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.Pilot’s Handbook of Aeronautical Knowledge (2016). U.S. Department of Transportation. Federal Aviation Administration, Flight Standards Service pdf. Errors are intentional actions that fail to achieve their intended outcomes.Error Management (OGHFA BN). Operator's Guide to Human Factors in Aviation. Skybrary 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."How exactly should I understand the term "accidental hull loss"?. Aviation stack overflow 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.
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 (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.Foyle, D.C., & Hooey, B.L. (Eds.). (2007). Human performance modeling in aviation. CRC Press.
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.Wiegmann, D.A., & Shappell, S.A. (2001). Human error perspectives in aviation. The International Journal of Aviation Psychology, 11(4), 341–357. 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.Stacey, Daniel (15 January 2015). "Indonesian Air-Traffic Control Is Unsophisticated, Pilots Say". The Wall Street Journal. Retrieved 26 January 2015
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. 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 'resilience'. Resilience, 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). 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: Potential threats to safety How the threats are addressed by the crew members The errors the threats generate How crew members manage these errors (action or inaction) Specific behaviors known to be associated with aviation accidents and incidents 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) 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: Decision making – the use of logic and judgement to make decisions based on available information Assertiveness – willingness to participate and state a given position until convinced by facts that another option is more correct Mission analysis – ability to develop short and long term contingency plans Communication – clear and accurate sending and receiving of information, instructions, commands and useful feedback Leadership – ability to direct and coordinate activities of pilots & crew members Adaptability/flexibility – ability to alter course of action due to changing situations or availability of new information Situational awareness – ability to perceive the environment within time and space, and comprehend its meaning 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: 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.