot error led to the crash of West Caribbean Airways Flight 708 in 2005?

The crew of West Caribbean Airways Flight 708 unknowingly decreased the aircraft's speed, causing it to stall. The situation was mishandled, with the captain incorrectly believing the engines had flamed out, leading to the crash near Machiques, Venezuela, killing all 160 people on board.

What was the cause of the Comair Flight 5191 crash in 2006?

Comair Flight 5191 failed to become airborne and crashed at Blue Grass Airport because the flight crew mistakenly attempted to take off from a shorter runway than intended. This pilot error resulted in the deaths of all but one of the 50 people on board.

What pilot error caused the crash of Adam Air Flight 574 in 2007?

The crew of Adam Air Flight 574 was distracted by a malfunction in the inertial reference system, causing them to overlook the aircraft's increasing descent and bank angle. Becoming spatially disoriented, they failed to arrest the descent, leading to loss of control and a mid-air breakup, killing all 102 people on board.

How did pilot error contribute to the crash of TAM Airlines Flight 3054 in 2007?

The thrust reverser on the right engine of TAM Airlines Flight 3054 was jammed, and although the crew was aware, the captain used an outdated braking procedure. This caused the Airbus A320 to overshoot the runway and crash into a building, killing all 187 people on board and 12 on the ground.

What pilot error led to the crash of Spanair Flight 5022 in 2008?

The crew of Spanair Flight 5022 failed to deploy the MD-82's flaps and slats for takeoff. This resulted in the aircraft not gaining enough lift and crashing after takeoff, killing 154 out of the 172 people on board.

What was the primary cause of the Colgan Air Flight 3407 crash in 2009?

Colgan Air Flight 3407 entered a stall and crashed due to the captain and first officer lacking situational awareness of the aircraft's airspeed and the captain's improper reaction to the stall warning. All 49 people on board and one person on the ground died.

How did pilot error contribute to the crash of Air France Flight 447 in 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. These actions led to a loss of control, killing all 228 passengers and crew.

Pilot Error Wiki: Navigating the Skies: Understanding Pilot Error and Aviation Safety

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Defining Pilot Error

Core Concept

In aviation, "pilot error" generally signifies an action or omission by a pilot that substantially contributes to an aviation accident. It encompasses failures to make correct decisions or take appropriate actions. The international definition of an "accident" excludes deliberate acts like intentional crashing, classifying such events differently from accidental occurrences.

Beyond Blame

Modern aviation accident investigation methodologies prioritize understanding the causal chain rather than assigning blame. The term "pilot error" is often avoided in official reports to acknowledge that pilots operate within a complex system. This system may influence their actions through factors like fatigue, work pressure, or inadequate training. The prevailing approach, adopted by organizations like the ICAO, utilizes models like James Reason's causation model to analyze the role of human factors.

Statistical Significance

Despite the shift in terminology, pilot error remains a significant factor in aviation incidents. Historically, it has been identified as the primary cause in a substantial percentage of general aviation accidents and a major contributor to accidents in scheduled air transport. The inherent psychological and physiological limitations of humans are central to understanding these occurrences.

Root Causes of Error

Human Limitations

Pilot errors stem from the inherent psychological and physiological limitations of human beings. These can be exacerbated by factors such as illness, medication, stress, substance use, fatigue, and emotional states. These limitations can lead to errors in judgment, information processing, and decision-making.

Cognitive Factors

Complex operational environments and situational stress can induce pilot error. Cognitive overload, poor interpersonal communication, imperfect information processing, and flawed decision-making processes are key contributors. These factors can manifest as mistakes in judgment, deviations from flight plans, or incorrect execution of procedures.

Workload and Fatigue

High workload and fatigue are critical elements that impair pilot performance. When pilots are overwhelmed or exhausted, their ability to accurately perceive the environment, process information, and make sound decisions is significantly compromised, increasing the likelihood of errors.

External Factors: Threats

Environmental Threats

These are factors beyond the direct influence of flight crews or airlines. They include adverse weather conditions, air traffic control shortcomings, bird strikes, and challenging terrain. While crews cannot control these elements, they must manage their impact on flight safety.

Airline-Related Threats

These threats originate from the airline's operations and management. Examples include aircraft malfunctions, operational pressures to maintain schedules, ground handling errors, inadequate maintenance, and deficiencies in manuals or charts. While not directly controllable by the flight crew, these factors create conditions that can lead to errors.

Types of Pilot Errors

Decision-Making Errors

These errors occur when pilots make incorrect choices regarding flight operations. Examples include misinterpreting navigation data (as in the Varig Flight 254 incident), selecting incorrect taxi routes (Linate Airport disaster), or misjudging maneuvers. These often stem from cognitive biases or a breakdown in information processing.

Execution Errors

These involve the incorrect implementation of procedures or actions. This can range from setting an incorrect altimeter (a factor in the UA 389 crash) to failing to deploy flaps or slats correctly (Northwest Airlines Flight 255), or exceeding aircraft operational limits (Fairchild B-52 crash).

Procedural Deviations

Errors can also arise from deviations from established procedures, such as failing to adhere to approach procedures (Alitalia Flight 112) or not monitoring aircraft instruments properly (Eastern Air Lines Flight 401). These often occur when crews become distracted or mismanage their tasks.

Managing Threats and Errors

Threat and Error Management (TEM)

TEM is a systematic approach focused on detecting and responding to factors that could compromise flight safety. It aims to equip crews with the ability to manage both routine situations and unexpected events, fostering resilience. Key components include Crew Resource Management (CRM) and Line Operations Safety Audits (LOSA).

Crew Resource Management (CRM)

CRM emphasizes the effective utilization of all available resources—including personnel, equipment, and procedures—to ensure safe and efficient operations. It trains crews in critical skills such as decision-making, communication, leadership, assertiveness, situational awareness, mission analysis, and adaptability.

Decision Making: Logical judgment based on available information.
Assertiveness: Confidently stating a position until convinced otherwise by facts.
Mission Analysis: Developing contingency plans for various scenarios.
Communication: Clear and accurate exchange of information.
Leadership: Directing and coordinating crew activities.
Adaptability/Flexibility: Adjusting actions based on changing circumstances.
Situational Awareness: Perceiving and understanding the environment and its implications.

Checklists and Task Management

Standardized checklists are crucial for managing errors by ensuring procedural adherence and aiding memory recall. Cockpit Task Management (CTM) focuses on how pilots initiate, monitor, prioritize, and terminate tasks, managing attentional capacity and working memory limitations. Modern integrated flight displays assist CTM by consolidating critical information.

Illustrative Case Studies

Tenerife Airport Disaster (1977)

A catastrophic collision between two Boeing 747s on the runway at Tenerife. The incident was attributed to multiple misunderstandings and communication failures, leading the KLM flight captain to attempt takeoff while the Pan Am flight was still on the runway. This event highlighted the critical need for clear communication and adherence to procedures.

Varig Flight 254 (1989)

This flight ran out of fuel hundreds of miles off course in the Amazon jungle due to a series of navigational errors. The pilot inadvertently used an incorrect flight plan, mistaking a magnetic heading for a VOR radial. This case exemplifies errors in decision-making and navigation.

Linate Airport Runway Collision (2001)

A collision on the taxiway in dense fog, caused by the flight crew taking the wrong route. Air traffic control had not provided clear taxiing instructions. This incident underscores the importance of precise navigation and clear communication in low-visibility conditions.

Eastern Air Lines Flight 401 (1972)

The flight crew became fixated on a faulty landing gear indicator light, neglecting to monitor the aircraft's instruments. This distraction led to an unintentional descent into the Everglades. The accident serves as a stark reminder of the dangers of fixation and the necessity of continuous instrument monitoring.

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References

Error Management (OGHFA BN). Operator's Guide to Human Factors in Aviation. Skybrary

Wiegmann, D.A., & Shappell, S.A. (2001). Human error perspectives in aviation. The International Journal of Aviation Psychology, 11(4), 341â357.

Stacey, Daniel (15 January 2015). "Indonesian Air-Traffic Control Is Unsophisticated, Pilots Say". The Wall Street Journal. Retrieved 26 January 2015

A full list of references for this article are available at the Pilot error Wikipedia page

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Disclaimer

Important Notice

This page was generated by an Artificial Intelligence and is intended for informational and educational purposes only. The content is based on a snapshot of publicly available data from Wikipedia and may not be entirely accurate, complete, or up-to-date.

This is not professional aviation advice. The information provided on this website is not a substitute for professional aviation consultation, training, or adherence to official safety protocols. Always refer to official aviation documentation, regulatory guidelines, and consult with qualified aviation professionals for specific operational needs and safety procedures. Never disregard professional advice or delay in seeking it because of something you have read on this website.

The creators of this page are not responsible for any errors or omissions, or for any actions taken based on the information provided herein.

Navigating the Skies: Understanding Pilot Error

💡 Dive in with Flashcard Learning! 💡

Defining Pilot Error ✈️

⚠️ Core Concept

⚖️ Beyond Blame

📊 Statistical Significance

Root Causes of Error 🧠

🔬 Human Limitations

📚 Cognitive Factors

📈 Workload and Fatigue

External Factors: Threats ☁️

🌍 Environmental Threats

🏢 Airline-Related Threats

Types of Pilot Errors 🛠️

🎯 Decision-Making Errors

⚙️ Execution Errors

❓ Procedural Deviations

Managing Threats and Errors 🛡️

🤝 Threat and Error Management (TEM)

👨‍👩‍👧‍👦 Crew Resource Management (CRM)

📝 Checklists and Task Management

Illustrative Case Studies 📚

💥 Tenerife Airport Disaster (1977)

🧭 Varig Flight 254 (1989)

🌫️ Linate Airport Runway Collision (2001)

📉 Eastern Air Lines Flight 401 (1972)

Teacher's Corner 🧑‍🏫

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📜 References

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📜 Important Notice

Dive in with Flashcard Learning!

Defining Pilot Error

Core Concept

Beyond Blame

Statistical Significance

Root Causes of Error

Human Limitations

Cognitive Factors

Workload and Fatigue

External Factors: Threats

Environmental Threats

Airline-Related Threats

Types of Pilot Errors

Decision-Making Errors

Execution Errors

Procedural Deviations

Managing Threats and Errors

Threat and Error Management (TEM)

Crew Resource Management (CRM)

Checklists and Task Management

Illustrative Case Studies

Tenerife Airport Disaster (1977)

Varig Flight 254 (1989)

Linate Airport Runway Collision (2001)

Eastern Air Lines Flight 401 (1972)

Teacher's Corner

True or False?

Test Your Knowledge!

Gamer's Corner

Discover other topics to study!

References

Feedback & Support

Disclaimer

Important Notice