Pilot Error - Let's be honest, it happens.
Thread Starter
Pilot Error - Let's be honest, it happens.
Media Quote:
US Air Line Pilots Association (ALPA) president Duane Woerth has accused the
US National Transportation Safety Board (NTSB) of overlooking human-factors
principles during the investigation of aviation accidents.
In a letter to NTSB acting chairman Mark Rosenker, Woerth urges deeper
consideration from the NTSB when it cites human error as a contributing
factor in crashes, accusing the agency of appearing to “favour the easy
route of citing ‘crew error’ and not delving further. Since the vast
majority of aviation accidents are the result of many factors, it is
shortsighted and troubling to simply say, in effect, ‘the flightcrew
failed to prevent the accident’,” says Woerth.
The NTSB on 8 September concluded that pilot error contributed to the 9 May,
2004 crash-landing of an American Eagle/Executive Airlines ATR 72 in San
Juan, Puerto Rico. The report says the captain “failed to execute proper
techniques to recover from the bounced landings” and failed to execute a
go-around
............................................................ ....................................
My comment:
Where does the buck stop? Time and again a pilot stuffs up through carelessness, incompetence or sheer overconfidence. The current trend is never to blame the pilot, but to sheet the blame on every other agency but the pilot himself. Whether the pundits like it or not, the term Pilot Error is still a completely valid description of the cause of many accidents.
In the case above, the pilot stuffs up a landing. In his ab initio training no doubt thousands of hours earlier, he would have been taught how to recover from a bounced landing otherwise no competent instructor would have sent him solo.
But even if by chance he had been sent solo without a check on his bounced landing procedure, he should have read many paragraphs on the subject in his study manuals. The basic bounced landing procedure is the same for practically all aircraft. There is no excuse for not reading up on these manoeuvres.
As a former military pilot back in the early Fifties, we were taught to take responsibility for our actions. If you were caught low flying against orders, you were punished and if necessary, scrubbed. You could not use the excuse that your flight commander never actually said you should not go low flying. In other words, bush lawyer excuses did not wear.
I would prefer to see a more honest and direct line of approach in accident reports. If the cause was a clear pilot error then say so - rather than lose the real cause among a flurry "systemic failure" buck passing down or up the line to the Commander-in-Chief. Of course, there are exceptions.
US Air Line Pilots Association (ALPA) president Duane Woerth has accused the
US National Transportation Safety Board (NTSB) of overlooking human-factors
principles during the investigation of aviation accidents.
In a letter to NTSB acting chairman Mark Rosenker, Woerth urges deeper
consideration from the NTSB when it cites human error as a contributing
factor in crashes, accusing the agency of appearing to “favour the easy
route of citing ‘crew error’ and not delving further. Since the vast
majority of aviation accidents are the result of many factors, it is
shortsighted and troubling to simply say, in effect, ‘the flightcrew
failed to prevent the accident’,” says Woerth.
The NTSB on 8 September concluded that pilot error contributed to the 9 May,
2004 crash-landing of an American Eagle/Executive Airlines ATR 72 in San
Juan, Puerto Rico. The report says the captain “failed to execute proper
techniques to recover from the bounced landings” and failed to execute a
go-around
............................................................ ....................................
My comment:
Where does the buck stop? Time and again a pilot stuffs up through carelessness, incompetence or sheer overconfidence. The current trend is never to blame the pilot, but to sheet the blame on every other agency but the pilot himself. Whether the pundits like it or not, the term Pilot Error is still a completely valid description of the cause of many accidents.
In the case above, the pilot stuffs up a landing. In his ab initio training no doubt thousands of hours earlier, he would have been taught how to recover from a bounced landing otherwise no competent instructor would have sent him solo.
But even if by chance he had been sent solo without a check on his bounced landing procedure, he should have read many paragraphs on the subject in his study manuals. The basic bounced landing procedure is the same for practically all aircraft. There is no excuse for not reading up on these manoeuvres.
As a former military pilot back in the early Fifties, we were taught to take responsibility for our actions. If you were caught low flying against orders, you were punished and if necessary, scrubbed. You could not use the excuse that your flight commander never actually said you should not go low flying. In other words, bush lawyer excuses did not wear.
I would prefer to see a more honest and direct line of approach in accident reports. If the cause was a clear pilot error then say so - rather than lose the real cause among a flurry "systemic failure" buck passing down or up the line to the Commander-in-Chief. Of course, there are exceptions.
Centaurus,
Have a look at http://www.pprune.org/forums/showthr...hreadid=194164
Yes it does exist but the question is always WHY.
Have a look at http://www.pprune.org/forums/showthr...hreadid=194164
Yes it does exist but the question is always WHY.
Centaurus, I agree that accident (and incident) investigation and reporting require a more ‘understanding approach’ where human error is involved. Part of the problem is that error and many other aspects of human activity are often poorly understood by the authorities, the management, and individuals.
Current thinking on human error (pilot error should not be used as error is not specific to pilots), focuses on the circumstances of the situation in which the error occurred. Humans do not decide to commit errors; errors will occur – “it is the downside of having a brain”. Human error is a classification of an outcome, the reasons for that outcome are the issues that need investigating and if warranted cited as where ‘the buck stops’.
An investigation should identify those threats to safety which the crew encountered and together with any isolated human error or previously mismanaged threats (as the result of other errors) be examined for causal circumstances. This process is essentially Threat and Error Management (TEM) which is (or should be) central to all CRM training. TEM should be applied both strategically and tactically; strategic TEM has to be part of safety management and also used by crews in their planning operations. Tactical TEM is more associated with daily operations or in managing abnormal or surprising events. Thus, accident investigation should also involve strategic and tactical threat and error analysis.
A serious problem in accident investigation is that authorities (with a few notable exceptions) either do not understand human factors or are not prepared to use or publish ‘speculative’ HF findings. Some of these problems originate from the outdated ICAO guidance on accident investigation, where the focus of a report is required to be on ‘technical failure’, using specific and quantifiable factual evidence; HF does not easily fit into these categories. However, there are many opportunities for investigators to ‘speculate’ on the many plausible human activities (error, thinking, behavior, attitude, etc) in an accident; this will enable them to confirm any contributing threats, latent errors, management oversight that was associated with the accident; a wider investigation into HF might also identify others circumstances that conventional reporting fails to identify. Speculate to accumulate
“Blaming individuals is emotionally more satisfying than targeting institutions”. (J. Reason)
Also see Managing human error
Current thinking on human error (pilot error should not be used as error is not specific to pilots), focuses on the circumstances of the situation in which the error occurred. Humans do not decide to commit errors; errors will occur – “it is the downside of having a brain”. Human error is a classification of an outcome, the reasons for that outcome are the issues that need investigating and if warranted cited as where ‘the buck stops’.
An investigation should identify those threats to safety which the crew encountered and together with any isolated human error or previously mismanaged threats (as the result of other errors) be examined for causal circumstances. This process is essentially Threat and Error Management (TEM) which is (or should be) central to all CRM training. TEM should be applied both strategically and tactically; strategic TEM has to be part of safety management and also used by crews in their planning operations. Tactical TEM is more associated with daily operations or in managing abnormal or surprising events. Thus, accident investigation should also involve strategic and tactical threat and error analysis.
A serious problem in accident investigation is that authorities (with a few notable exceptions) either do not understand human factors or are not prepared to use or publish ‘speculative’ HF findings. Some of these problems originate from the outdated ICAO guidance on accident investigation, where the focus of a report is required to be on ‘technical failure’, using specific and quantifiable factual evidence; HF does not easily fit into these categories. However, there are many opportunities for investigators to ‘speculate’ on the many plausible human activities (error, thinking, behavior, attitude, etc) in an accident; this will enable them to confirm any contributing threats, latent errors, management oversight that was associated with the accident; a wider investigation into HF might also identify others circumstances that conventional reporting fails to identify. Speculate to accumulate
“Blaming individuals is emotionally more satisfying than targeting institutions”. (J. Reason)
Also see Managing human error
Last edited by alf5071h; 31st Oct 2005 at 08:17.
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Centaurus: your military background differs from civil litigation liabilities. When a military jet gets trashed because of human error it has already been paid by the taxpayers. When a civil transport gets trashed it becomes the usual "blame game" between private sector insurance companies, the operator, the leasing company or owner, the airport, ATC, and the manufacturer.... That's why air carriers and its employes are instructed by insurance companies "never to admit guilt."
