Pilot error

1994 Fairchild Air Force Base B-52 crash, caused by flying the aircraft beyond its operational limits. This history is now used in military and civilian aviation environments as a case study in teaching crew resource management

Pilot error (sometimes called cockpit error) is a term used to describe the cause of an accident involving an airworthy aircraft where the pilot is considered to be principally or partially responsible. Pilot error can be defined as a mistake, oversight, lapse in judgement, or failure to exercise due diligence by an aircraft operator during the performance of his/her duties.

Usually in an accident deemed due to "pilot error", the pilot in command (Captain) made the error unintentionally. However, an intentional disregard for a standard operating procedure (or warning) is still considered pilot error, even if the pilot's actions justified criminal charges.

An aircraft operator (airline or aircraft owner) is generally not held accountable for an incident that is principally due to a mechanical failure of the aircraft unless the mechanical failure occurred as a result of pilot error.

The pilot may be declared to be in error 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.

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 pilot, co-pilot, and Flight Engineer had become fixated on a faulty landing gear light and had failed to realize that the autopilot buttons had been bumped by one of the crew altering the settings from level flight to a slow descent. Told by ATC to hold over a sparsely populated area away from the airport (with, as a result, very few lights on the ground visible to act as an external reference) while they dealt with the problem, 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.

Placing pilot error as a cause of an aviation accident is often controversial. For example, the NTSB ruled that the crash of American Airlines Flight 587 was due to 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.

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.^[1] For scheduled air transport, pilot error typically accounts for just over half of worldwide accidents with a known cause.^[2]

Notable examples

• 28 July 1945 – a United States Army Air Forces B-25 bomber bound for Newark Airport crashed into the 79th floor of the Empire State Building after the pilot became lost in a heavy fog bank situated over Manhattan. All three crewmen were killed as well as eleven office workers in the building.

• 2 August 1947 – Star Dust, a British South American Airways Avro Lancastrian, crashed in the Tupungato glacier field high in the Andes about 60 miles (100 km) from its destination of Santiago, Chile; killing all eleven occupants. The aircraft was instantly buried from the resulting avalanche and heavy snowfall; it then became encased in glacier ice. The wreckage was not discovered until 2000. Details of the crash are somewhat unclear, but modern investigators believe a navigation error on the part of the flight crew was the principal cause of the accident. They appear to have encountered the jet stream which retarded their advance and they descended when they thought they had passed over the peak but where still in front of the mountain.

• 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.

• 28 February 1966 – American astronauts Elliott See and Charles Bassett were killed when their T-38 Talon crashed into a building at Lambert-St. Louis International Airport during bad weather. A NASA investigation concluded that See had been flying too low on his landing approach.

• 29 December 1972 - Eastern Air Lines Flight 401 crashes into the Florida Everglades after the flight crew fails to notice the deactivation of the plane's autopilot, distracted by their own attempts to troubleshoot a problem with the landing gear. Out of 163 occupants, 75 survive 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.

• 13 January 1982 – Air Florida Flight 90, a Boeing 737-200 with 79 passengers and crew, crashed into the 14th Street Bridge and careened into the Potomac River shortly after taking off from Washington National Airport. Seventy-five passengers and crew, and four motorists on the bridge were killed. The NTSB report blamed the flight crew for not properly employing the plane's de-icing system.

• 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.

• 21 October 1989 – Tan-Sahsa Flight 414 crashed into a hill near Toncontin International Airport in Tegucigalpa, Honduras, because of a bad landing procedure by the pilot. 127 people died in the accident.

• 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 the past histories, Mark McGeehan, the 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 attempt to save the plane immediately before the crash was not successful. This crash is now used in military and civilian aviation environments as a case study in teaching crew resource management

• 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.

• 16 July 1999 – John F. Kennedy, Jr. died when the Piper Saratoga light aircraft he was piloting crashed into the Atlantic Ocean off the coast of Martha's Vineyard, Massachusetts. The NTSB declared the crash was caused by "the pilot's failure to maintain control of his airplane during a descent over water at night, which was a result of spatial disorientation". Kennedy did not hold a certification for IFR flight, but did continue to fly after weather conditions obscured visual landmarks.

• 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 July 2000 – Hapag-Lloyd Flight 3378 crash-landed a few hundred metres short of the runway at Vienna International Airport after the aircraft ran out of fuel. There was no loss of life.

• 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.

• 15 April 2002 – Air China Flight 129, a Boeing 767-200, crashed near Pusan, South Korea killing 128 of the 166 people aboard. The co-pilot had been flying too low.

• 25 October 2002 – eight people, including US Senator Paul Wellstone, were killed in a crash near Eveleth, Minnesota. The NTSB concluded that "the flight crew did not monitor and maintain minimum speed."

• 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, 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.^[3]

• 7 March 2007 – Garuda Indonesia Flight 200; poor Crew Resource Management and the failure to extend the flaps led the aircraft to run off the end of the runway after landing. Twenty-two of the 140 occupants were killed.

• 12 May 2010 – Afriqiyah Airways Flight 771 undershot the runway on approach to Tripoli, killing 103 of the 104 occupants on the plane.

• 28 July 2010 – Airblue Flight 202 crashed into the Margalla Hills due to the pilot going the wrong way, killing all 152 occupants aboard.

See also

• Human factors in air safety
• Airmanship
• Controlled flight into terrain
• Human reliability
• Korean Air Lines Flight 007
• Spatial disorientation
• Sensory illusions in aviation
• Jet lag

References

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. ^ 2005 Joseph T. Nall Report
2. ^ PlaneCrashInfo.com accident statistics
3. ^ 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