Pilot Error ?
Thread Starter
Join Date: Jan 2001
Location: In the boot of my car!
Posts: 5,982
Likes: 0
Received 0 Likes
on
0 Posts
Pilot Error ?
I am sure we are all aware that the vast majority of accidents are pilot error
But what classifies as pilot error?
Some situations are obvious! An aircraft over banks on base gets slow stalls and spins into the ground! Pilot error.
Pilot gets his navigation wrong and flies into mountain! Pilot error
But then we get aurcraft failures? Failures we are trained to deal with if we don't deal with those failures correctly pilot error ??
Engine fails after take off? If it crashes ? Pilot error ?
The guy is very unlucky and takes birds through both engines and crashes in the subsequent forced landing ? Pilot error ?
I am not surprised that the vast majority of accidents can be attributed to pilot error but then I cannot think of many situations other than a bomb or missile or non pilot induced structural failure which could not be made to fit the pilot error category ?what do you think
Should pilot error just be in a perfectly serviceable aircraft ? Or are we expected to handle failures and if so to what level of failures ?
Pace
But what classifies as pilot error?
Some situations are obvious! An aircraft over banks on base gets slow stalls and spins into the ground! Pilot error.
Pilot gets his navigation wrong and flies into mountain! Pilot error
But then we get aurcraft failures? Failures we are trained to deal with if we don't deal with those failures correctly pilot error ??
Engine fails after take off? If it crashes ? Pilot error ?
The guy is very unlucky and takes birds through both engines and crashes in the subsequent forced landing ? Pilot error ?
I am not surprised that the vast majority of accidents can be attributed to pilot error but then I cannot think of many situations other than a bomb or missile or non pilot induced structural failure which could not be made to fit the pilot error category ?what do you think
Should pilot error just be in a perfectly serviceable aircraft ? Or are we expected to handle failures and if so to what level of failures ?
Pace
Join Date: May 2004
Location: Bear Island
Posts: 598
Likes: 0
Received 0 Likes
on
0 Posts
An interesting question. My personal and professional view is that whilst a high proportion of accidents / incidents may be directly attributable to the crew, the systemic model (aka the Swiss Cheese) may demonstrate that the dice were loaded towards of a set of potentially negative outcomes.
At one end of the scale, there is the accident alluded to:
Aircraft hits flock of birds, loses power and and accident occurs.
As most of us will appreciate, you can read and re-read the NOTAMS regarding bird activity but a) there is little that can be done once away from the protected airport environment, and b) the inescapable fact is that birds do not read NOTAMS.
Risk mitigation such as managing local populations will help, but when the hazard comes from migratory birds the nature of the problem has shifted.
The incident did happen, and the last layer of cheese was the outcome achieved by the crew.
The driving force behind safety culture is to reduce the holes in the cheese to an acceptable level, although in reality, zero risk is not achievable.
At one end of the scale, there is the accident alluded to:
Aircraft hits flock of birds, loses power and and accident occurs.
As most of us will appreciate, you can read and re-read the NOTAMS regarding bird activity but a) there is little that can be done once away from the protected airport environment, and b) the inescapable fact is that birds do not read NOTAMS.
Risk mitigation such as managing local populations will help, but when the hazard comes from migratory birds the nature of the problem has shifted.
The incident did happen, and the last layer of cheese was the outcome achieved by the crew.
The driving force behind safety culture is to reduce the holes in the cheese to an acceptable level, although in reality, zero risk is not achievable.
Join Date: Jan 2008
Location: another place
Posts: 736
Likes: 0
Received 0 Likes
on
0 Posts
Pilot error is an erroneous term in my view(relating to the technical task of actually flying the aircraft).
More accurate would be monitoring error. The guy flying can and will make errors in many forms. selection error, decision making error etc, but it's up to the guy sitting next to him to say no!
We all know the rules and procedures but when loaded heavily or overloaded we need the monitoring over site. The probl m gets compounded when you as PF or the situation overloads both crew. My view now after an ahem.. Issue is if either one of us is pedelling like Chris froome on the Tour de France, then take up the hold at a known point above MSA and sort it before proceeding. Break the chain and the cycle.
In flight break up due mx issue bomb or shoot down is systemic failure not pilot.
Discuss
More accurate would be monitoring error. The guy flying can and will make errors in many forms. selection error, decision making error etc, but it's up to the guy sitting next to him to say no!
We all know the rules and procedures but when loaded heavily or overloaded we need the monitoring over site. The probl m gets compounded when you as PF or the situation overloads both crew. My view now after an ahem.. Issue is if either one of us is pedelling like Chris froome on the Tour de France, then take up the hold at a known point above MSA and sort it before proceeding. Break the chain and the cycle.
In flight break up due mx issue bomb or shoot down is systemic failure not pilot.
Discuss
Thread Starter
Join Date: Jan 2001
Location: In the boot of my car!
Posts: 5,982
Likes: 0
Received 0 Likes
on
0 Posts
TheIc
I take your point but within our own circles its referred to as Pilot Error maybe in contrast to aircraft error?
But that itself is a contradiction as even with aircraft error if the pilot mishandles the aircraft error it becomes the pilots error? We are trained to deal with the huge majority of aircraft errors
So probably 95% of accidents can be attached to the pilot probably unfairly
Pace
I take your point but within our own circles its referred to as Pilot Error maybe in contrast to aircraft error?
But that itself is a contradiction as even with aircraft error if the pilot mishandles the aircraft error it becomes the pilots error? We are trained to deal with the huge majority of aircraft errors
So probably 95% of accidents can be attached to the pilot probably unfairly
Pace
Join Date: Oct 2008
Location: Camped on the doorstep
Posts: 76
Likes: 0
Received 0 Likes
on
0 Posts
It's my opinion that you need to set our your terms before you can have any meaningful examination of what is and what isn't pilot error.
It's like cause of death: cause of death is always cardiac failure, but it would be absurd and pointless if we said that someone who got drunk and inadvertently shot themselves in the head whilst trying to scare a pigeon off their TV aerial, had died of cardiac failure rather than gross stupidity.
We tend to look at the last point at which the pilot could have said no, and then assess whether it was reasonable that that moment was missed.
To say (as was said in the other thread) that *all* accidents are pilot error is to reduce the examination down to a point where it's pointless bothering with. In Sioux City (foolish) people could argue that some of the deaths were attributable to pilot error. That would be literally true but clearly absurd.
What are we saying is the meaning of Pilot Error?
Is it, for example, a pilot making and acting on a decision that a reasonably skilled pilot would not have made had s/he had a chance to examine all the options carefully?
I'm just offering that as a starting point. I just made it up. It may be full of holes - feel free to take it to pieces if you've got something better.
It's like cause of death: cause of death is always cardiac failure, but it would be absurd and pointless if we said that someone who got drunk and inadvertently shot themselves in the head whilst trying to scare a pigeon off their TV aerial, had died of cardiac failure rather than gross stupidity.
We tend to look at the last point at which the pilot could have said no, and then assess whether it was reasonable that that moment was missed.
To say (as was said in the other thread) that *all* accidents are pilot error is to reduce the examination down to a point where it's pointless bothering with. In Sioux City (foolish) people could argue that some of the deaths were attributable to pilot error. That would be literally true but clearly absurd.
What are we saying is the meaning of Pilot Error?
Is it, for example, a pilot making and acting on a decision that a reasonably skilled pilot would not have made had s/he had a chance to examine all the options carefully?
I'm just offering that as a starting point. I just made it up. It may be full of holes - feel free to take it to pieces if you've got something better.
"Mildly" Eccentric Stardriver
Just a nit-pick, but I think the cause of death is always lack of oxygen to the brain, resulting in brain death. Of course, cardiac arrest would have that effect.
Join Date: Oct 2008
Location: Camped on the doorstep
Posts: 76
Likes: 0
Received 0 Likes
on
0 Posts
Originally Posted by Herod
Just a nit-pick, but I think the cause of death is always lack of oxygen to the brain, resulting in brain death. Of course, cardiac arrest would have that effect.
One could reasonably argue that it makes little odds whether it's cardiac arrest or lack of oxygen - you're still dead - and that's the issue here.
Thread Starter
Join Date: Jan 2001
Location: In the boot of my car!
Posts: 5,982
Likes: 0
Received 0 Likes
on
0 Posts
The other angle of the badge of pilot error is in accidents which cause death either with people in the ground or in the air!
It implies that the pilot caused those deaths yet the mantle of pilot error which is so broad yet so damning
I pilot who does something stupid which is also classified as reckless is the worst while a pilot dealing with multi aircraft failures who does his best but fails comes in at the other end of the spectrum
Yet they could both be classified as pilot error )
In the eyes of the authorities it is still not clear to me what classifies as pilot error ?
I could have a battery overheat situation which could be contained! If I failed to do so and the aircraft caught fire is that pilot error ? Just an example of the scope of pilot or human error
Pace
It implies that the pilot caused those deaths yet the mantle of pilot error which is so broad yet so damning
I pilot who does something stupid which is also classified as reckless is the worst while a pilot dealing with multi aircraft failures who does his best but fails comes in at the other end of the spectrum
Yet they could both be classified as pilot error )
In the eyes of the authorities it is still not clear to me what classifies as pilot error ?
I could have a battery overheat situation which could be contained! If I failed to do so and the aircraft caught fire is that pilot error ? Just an example of the scope of pilot or human error
Pace
Join Date: Aug 2007
Location: Germany
Posts: 122
Likes: 0
Received 0 Likes
on
0 Posts
Hi Pace,
If I may chime in here, you are absolutely right in what you and JonDyer (great analogy, btw) wrote about pilot error being a catch-all that doesn't provide any meaningful explanation of what caused an accident. This has been widely recognized, and most safety professionals such as accident investigators etc have done away with the term. Unfortunately, it is still at large in media reports. Bottomline: If someone talks about "80% of all accidents are caused by pilot error/human error" or similar, you know he or she doesn't have a clue.
Cheers,
Cpt. S.
If I may chime in here, you are absolutely right in what you and JonDyer (great analogy, btw) wrote about pilot error being a catch-all that doesn't provide any meaningful explanation of what caused an accident. This has been widely recognized, and most safety professionals such as accident investigators etc have done away with the term. Unfortunately, it is still at large in media reports. Bottomline: If someone talks about "80% of all accidents are caused by pilot error/human error" or similar, you know he or she doesn't have a clue.
Cheers,
Cpt. S.
Join Date: Apr 2011
Location: Sao Jose dos Campos-Brazil
Age: 54
Posts: 104
Likes: 0
Received 0 Likes
on
0 Posts
Hi Chronus,
I remember 2 of them:
Transbrasil Boeing 727 303 in Florianopolis, Brazil, in 1980. Crashed into a hill;
SSJ-100 accident in Jacarta, Indonesia, in 2012.
Pilot error happens, it is in human nature.
All the best,
Sydy
I remember 2 of them:
Transbrasil Boeing 727 303 in Florianopolis, Brazil, in 1980. Crashed into a hill;
SSJ-100 accident in Jacarta, Indonesia, in 2012.
Pilot error happens, it is in human nature.
All the best,
Sydy
Join Date: Jan 2008
Location: Hotel Sheets, Downtown Plunketville
Age: 76
Posts: 0
Likes: 0
Received 0 Likes
on
0 Posts
PACE kicked the ball into play with:
But what classifies as pilot error?
To list individual accidents would not answer this question. The question requires that it be classified, that various accidents attributed to pilot error be designated under categories of a fundamental prime error.
I believe that this classification falls simply under two main headings.
Errors of commission
Errors of omission
The first is where the action was incorrect.
The second is where the action required was not carried out.
What we now find, in a world of ever increasing reliance on automation is the emergence of a new phenomenon referred to as Automation Bias. This acts to reduce cognitive effort and increase dependency on automation. The comfort and luxury offered by the state of the art aircraft slipping through the air with a crew seated in armchairs a cockpit where a pin drop would offend, watching video displays of any particular system or image they wish , creates an illusion that they are not in a perilous situation. They soon loose the reality of the fact that their armchairs are covering mother Earth at the rate of 8 nm every minute of time elapsed and the effects of a sudden reduction of this rate to a value of 0. Who and for what reason has decreed they must do their job in such an office. Surely not the pilots.
By the way have you recently seen one of these modern diggers, amazing really, it is no longer your common to all gardens, every day type of navvy who now sits on arse biting stool in a sweat box of a cab with a fag clenched between his teeth, no Siree it is a young grad with a Masters in computer sciences who is seated in luxurious comfort stroking a video screen with one of his delicate digits.
But what classifies as pilot error?
To list individual accidents would not answer this question. The question requires that it be classified, that various accidents attributed to pilot error be designated under categories of a fundamental prime error.
I believe that this classification falls simply under two main headings.
Errors of commission
Errors of omission
The first is where the action was incorrect.
The second is where the action required was not carried out.
What we now find, in a world of ever increasing reliance on automation is the emergence of a new phenomenon referred to as Automation Bias. This acts to reduce cognitive effort and increase dependency on automation. The comfort and luxury offered by the state of the art aircraft slipping through the air with a crew seated in armchairs a cockpit where a pin drop would offend, watching video displays of any particular system or image they wish , creates an illusion that they are not in a perilous situation. They soon loose the reality of the fact that their armchairs are covering mother Earth at the rate of 8 nm every minute of time elapsed and the effects of a sudden reduction of this rate to a value of 0. Who and for what reason has decreed they must do their job in such an office. Surely not the pilots.
By the way have you recently seen one of these modern diggers, amazing really, it is no longer your common to all gardens, every day type of navvy who now sits on arse biting stool in a sweat box of a cab with a fag clenched between his teeth, no Siree it is a young grad with a Masters in computer sciences who is seated in luxurious comfort stroking a video screen with one of his delicate digits.
Join Date: Jan 2008
Location: Hotel Sheets, Downtown Plunketville
Age: 76
Posts: 0
Likes: 0
Received 0 Likes
on
0 Posts
On another thread of this forum the publication of the accident report by the BEA on the 2012 G IV crash in Le Castellet has been announced.
The report reveals that this was due to pilot error. Error of omission in not arming the spoilers and error of commission in forcing down the nose wheel on to the tarmac.
The 60 year old career PIC was highly experienced with over 22000 Hrs.to his credit.
The report explains how the accident occurred but does not say why. So common to most accidents involving pilot error. It is just another example of the fallibility of humans, to err. The question is when and under what circumstances when the risk for error is high. The extremities of this is when everything is just so easy and perfect and the normal defence mechanisms are not called into action and the other extreme is when work load and stress is very high. I believe this particular accident is a sad demonstration of the everything easy end of the error risk spectrum.
The report reveals that this was due to pilot error. Error of omission in not arming the spoilers and error of commission in forcing down the nose wheel on to the tarmac.
The 60 year old career PIC was highly experienced with over 22000 Hrs.to his credit.
The report explains how the accident occurred but does not say why. So common to most accidents involving pilot error. It is just another example of the fallibility of humans, to err. The question is when and under what circumstances when the risk for error is high. The extremities of this is when everything is just so easy and perfect and the normal defence mechanisms are not called into action and the other extreme is when work load and stress is very high. I believe this particular accident is a sad demonstration of the everything easy end of the error risk spectrum.
ECON cruise, LR cruise...
Join Date: Apr 2002
Location: MIRSI hold - give or take...
Age: 52
Posts: 568
Likes: 0
Received 0 Likes
on
0 Posts
Chronus,
The report quite clearly stated why the accident happened:
1) The crew were habitually not completing checklists in the prescribed fashion, or at all
2) The crew on other approaches did not arm speed-brakes and only corrected this on touch-down, yet did not manage to correct this trend in themselves
3) The crew did not plan the short flight in respect of LDA vs. LDR, and preflight planning was deemed ineffective by the BEA
In short - crew training, crew integrity & professionalism did not stop some habits developing over the years, as transgressions of procedures were repeatedly reinforced as having no apparent negative consequences. Modern aviation is so safe, with so wide safety boundaries that we can violate procedure 999 times and it'll all go smooth-as-you-like. The 1000th time you try it, you'll find out why the procedure was put in place in the first place.
Part of the problem resides in us pilots thinking individually, on the individual risk we perceive. Concepts such as cumulative risk, herd immunity and basic probability rarely enter our thoughts - and this will need to change.
Perhaps time to include 'Statistics & Probability 101' in the ATPL syllabus, i.s.o. making sure the youngsters know what kind of N2 is used to service the tyres?
The report quite clearly stated why the accident happened:
1) The crew were habitually not completing checklists in the prescribed fashion, or at all
2) The crew on other approaches did not arm speed-brakes and only corrected this on touch-down, yet did not manage to correct this trend in themselves
3) The crew did not plan the short flight in respect of LDA vs. LDR, and preflight planning was deemed ineffective by the BEA
In short - crew training, crew integrity & professionalism did not stop some habits developing over the years, as transgressions of procedures were repeatedly reinforced as having no apparent negative consequences. Modern aviation is so safe, with so wide safety boundaries that we can violate procedure 999 times and it'll all go smooth-as-you-like. The 1000th time you try it, you'll find out why the procedure was put in place in the first place.
Part of the problem resides in us pilots thinking individually, on the individual risk we perceive. Concepts such as cumulative risk, herd immunity and basic probability rarely enter our thoughts - and this will need to change.
Perhaps time to include 'Statistics & Probability 101' in the ATPL syllabus, i.s.o. making sure the youngsters know what kind of N2 is used to service the tyres?
Join Date: Jan 2008
Location: Hotel Sheets, Downtown Plunketville
Age: 76
Posts: 0
Likes: 0
Received 0 Likes
on
0 Posts
With the Castellet G IV accident as a case in point, what are the causes of pilot error. I believe the reason is Task induced complacency".
They left Istanbul Sabiha Gokcen at 0600 for Athens, from where they flew to Nice, departing there at 1256 for a five minute flight to Le Castellet. Assuming they rose at their hotel and hour be reporting at Sabiha Gokcen, they could have been on duty well in excess of nine hours. So when they took off from Nice, the job was done and a long days of work was over. They could now relax and look forward to well earned rest.
"Complacency is caused by the very things that should prevent accidents, factors like experience, training and knowledge contribute to complacency. Complacency makes crews skip hurriedly through checklists, fail to monitor instruments closely or utilize all navigational aids. It can cause a crew to use shortcuts and poor judgement and to resort to other malpractices that mean the difference between hazardous performance and professional performance."
Wiener, E.L. (1981). "Complacency: Is the term useful for air safety?" In Proceedings of the 26th Corporate Aviation Safety Seminar. Denver, CO: Flight Safety Foundation.
Fahlgren and Hagdahl defined complacency as "A mental state where an aviator acts, unaware of actual danger or deficiencies. He still has the capacity to act in a competent way - but for some reason, or another, this capacity is not activated. He has lost his guard without knowing it".
Fahlgren, G and Hagdahl, R. (1990). "Complacency" Proceedings of the 43rd Annual International Air Safety Seminar, Rome, Italy: Flight Safety Foundation.
At some time or another we all let our guard down, especially when we think the real hard work is done, it is in our nature after all.
They left Istanbul Sabiha Gokcen at 0600 for Athens, from where they flew to Nice, departing there at 1256 for a five minute flight to Le Castellet. Assuming they rose at their hotel and hour be reporting at Sabiha Gokcen, they could have been on duty well in excess of nine hours. So when they took off from Nice, the job was done and a long days of work was over. They could now relax and look forward to well earned rest.
"Complacency is caused by the very things that should prevent accidents, factors like experience, training and knowledge contribute to complacency. Complacency makes crews skip hurriedly through checklists, fail to monitor instruments closely or utilize all navigational aids. It can cause a crew to use shortcuts and poor judgement and to resort to other malpractices that mean the difference between hazardous performance and professional performance."
Wiener, E.L. (1981). "Complacency: Is the term useful for air safety?" In Proceedings of the 26th Corporate Aviation Safety Seminar. Denver, CO: Flight Safety Foundation.
Fahlgren and Hagdahl defined complacency as "A mental state where an aviator acts, unaware of actual danger or deficiencies. He still has the capacity to act in a competent way - but for some reason, or another, this capacity is not activated. He has lost his guard without knowing it".
Fahlgren, G and Hagdahl, R. (1990). "Complacency" Proceedings of the 43rd Annual International Air Safety Seminar, Rome, Italy: Flight Safety Foundation.
At some time or another we all let our guard down, especially when we think the real hard work is done, it is in our nature after all.
Join Date: Jun 2006
Location: Manchester
Posts: 122
Likes: 0
Received 0 Likes
on
0 Posts
Yes I think "Task induced complacency " well describes the issue.
Of course that is where all the recurrent training, six monthly visits to the sim etc all come in. All this is designed to maintain the basic levels of rock hard professionalism that defines a safe and proficient pilot.
Never however underestimate the extent to which, even subconsciously, companies put upon their crews directly or indirectly to " get the job done" and the effect this has on the judgement and functioning of an otherwise competent pilot.
One of the most shocking things i heard was about a highly experienced crew who recently took off in a Challenger with a pitot cover on and consciously chose to continue the flight at night from ZRH to MUC despite huge downgrading of automation and safety.
When questioned, the very experienced pilot had no answer as to why he was so reckless and did not land immediately.
I firmly believe that a lot of GA companies are walking on a knife edge and put so much pressure on their crews as to render all the talk of prioritisation of safety....as just that....talk.
The CAA are complicit in this as they neither have the guts nor the manpower to ensure compliance.
A charge of corporate manslaughter in an appropriate case would concentrate the minds of all concerned in the industry.
Of course that is where all the recurrent training, six monthly visits to the sim etc all come in. All this is designed to maintain the basic levels of rock hard professionalism that defines a safe and proficient pilot.
Never however underestimate the extent to which, even subconsciously, companies put upon their crews directly or indirectly to " get the job done" and the effect this has on the judgement and functioning of an otherwise competent pilot.
One of the most shocking things i heard was about a highly experienced crew who recently took off in a Challenger with a pitot cover on and consciously chose to continue the flight at night from ZRH to MUC despite huge downgrading of automation and safety.
When questioned, the very experienced pilot had no answer as to why he was so reckless and did not land immediately.
I firmly believe that a lot of GA companies are walking on a knife edge and put so much pressure on their crews as to render all the talk of prioritisation of safety....as just that....talk.
The CAA are complicit in this as they neither have the guts nor the manpower to ensure compliance.
A charge of corporate manslaughter in an appropriate case would concentrate the minds of all concerned in the industry.