Why are human conditions, such as fatigue, complacency and stress, so important in aviation? These conditions, along with many others, are called human factors. Human factors directly cause or contribute to many aviation accidents and have been documented as a primary contributor to more than 70 percent of aircraft accidents.
Typically, human factor incidents/accidents are associated with flight operations but recently have also become a major concern in aviation maintenance and air traffic management as well. [Figure 2-8] Over the past several years, the FAA has made the study and research of human factors a top priority by working closely with engineers, pilots, mechanics, and ATC to apply the latest knowledge about human factors in an effort to help operators and maintainers improve safety and efficiency in their daily operations.
Human factors science, or human factors technologies, is a multidisciplinary field incorporating contributions from psychology, engineering, industrial design, statistics, operations research, and anthropometry. It is a term that covers the science of understanding the properties of human capability, the application of this understanding to the design, development and deployment of systems and services, and the art of ensuring successful application of human factor principles into all aspects of aviation to include pilots, ATC, and aviation maintenance. Human factors is often considered synonymous with CRM or maintenance resource management (MRM) but is really much broader in both its knowledge base and scope. Human factors involves gathering research specific to certain situations (i.e., flight, maintenance, stress levels, knowledge) about human abilities, limitations, and other characteristics and applying it to tool design, machines, systems, tasks, jobs, and environments to produce safe, comfortable, and effective human use. The entire aviation community benefits greatly from human factors research and development as it helps better understand how humans can most safely and efficiently perform their jobs and improve the tools and systems in which they interact.
Studies of human behavior have tried to determine an individual’s predisposition to taking risks and the level of an individual’s involvement in accidents. In 1951, a study regarding injury-prone children was published by Elizabeth Mechem Fuller and Helen B. Baune, of the University of Minnesota. The study was comprised of two separate groups of second grade students. Fifty-five students were considered accident repeaters and 48 students had no accidents. Both groups were from the same school of 600 and their family demographics were similar.
The accident-free group showed a superior knowledge of safety, was considered industrious and cooperative with others, but were not considered physically inclined. The accident-repeater group had better gymnastic skills, was considered aggressive and impulsive, demonstrated rebellious behavior when under stress, were poor losers, and liked to be the center of attention. One interpretation of this data—an adult predisposition to injury stems from childhood behavior and environment—leads to the conclusion that any pilot group should be comprised only of pilots who are safety-conscious, industrious, and cooperative.
Clearly, this is not only an inaccurate inference, it is impossible. Pilots are drawn from the general population and exhibit all types of personality traits. Thus, it is important that good decision-making skills be taught to all pilots.
Historically, the term “pilot error” has been used to describe an accident in which an action or decision made by the pilot was the cause or a contributing factor that led to the accident. This definition also includes the pilot’s failure to make a correct decision or take proper action. From a broader perspective, the phrase “human factors related” more aptly describes these accidents. A single decision or event does not lead to an accident, but a series of events and the resultant decisions together form a chain of events leading to an outcome.
In his article “Accident-Prone Pilots,” Dr. Patrick R. Veillette uses the history of “Captain Everyman” to demonstrate how aircraft accidents are caused more by a chain of poor choices rather than one single poor choice. In the case of Captain Everyman, after a gear-up landing accident, he became involved in another accident while taxiing a Beech 58P Baron out of the ramp. Interrupted by a radio call from the dispatcher, Everyman neglected to complete the fuel cross-feed check before taking off. Everyman, who was flying solo, left the right-fuel selector in the cross-feed position. Once aloft and cruising, he noticed a right roll tendency and corrected with aileron trim. He did not realize that both engines were feeding off the left wing’s tank, making the wing lighter.
After two hours of flight, the right engine quit when Everyman was flying along a deep canyon gorge. While he was trying to troubleshoot the cause of the right engine’s failure, the left engine quit. Everyman landed the aircraft on a river sand bar but it sank into ten feet of water.
Several years later Everyman flew a de Havilland Twin Otter to deliver supplies to a remote location. When he returned to home base and landed, the aircraft veered sharply to the left, departed the runway, and ran into a marsh 375 feet from the runway. The airframe and engines sustained considerable damage. Upon inspecting the wreck, accident investigators found the nose wheel steering tiller in the fully deflected position. Both the after takeoff and before landing checklists require the tiller to be placed in the neutral position. Everyman had overlooked this item.
Now, is Everyman accident prone or just unlucky? Skipping details on a checklist appears to be a common theme in the preceding accidents. While most pilots have made similar mistakes, these errors were probably caught prior to a mishap due to extra margin, good warning systems, a sharp copilot, or just good luck. What makes a pilot less prone to accidents?
The successful pilot possesses the ability to concentrate, manage workloads, and monitor and perform several simultaneous tasks. Some of the latest psychological screenings used in aviation test applicants for their ability to multitask, measuring both accuracy, as well as the individual’s ability to focus attention on several subjects simultaneously. The FAA oversaw an extensive research study on the similarities and dissimilarities of accident-free pilots and those who were not. The project surveyed over 4,000 pilots, half of whom had “clean” records while the other half had been involved in an accident.
Five traits were discovered in pilots prone to having accidents. These pilots:
- Have disdain toward rules
- Have very high correlation between accidents on their flying records and safety violations on their driving records
- Frequently fall into the “thrill and adventure seeking” personality category
- Are impulsive rather than methodical and disciplined, both in their information gathering and in the speed and selection of actions to be taken
- Have a disregard for or tend to under utilize outside sources of information, including copilots, flight attendants, flight service personnel, flight instructors, and ATC