Human Error in AviationMatthew R. GriffithEmbry-Riddle Aeronautics university

AbstractIt is unreasonable to assume that any person could operate continuously without ever making a mistake. Thus, human error is a very real and inevitable problem in the aviation industry. Unfortunately, for those involved, it is usually met with disastrous results. One momentary lapse of judgment might very well result in a large numbers of fatalities, as well as, hundreds of millions of dollars in damages. Human error can be described as any event that takes place because a task, or portion of a task, was not performed with its exact specifications. Human error can stem from a very wide spectrum of circumstances. Three critical areas of concern that will be carefully reviewed in this paper are the following: fatigue, vision, and communication. It is important to study these primary causes of human error and look for trends or break downs that might very well serve to protect the safety of future flights. Only through the management of human error can continue the outstanding reputation of safety in the world of aviation.

Human Error in AviationBefore an accurate discussion on the root causes of human error can take place, it is necessary to understand the fast pace setting of the aviation industry. One visit to any major airport, such as Atlanta's international airport, and one will come to appreciate the tremendous demands placed upon all the aviation professionals involved along the process. There is continuous communication taking place between the different sectors, from the aircrew, to air traffic control, to maintenance, and all the other facets in between. Any position in aviation can be very exciting and rewarding, but it also demands a great deal of attention and situational awareness.
It is human nature to make mistakes from time to time. Certainly one would not expect that anyone on the planet could work, or do anything for that matter, continuously without eventually producing some type of mistake. Although training, compensation, natural ability, and a host of other factors will defiantly serve to mitigate error, it is essentially unavoidable at some point. There are many examples to prove this statement, some of which are quite humorous, such as a professional basketball player who is payed very lucrative wages, making a basket on the wrong goal. This has actually taken place on several occasions in scheduled NBA games. Some setting afford human error to be a laughable event but this is far from the truth in the aviation world.
When a part 121 aircraft goes down or there is a mid-air collision it typically produces countless fatalities and can easily cost hundreds of millions of dollars. Thankfully, accidents such as these are incredibly isolated events. However, aviation professionals must continue to strive to understand what causes accidents and more importantly what can be done to avoid them. It is rather unfortunate that most safety programs and initiatives have stemmed from past accidents. The investigations of these historic accidents have proved to yield very valuable insight into the exact cause, or causes, of the accident. The analysis of the investigation must remain clear and focused on the relevant facts in order to produce the best safety recommendations.
As the years have progressed and the information from all the accidents has been analyzed and studied, there has appeared very sharp trends to what has been deemed the probable cause of most aircraft accidents. One report found that flight crew error was responsible for sixty-six percent of all accidents (Boeing, 2002, p. 19). Other studies have found this number to be slightly lower, but no matter how you look at it, the majority of accidents have been proven to stem from flight crew error (Dole & Lewis, 2000, p. 213).
Incident reporting has also produced similar findings. Incidents can be looked at as near accidents and are a great way to learn valuable information without paying the price of blood. The main obstacle to overcome with incident reporting is getting all of the facts. The higher the degree off confidentiality involved with the reporting process, the more likely that the human aspect will be correctly represented. Simply put, people are more reluctant to tell their employers and agencies that license them about the mistakes they made when they could instead remain quiet and not worry about the potential negative impacts on their character or jeopardizing their career (Wells & Rodrigues, 2004, p. 77). Because of this known fact, many countries, including the United States, have incorporated voluntary incident reporting programs to compliment their mandatory programs.
With the help of past data, we have been able to factually come to the conclusion that human error is the number one enemy of the aviation industry. So what can we do with this information? One idea is to break it up into smaller more meaningful categories which are more easy to deal with to find specific determinations. It also allows management something very direct to present to flight crews and others as a safety concern. You could not expect to tell the flight crew members that “Human error is the main cause of accidents and you all need to pay more attention to what is going on in order to avoid these mistakes”. Sure, it is a true statement but also one that will not produce very effective results. However, if you can illustrate to them the primary causes of the human error and give appropriate examples where needed, then the likelihood of improving safety will increase exponentially. There are of course many causes for human error and it would be improper to ignore the fact that so many conditions exist which are worthy of in-depth discussion. However, for the sake of brevity we will cover three areas that have plagued the human aspect of flight ever since man began in their quest to master the air. These three areas of concern are: fatigue, vision, and communication; each of these factors have caused many aircraft accidents and incidents while cutting short the lives of scores of people. Because of this fact, fatigue, vision, and communication have each been the target of specific legislation passed in order to combat their potential hazard to the safety of flight.
We have all experienced fatigue at some point in our lives. It affects people very differently but no matter what effects the condition has on an individual, it makes it much more difficult to perform at the optimal level. WebMD (2011) defines fatigue as:
A feeling of tiredness or exhaustion or a need to rest because of lack of energy or strength. Fatigue may result from overwork, poor sleep, worry, boredom, or lack of exercise. It is a symptom that may be caused by illness, medicine, or medical treatment such as chemotherapy. Anxiety or depression can also cause fatigue. (p.1)
Other definitions of fatigue suggest that circadian rhythm disruption plays an important role in the development of the symptom. A study put out by the (Federal Aviation Administration [FAA], 2011) points out that commercial pilots face many occupational stresses that general aviation pilots do not encounter (p. 3). However, fatigue is a serious problem for pilots of all types. The high level mental process that is encountered by pilots is especially affected by weariness. Being inadequately rested also makes people more prone to annoyances and drastically slows reaction times to virtually any situation. We have long been aware of the detrimental role of fatigue in regards to flight. This is evident in the limits placed on duty hours for pilots during the early stages of legislation. It is interesting to note that the laws on flight hours have become more demanding through the years.
Caldwell et al. (2009) explains the different types of countermeasures for aviation weariness. Their work goes from the obvious techniques, such as getting appropriate amounts of rest before reporting to work, to the less conventional approaches, such as cockpit napping, activity breaks, bunk sleep, and even lighting in the flight deck. The work concludes with a detailed discussion of the benefits of proper nutrition as well as their stance on using performance enhancing stimulants during operations and sleep educing agents prior to such operations. There is no doubt a lot to be said about these measures, however, the report by the FAA (2011) sums it up the best when they emphasize that “No degree of experience, motivation, medication, coffee, or will power can overcome fatigue (p. 3). An important concept to grasp is that a fatigued person is probably unaware of how tired they really are. The bottom line here is that a tired person will not be aware of the actual extent of impairment that the fatigue will have on them until it is too late.
The role of vision as a component of human error has manifested itself in many occasions through the years. The sense of sight is paramount in our ability to function and to do complex tasks that require precision. Over eighty percent of what we learn and experience comes through our sense of sight (All About Vision, 2011). For pilots and aircrew, the accuracy and precision needed from visual identification can be the difference of life and death for not only themselves but for the passengers that have put their trust and confidence in them. Some of the most horrific and deadliest aircraft accidents that come to mind are directly related to vision or the lack thereof. Take for example the Polish air disaster in 2010 that killed the Polish president along with numerous senior dignitaries of that country, the pilot of this infamous crash ignored multiple warning not to land at the Russian airstrip which had become masked with a thick heavy fog (Leask, 2011).
There is also a serious risk for accidents and incidents for aircraft that are taxing or on the runways. This problem has become much more prevalent because of the huge growth of the industry after it was deregulated. The deregulation of the industry brought about more flights but, for obvious reasons, there has not been a corresponding growth in airport sizes (Wells & Rodrigues, 2004, p. 203). Pilots, controllers, and ramp workers must all find ways to capitalize on the limited real estate available to them while being on guard continually for safety concerns that seemingly lurk around every corner. As you might guess, night operations place an even more serious risk to encountering human error based on visual oversight. Much study has been done on aircraft accidents and incidents that are associated with visual effects from bright light exposures during low-light flight operations. The National Transportation Safety Board (NTSB, 2011) query of accidents and incidents revealed that the majority of accidents took place during the landing phase of flight while most incidents occurred during taxing. The conclusion of the study determined that exposure to bright lights in night operations poses very real and significant safety hazards. Recommendations followed that suggest identifying and eliminating hazardous lighting that occurs near flight paths as well as options of avoidance (National Center for Biotechnology Information [NCBI], 2007).
New technology is becoming very helpful at preventing accidents in situations where visual flight rules apply. We have came a long way since the Grand Canyon disaster between TWA flight 2 and United Airlines flight 718, an accident that was deemed one of the top ten plane crashes that changed aviation (Popular Mechanics (2011). The accident would have never been allowed to take place with today’s advancements in air traffic control and on board equipment that warns of proximity issues. However, we have seen similar accident such as the mid-air collision of a small plane and a helicopter flying tourist over the Hudson River in 2009 (Huff Post, 2009). As with most mid-air collisions, there were no survivors.
The final area of human error that we will cover is that of communication. You can not place enough emphasis on the ability to effectively communicate. This not only refers to voice transmissions but also body language and a host of other intangibles. The typical communication systems on modern aircraft are very effective. Pilots use their radio to talk to the tower where they receive instructions, request specific assistance, and so forth. However, like anything in life, sometimes the communication equipment on board can experience problems. The pilots need to be able to continue to receive information from the airport control tower and have established a secondary method of relaying the most basic instructions such as, whether or not it's okay to land. This back-up process uses a system of light to convey necessary information to pilots upon approach (Pilot Friend, 2011) and is defiantly not the preferred way to do business but is an excellent last resort.
Even when radio communication is available there is still great risk for miscommunication to arise. Knowing what words to use and how to talk like a professional when making transmissions is a vital part of flying. You can be the best pilot in the world but if you do not have the ability to communicate well enough, you pose a serious safety risk to yourself and others around you. Some commonly reported problem with radio transmissions is that they are either too long or too brief (Snow, 2011). When a transmission is too long it takes up a lot of the controllers time and if the controller is covering other aircraft, it puts them at a greater risk. When the transmission is too short it usually doesn't contain all of the information that is needed. The controller must then ask for the additional information which defeats the purpose of the transmission being brief in the first place.
Another aspect of communication in aviation is that of Crew Resource Management (CRM). CRM training is a broad-scaled approach to social communication-based behaviors and attitudes (Wells & Rodrigues, 2004, p. 173). This training, which is mandatory for all pilots, was developed by NASA after several key accidents and incidents made the need for such a program unquestionable. Most notable was the 1978 crash of United Airlines flight 173 that crashed after a terrible breakdown in communication between the captain and flight officers concerning fuel levels. The accident led to the idea that everyone should have a voice and be able to express their concerns regarding issues of safety (AirDisaster.com, 2008).
Fatigue, vision, and communication are all no doubt, some of the key areas that attribute to human error in aviation. On the other side of the coin we see that, it is people who are also instrumental in aviation safety. Interestingly enough, the rate of pilot error shows little evidence of improvement in the recent past. An intriguing theory that has been deducted from the mounds of accident investigations is that if only a portion of the human error could be removed, a substantial reduction in the risk of having an accident will be achieved (Wells & Rodrigues, 2004, p. 181). Again, it will never be possible to totally eliminate the error that emerges from the human factor of flight. Although, through intensive monitoring of accidents and incidents, reporting systems, and all the safety programs and initiatives that have been established, we can, and have made great strides to eliminate risk and make air, the safest way to travel (Wilson, 2011).
As we look at how to manage human error, two basic strategies have predominated. They are engineering strategies and administrative strategies. Engineering strategies, as the name implies, uses technology in the design phase to overcome the human factor. A great example of this is the program that is currently under-way in our nation that boast of revolutionizing the industry. It is too early to know exactly what effects the Federal Aviation Administration's comprehensive transformation of our national airspace system will have on safety of flight. This is, of course, referring to the NextGen measures which will provide real time information to both pilots and controllers amongst other things. It is completely reasonable to assume that once in full operation this system will make air traffic not only safer but much more predictable and thus reliable. Perhaps the most compelling selling point of NextGen. is its ability to adequately deal with the expected fifty percent increase in air traffic by the year 2025 (FAA, 2011).
Administrative Strategies is about employee training and operating rules. There has been continuous legislation throughout the history of aviation that was designed to engage the way pilots and air crew are trained as well as workload restrictions. The nature of the industry is very fluid, aircraft are getting larger and faster. They are carrying more fuel and passengers which increases the weight. Also, new technology is constantly being developed. Aside from all these issues and many more, the men and women that make up our nations aviation sector are professionals who are striving to be the best that they can be while doing what they love. They understand that there is a lot of responsibility and pressure involved in what they do and that is perhaps the very reason they do it. References
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