Is Pilot Error Inevitable?

[Kelvin]

Is Human Error Inevitable?

 

"Bermuda Triangle: Secrets Revealed" was televised on CH9 2.5.08 and presented their findings of Flight 19 that took off from Fort Lauderdale, Florida East Coast on 1.12.1945. It was an authorised navigation training flight involving five torpedo bombers (TBM Avengers) with a total of 14 crew with some having only 50hours experience in their Avenger. The flight leader had 2500 flying hours was monitoring the student pilots dead reckoning principles on a navigation exercise over a triangular course. There were differences of opinions after 3:00pm as to where they were and what course they should take to get back to the Florida coast line. They kept going East when some wanted to go West. The last radio message was at 6:20pm that said, "All planes close up tight . . . we'll have to ditch unless . . . when the first plane drops below 10 gallons, we all go down together." They all disappeared sometime after dark.

 

My question is that given the pilot error has occurred and they had radio. two compass each, watches and standard IFF transmitter that did not help them backtrack their error, then why not?

 

Kelvin (who has not started nav training yet).

 

 

[storchy neil]

yes mistakes are eror of judgment neil

 

 

[Ben Longden]

In a word, they were lost.

 

These guys assumed their equipment was faulty - and assumed their position was somewhere else on the map. If they had trusted their compass and gone from there, they would have been fine.

 

2.2c worth, including GST

 

Ben

 

 

[facthunter]

Error or management.

 

In flying never trust a single source of information, always have at least one other independent source to confirm it. (back-up).This is a situational management thing. Good example the Mt Erebus DC-10 accident. Nev..

 

 

[Kelvin]

Case Example: Flight 19 .

 

Thanks Neil and Ben,

 

They had some magnetic compass swing faults that they knew about. They called their tower and explained their off course dilemma. The tower said, "Head due West". Even with compass problems they could have just turned towards the sun to know they were heading West, but they didn't. Two other pilots were heard to have said. "Dammiit, if we could just fly West we would get home; head West dammit" but their leader wouldn't turn. He also wouldn't switch to their emergency channel to allow an immediate fix on their position. He was worried about loosing contact with his pilots who were dependent on his leadership to resolve the problem. They all knew the consequences if they could not resolve their dilemma. Why couldn't they rationalise their single priority under inflight stress? What should we know about what happened that could help us, if needed, through a little behavioural science? i_dunno

 

Kelvin (with a long way to go on understanding inflight stress management)

 

 

[Guest brentc]

Someone with a good memory might remember, it was perhaps the Vampires? down at East Sale (a pre-decessor to the Roulettes). They were performing aerobatics and all of them (except one that got out) looped into the ground during training because they all followed the leader. They ironically flew into 'Dead Man's Hill' if memory serves me correctly.

 

The trouble is that in the Military they break your spirits down then build you up into what they want you to be, which includes following your orders and in this case, they followed the orders of their leader to their ultimate deaths.

 

 

[Mazda]

'High cockpit gradient' is a term used when the Captain (or leader in this case) has significantly more experience than the other crew. It has led to numerous incidents and accidents because the young inexperienced crew think that the experienced Captain must know what he's doing and shouldn't be challenged. It's now a known human factors problem and I think most multi-crew operations try to address this.

 

I think this has implications for us too because anyone can make a mistake.

 

One thing that worries me sometimes is blind acceptance of ATC instructions. Of course we comply with ATC instructions normally, but if something doesn't seem right or you can't cope with their request, say so. You are the one up there in the aircraft.

 

I'm still haunted by that terrible fatal crash in the UK involving a 16yo solo student who was given instructions from ATC that he didn't understand, then he was held, then cleared, then told to orbit on final to allow something faster to get in. That poor student couldn't cope and paid for that with his life.

 

 

[facthunter]

Leader.

 

When you are in formation, you follow the LEADER. How else could you do it? IF he mucks it up, it is all over.

 

The phenomen with the TBM's is probably a psychological one, involving mental blocks and "fixation" behaviour. In a stress environment, decisions are often made that defy common sense or analysis in the normal way. Nev..

 

 

[Mazda]

It reminds me of that Richard Bach story. Richard was leading a two ship and was distracted by a minor technical problem. His wing man casually asked if the intention was to fly into the hill in front of them. In the story it sounded as though if Richard had said yes, the wing man would have gone in too! However Richard had just been distracted, and the question from the other pilot saved his life. Asking for clarification doesn't hurt.

 

 

[Guest Flyer40]

Kelvin, human error is a huge subject. Much has been written about the cognitive mechanisms that result in error. Error is a natural part of the human condition and can't be eliminated. In risk management terms our processes and equipment should have defenses against error designed-in so they are able to detect and trap errors when they occur, and also be tolerant of those errors that slip through the traps.

 

Any activity where a single error can have a catastrophic outcome is a situation that is not error tolerant. Certainly a situation to be avoided.

 

I didn't see the TV show, but the fixation we sometimes observe that seems to defy common sense is a type of selection bias. It's a typical human condition whereby a person latches onto the first plausible explanation/solution/whatever, then seeks reasons to validate their first assumption rather than testing its validity and seeking alternatives. People do this every day, but if it arises in a situation where the risk/consequences are high and the defenses are low then we'll probably read about it.

 

We've all heard how some situations go from bad to worse and spiral out of control, and wondered how. It's easier to understand when you learn that some researchers have put the probability of error following a critical event at 100%. You've probably heard before that once a person becomes stressed, the quality of their decision making plummets. There's quite a good understanding of these behaviours now.

 

Mazda the term you're thinking of is 'authority gradient'. Another complex issue that has some definite cultural variations, but is often characterised in aviation in the west by the over bearing authoritarian captain and in the east by the obedient unchallenging FO.

 

Interestingly, after considering factors such as terrain/weather/traffic density/etc, it was the lack of an authority gradient in Australian cockpits that Graham Braithwaite attributed Australia's good safety record to.

 

 

[facthunter]

comment.

 

Good comment, both. Mazda, if there is any doubt, check it again. If you are not sure you got a clearance to land , or whatever, get it again, IF they think you are dumb, wear it. Dumber not to check it....... and I agree with Graham Braithwaite. What is the use of a co-pilot who sees an error being committed and doesn't say anything about it? Nev....

 

 

[farri]

Inevitable Pilot Error.

 

Yes, pilot error, is, INEVITABLE, because, as in all walks of life,Humans make mistakes,for a whole range of reasons.

 

I wish it wasn`t so.

 

Frank.

 

 

[poteroo]

In my youth I was in such a hurry to gain experience that I made many,many errors. Now that I've gained the experience, I'm still making errors because I can't remember everything. It's a worry !!

 

 

[Kelvin]

Thanks Flyer40,

 

Much of what you and subsequents posts have said fits well with what I have become aware of over 35 years in my professon in OHS. Another OHS Professional and pilot who gained his CPL in the US advised me today to lookup www.gsf.org and I found it to very enlightening. As I become more aware of pilot error avoidance concepts and any widespread understanding there may be, I'm going to be one happy chappie :big_grin:.

 

Kelvin (with a long way to go with a little help)

 

 

[Guest Flyer40]

No worries. If you want to pursue the subject I can provide many references. But the best place to start would be Jim Reasons book Human Error. It was a seminal work that pulled together and gave prominence to a lot of concepts that are now widely understood by industry, such as the swiss cheese model of accident causation.

 

http://books.google.com.au/books?id=WJL8NZc8lZ8C&dq=James+Reason&hl=en&prev=http://www.google.com.au/search%3Fhl%3Den%26q%3Djames%2Breason%26btnG%3DSearch&sa=X&oi=print&ct=result&cd=1&cad=author-navigational

 

 

[facthunter]

Safety concepts.

 

Kelvin, I feel compelled to mention the topic, "Pilot Error" and comment on it. That term has been around for Yonks and I thought it had been consigned to the realm of the newspapers only. It is so nebulous and non-specific that it almost has no sense to it. IF it is used in a psychologically orientated forum, I hope it is only used as an attention getter. What the term does is neatly lay the blame and "solve" the Problem by assigning it to the human,(who may be deceased) before it has even been looked at.

 

As an example, a pilot using a RED/WHITE VASIS. during a rain event lands short of the runway. NOTHING is found to be wrong with the aircraft pre- impact PILOT ERROR. Sure!!!! except that years later we find that REFRACTION causes errors with this system in rainstorms.& there are plenty of similar examples where the man/machine interface gives wrong messages to the pilot. We can design a lot of the so-called pilot error out of the system and TRAIN better to Prevent it. I don't like the term.. Nev

 

 

[Kelvin]

Thanks Facthunter, I have already overloaded your reputation and it wont let me add any more. You are in harmony with Flyer40 (and I expect 100's of others) on this issue of blame that I believe has never done any good, never will and it's just not consistant with safety science. James Reason who has also been around for yonks and published his book called "Human Error" and although I have it on order, I have studied some of his concepts particulrly on his models that views both the human approach and the systems approach in different ways. While PILOT ERROR is emotive it has to be commented on as you have just done. Otherwise we keep sending and receiving the wrong message. Should I change the thread to PILOT SYSTEMS DESIGN?

 

Kelvin (with a long way to go and happy with the journey so far)

 

 

[Guest Flyer40]

Just to put your mind at ease Nev, safety science considers human error a consequence, not a cause, ie pilots are the inheritors of an accident scenario not the initiators. In this context it's not remotely compatible with the term 'pilot error' as used by the media. No need to be concerned about the work that HF practitioners and risk managers do, they're not attention getting, most of them are motivated by preventing injury and death. There's now a very high level of understanding about the causes of error from the neuropsychology, ergonomic and organisational perspectives which reassuringly has has made air transport a lot safer than it was.

 

Unfortunately training has a limited effect on error prevention because it only prevents knowledge based errors, which is only a part of the error spectrum. No amount of training or experience can make a person immune to error. We need to remain wary if we're to avoid an unpleasant end. Complacency kills and all that........ Your signature captures it well Nev. So lets not stigmatise the discussion on human error because of the way newspapers handle it. A better understanding of error prevention may help some of us live longer.

 

Perhaps you could change the heading to 'human error' Kelvin.

 

 

[Guest High Plains Drifter]

In relation to single pilot ultralight flying, I sometimes wonder if a concern for gaining procedural skills outweights the commen sense attainment of good perceptualmotor skills.

 

 

[Guest Flyer40]

They're both important HPD. The procedural stuff needs to be learned through training, the motor skills come with experience. Then they become the same thing, muscle memory, including the muscle between our ears.

 

 

[Kelvin]

Just to put your mind at ease Nev, safety science considers human error a consequence, not a cause, ie pilots are the inheritors of an accident scenario not the initiators. Perhaps you could change the heading to 'human error' Kelvin.[/quote]In the automotive design industry they went from a simple fuel gauge but because of human error with people running out of fuel, they eventually progressed to audible warnings at 80, to 60, 40, 20klms to go before running out. At one time we would have thought it was way over the top. Now we dont.

 

It seems to me aviation has always been at the leading edge of human error avoidance technology because of the terrible consequences.

 

Wouldn't it be great if new human error avoidance technology were developed from the ranks of RAA to benefit the whole aviation industry in the long term:idea:.

 

Kelvin (with along way to go and looking forward to new innovations).

[Guest High Plains Drifter]

audible warnings at 80, to 60, 40, 20klms to go before running out

Kelvin, in regards to fuel management in aircraft - after dipping my tanks pre flight, I fly by time and fuel burn at given power setting. I never trust my gauges unless they show lower then I expect.

 

I'm sorta thinking in ultralight flying any safety gains will be in initial training and the further training of proved preprogrammed responses to certain inflight profiles/dificulties.

 

.

 

 

[facthunter]

Relevence.

 

Once you are above 50 Kts and 5 feet height , you are in the real world of recreational flying, where you are doing it primarily for fun. We are very dollar sensitive, so the investment (costs) should be targetted carefully at things that specifically relate to us. (as in NO IMPOSED COSTS, THAT DON"T HELP US)..Kelvin, we do have a great scope to accept change, Because of our freedoms, we can incorporate change rapidly, we could even be in the vanguard of it , BUT I believe that may be beyond our brief, where we venture into territory, where if it comes unstuck, we may attract adverse attention and lose the amazing abilities to indulge ourselves in our sport, and that is what it is.

 

Regarding Prangs, accidents etc. Most of the Data is not new, and most of it applies right across aviation, so the communication (getting the message across) would be the first area to address. Data collection in Rec. aviation is not at a high level of sophistication and unlikely to change due to lack of resources, and we operate in a different structure as being less inspected/ restricted we rely on INDIVIDUAL responsibility, with a limited exposure to LIABILITY as a consequence. Regards Nev..

 

 

[Kelvin]

Tread Lightly

 

Kelvin, we do have a great scope to accept change, Because of our freedoms, we can incorporate change rapidly, we could even be in the vanguard of it , Regards Nev..

Thanks Nev (again),

 

By the very nature of what we do, I agree and suspect there are many who have experienced uncomfortable inflight scenario's and found innovative ways to resolve them to to their own requirements. On the one hand it's not easy to imagine there are human error avoidance systems and concepts that's not already available to modern aviation. On the other, there may be innovations that has not seen-the-light-of-day for want of a bit of encouragement, direction or help. Is it worth our while to try and findout?

 

Kelvin (with a long way to go but who knows where that may lead)

 

 

[ab0767]

Anyone can fly a plane - you could teach a 5 year old that. It is the ability to handle an abnormal situation that makes a pilot, I love to read the speculation that goes with an incident reported on this forum as it reflects the thoughts going through the pilots mind at the time. We have the pleasure of thinking about it for days if not weeks, the pilot had about 3 seconds to make a decision at the time. This is why so much time is spent during training on recovery from unusual attitudes so that we recognise the unusual attitude and can correct it before we meet mother earth. That is what the 20 hrs minimum is for. We can't prepare for every situation but we can be prepared to correct our attitude.