Berkel 1

Gervaughn Berkel

Professor Soya

COM 1101-15

7 April 2017

Reduction of pilot error in Aviation

A subject that impacts everyone is aviation accidents. The topic that came directly to

my mind after a few second of brainstorming was aviation accidents. Millions of people

travel across the globe every day. Doing some research, I discovered that the main source of

aviation accidents today is caused by human error. Despite all new, advanced forms of

technology being integrated into the cockpit created to make a pilots job easier and more

effective, humans are still one of the main causes of accidents today. Experts are trying to

reduce or prevent these fatal accidents caused by the. Human error can be avoided and

minimized by learning from previous fatal accidents, pilots taking part in trainings and

practicing detection strategies.

Some examples to pilot error and the accidents followed by those errors are explained

by the authors Key Disumkes, Benjamin Berman, and Loukia Loukopoulos in their book.

They give us some of the most fatal accidents from 1990 to 2007 caused by small mistakes

on the pilots side. One example is about a USAir flight that crashed into a residential

neighbourhood shortly after executing a go-around. A go-around is a procedure done by

airline pilot when the aircraft is not in a proper approach setup to land on a runway. For

example, if the aircraft is too high or too low to make the runway or if the descent down to

the runway is not stable and smooth enough. Once they determine that the aircraft is not

coming to land as it should, the then advance the throttle, fly back up to a desired altitude,

circle around the airport and try to land the airplane again. In this situation, the pilots, both
 Berkel 2

well experienced, but failed to recognize windshear activity quickly enough, and continued

their approach into weather that should not have been flown into (pg. 1). Another crash to

review was Continental flight 795. The plane overran the end of the runway at LaGuardia

Airport due to the captain aborting the take-off over the speed limit for rejecting a take-off.

Again, the pilots were well experienced with a total of more than 8000 hours combined.

Pressed for time, they missed some key points on the pre-taxi checklist which led to an

accident at the end of the runway. Although these pilots had been well experienced, they still

found themselves in situations that turned fatal (pg. 11). February 19, 1996 Continental flight

1493 landed at Bush Intercontinental Airport in Houston, Texas with the landing gear

retracted. The aircrafts lower body was completely damaged, and 15 passengers were

seriously injured. The accident was caused by the crew not selecting the high pressure setting

on the hydraulic system. During the decent, the pilots were required based on company

regulation and the aircraft checklist to turn the high pressure on the hydraulic system on, but

had failed to do so82 passengers and 5 flight crew members onboard (page 9).

As experiences like these occur, aviation experts consider practices or regulation that

can be created to decrease the amount of errors made by pilot today. Created especially for

airline pilots, the Pilot Reliability Certification program, is set up by the Federal Aviation

administration (FAA) with the goal of increasing overall knowledge of human errors and

reducing human/pilot error. This training is mainly used in airlines. The training focuses on

human factors, including identifying personal error, and improving an individuals weakness.

It consists of 6 courses, 2 of the 6 being Personal Error and Awareness and Control and

Operational and Risk management that directly combat human error in the cockpit. At the

end of the training, pilots show improvement in their attitude and knowledge related to the

training objectives.
 Berkel 3

To reduce errors being made, the crew must also be familiar with ways of how to

detect error within the cockpit. Tom Kontogiannis, in his book, reviews strategic error

detection practices. His book talks about a study that was done tocreate strategies to detect

pilot error. Different forms of detection include revising plans, being fully aware of the

current task, double checking data for reliability (chapt. 3). Error detection is simply

realizing that an error is about to occur or suspecting that an error has occurred, independent

from understanding the nature and cause of the error Zapf. Detecting errors by using

cognitive strategies is essential to pilots today to maintain safe flight. Mitsotakis states that

the detection of errors can be made when creating a plan of action for a task. Errors can also

be detected when there is a difference between the executed plan or task and how it was

planned to be is executed. Detections should also be made by the other crew member which

strengthens communications and cross checking in the cockpit as well (page 3).

Once an error is detected, it must then be quickly corrected. There are two strategies

Kontogiannis book provides analysed by J. Mo and Y Crouzet. The first strategy focuses on

3 main steps: backward recovery where the system is brought back to its initial state prior to

the occurrence of the failure. Secondly, recover where the system is where it can be brought

into an intermediate state for the operators to buy time and find a better solution later. Last,

implement compensatory recovery where redundant equipment is activated to bring the

system to the final state that was desired.

L. Kanse gives another strategy on error correction. He talks about first neutralizing

the error to keep the problem from getting out of hand. For example, climbing to a higher,

safer altitude in order for the crew to diagnose the problem. Then, diminish the problem by

reviewing the impacts of its consequences. Next, the pilots work around the problem to create

a temporary fix. And lastly, you create a permanent fix for the error.
 Berkel 4

The biggest obstacle and danger for aviation enthusiast and professionals is

themselves. As accidents happen, experts learn from them and correct for it to not happen

again. It shouldnt be that someone must be in an emergency or fatal situation until new

safety changes can be made. The more accidents and errors that can be prevented from

beforehand, the better and safer flying will be. Not only for pilots and aviation enthusiasts,

but also for everyone.

 Berkel 5

Work cited:
Boedigheimer, Dan. "Exploring the Pilot Reliability Certification Program and Changing

Attitudes on Reducing Pilot Errors: Pilots Covered by Federal Aviation Regulations 91 and

135." Transportation Research Record, vol. 2184, no. 2184, 2010, pp. 49-56.

Dismukes, Key, et al. The Limits of Expertise: Rethinking Pilot Error and the Causes of

Airline Accidents. Ashgate, Aldershot, 2012.

Kontogiannis, Tom, and Stathis Malakis. "A Proactive Approach to Human Error Detection

and Identification in Aviation and Air Traffic Control." Safety Science, vol. 47, no. 5, 2009,

pp. 693-706.

Masys, A. J. "Pilot Error." Disaster Prevention and Management: An International Journal,

vol. 17, no. 2, 2008, pp. 221-231.

Salas, Eduardo, et al. "Does Crew Resource Management Training Work? an Update, an

Extension, and some Critical Needs." Human Factors: The Journal of the Human Factors

and Ergonomics Society, vol. 48, no. 2, 2006, pp. 392-412.

Stanton, Neville A., et al. "Predicting Pilot Error: Testing a New Methodology and a Multi-

Methods and Analysts Approach." Applied Ergonomics, vol. 40, no. 3, 2009, pp. 464-471.
Berkel 6