Introduction
This lesson aims to equip learners with the skills to dissect and understand the causes of aviation accidents and incidents. By focusing on real case studies, learners will develop the ability to construct accident chains and propose safety recommendations, enhancing their overall understanding of aviation safety and risk management practices.
Attention and Motivation
It has been said that “aviation is not inherently dangerous,” but it is “terribly unforgiving of any carelessness, incapacity or neglect” (Captain Alfred Lamplugh circa the early 1930s). This statement underlines the fact that even minor oversights can have significant consequences.
Objectives
After this lesson, the learner will be able to:
- Analyze the key elements of aviation accident and incident reports.
- Identify and classify factors contributing to aviation accidents.
- Construct an accident chain and formulate practical safety recommendations.
Tips for Instructors
Reports that would interest and benefit the learner should be selected. For example, accidents caused by a catastrophic airframe failure don’t offer the learner an opportunity to evaluate human factors and risk management.
Lesson Components
- Presentation: Give a brief presentation covering the accident investigation process and a review of risk management principles.
- Self-Evaluation: Provide the learner with the selected accident or incident report and the Accident Analysis Worksheet. Allow some time for the learner to analyze the report.
- Guided Discussion: Assess the learner’s analysis of the accident or incident using the Accident Analysis Worksheet as a guide.
Lesson Preparation
- Select an Accident Report: Choose an aviation accident or incident report that is comprehensive yet suitable for the learner’s level (see the resources section).
- Redact Details: Remove or obscure information related to the probable cause (causal factor) and contributing factors. Learners should develop their own conclusions.
Lesson Presentation
Risk Management
- Failure to identify the steps in the poor judgment chain
- Failure to learn from others’ mistakes due to perceived differences in ability or personal biases
Scenario
The scenario will involve the analysis of a case study selected by the instructor. Learners should evaluate each aspect of the report, with the instructor acting as a guide.
Resources
- Risk Management Handbook (FAA-H-8083-2)
- AC 60-22: Aeronautical Decision Making
- https://www.ntsb.gov/_layouts/ntsb.aviation/index.aspx (NTSB Investigations)
- https://data.ntsb.gov/Docket/Forms/searchdocket (NTSB Dockets)
- https://lessonslearned.faa.gov/index.cfm (FAA Lessons Learned)
- https://asrs.arc.nasa.gov/search/database.html (NASA ASRS Database)
- http://www.kathrynsreport.com (Accident Descriptions)
Schedule
- Lesson Presentation (0:15)
- Case Study Analysis (0:10)
- Review and Assessment (0:15)
Equipment
- Whiteboard, markers, and erasers
- Selected aviation accident or incident report(s)
Review and Assessment
The learner’s case analysis is followed by a guided discussion, with the instructor summarizing the key insights from the report and applying these findings to enhance aviation safety practices. This discussion includes an informal assessment and a review of the main points.
Completion Standards
Note: There are no Airman Certification Standards associated with this lesson.
This lesson is complete when the lesson objectives are met and the learner:
- Recalls the NTSB’s accident and incident reporting requirements.
- Demonstrates a comprehensive understanding of the causes and contributing factors to accidents.
- Identifies and articulates key elements in the poor judgment chain.
- Provides well-reasoned safety recommendations that address identified issues in an accident.
Lesson Content
Frequent Causes of General Aviation Accidents
Reference: AIM 7-6-1
The 10 most frequent causes of GA accidents that involve the PIC:
- Inadequate preflight preparation or planning
- Failure to obtain or maintain flying speed
- Failure to maintain directional control
- Improper level off (continued descent into terrain)
- Failure to see and avoid objects or obstructions
- Mismanagement of fuel
- Improper inflight decisions or planning
- Misjudgment of distance and speed
- Selection of unsuitable terrain
- Improper operation of flight controls
Teaching Accident Analysis
Reference: 49 CFR Part 831
By evaluating reports of past aircraft accidents, pilots can develop decision-making and risk-management skills. The target of such analysis should be the causes and contributing factors of accidents that can be shaped by a pilot’s actions or inactions, such as human error and external pressures.
Four things cause accidents if you factor out catastrophic airframe failures, engine failures, and pilot incapacitation. If you factor those things out, you’re left with (1) arrogance, (2) ignorance, (3) complacency, and (4) distractions. One or more of those four things are present in every NTSB report.
Pat Brown, AOPA Ambassador
The Accident Investigation Process
The accident investigation process involves evidence collection, data analysis, and event reconstruction to identify the cause of an accident. The goal is to provide insights into mechanical, human, and environmental factors.
In the U.S., aviation accidents are investigated by:
- The NTSB to determine the probable cause and make safety recommendations.
- The FAA to determine if the accident was caused by deficiencies in pilot training, aircraft certification, or ATC.
- Subject matter experts, such as aircraft engine manufacturers.
Types of NTSB Accident Reports
- Preliminary Reports: Released within a few days after an accident. These reports provide an initial synopsis of known facts at the time of a crash, which is subject to change as the investigation unfolds.
- Factual Reports: A comprehensive account of an accident, compiled after extensive investigation. This report, which replaces the Preliminary Report, offers a full narrative description of the accident.
- Final Reports: Conclusive reports that include the NTSB’s official determination of the probable cause(s) of the accident.
Note: The NTSB creates accident dockets (document repositories) containing factual reports and the evidence investigators consider to develop a probable cause. Dockets are made available to the public and are accessible when viewing a factual report or by a separate search.
Links:
- https://www.ntsb.gov/_layouts/ntsb.aviation/index.aspx (NTSB Investigations)
- https://data.ntsb.gov/Docket/Forms/searchdocket (NTSB Dockets)
Aircraft Accident and Incident Reporting
References: 49 CFR Part 830, AIM 7-7-2
Definitions
Accident: An occurrence associated with the operation of an aircraft which takes place between the time any person boards the aircraft with the intention of flight and all such persons have disembarked, and in which any person suffers death or serious injury, or in which the aircraft receives substantial damage. This definition includes unmanned aircraft accidents.
Incident: An occurrence other than an accident that affects or could affect the safety of operations.
Substantial Damage: Damage or failure which adversely affects the structural strength, performance, or flight characteristics of the aircraft, and which would normally require major repair or replacement of the affected component.
Note: Engine failure or damage limited to an engine if only one engine fails or is damaged, bent fairings or cowling, dented skin, small punctured holes in the skin or fabric, ground damage to rotor or propeller blades, and damage to landing gear, wheels, tires, flaps, engine accessories, brakes, or wingtips are not considered substantial damage.
Serious Injury: Any injury which:
- Requires hospitalization for more than 48 hours, commencing within 7 days from the date of the injury was received;
- Results in a fracture of any bone (except simple fractures of fingers, toes, or nose);
- Causes severe hemorrhages, nerve, muscle, or tendon damage;
- Involves any internal organ; or
- Involves second- or third-degree burns, or any burns affecting more than 5% of the body surface.
Fatal Injury: Any injury which results in death within 30 days of the accident.
Immediate Notification Requirements
The operator of an aircraft shall immediately, and by the most expeditious means available, notify the nearest NTSB field office when an aircraft accident occurs. A phone call is sufficient initially, but a written follow-up will be required.
Immediate notification is also required when any of the following serious incidents occur:
- An aircraft is overdue and is believed to have been involved in an accident;
- A flight control system malfunction or failure;
- The inability of any required flight crewmember to perform normal flight duties as a result of injury or illness;
- An inflight fire;
- An aircraft collision in flight;
- Damage to property, other than the aircraft, estimated to exceed $25,000 for repair (including materials and labor) or fair market value in the event of total loss, whichever is less;
- The release of all or a portion of a propeller blade from an aircraft, excluding release caused solely by ground contact; or
- A complete loss of information, excluding flickering, from more than 50% of an aircraft’s cockpit displays known as:
- Electronic Flight Instrument System (EFIS) displays;
- Engine Indication and Crew Alerting System (EICAS) displays;
- Electronic Centralized Aircraft Monitor (ECAM) displays; or
- Other displays of this type, which generally include a PFD, primary navigation display (PND), and other integrated displays.
Reports and Statements to be Filed
The operator of an aircraft must file a report within 10 days after an accident or after 7 days if an overdue aircraft is still missing. A report on an incident that requires immediate notification shall be filed only as requested by an authorized representative of the NTSB (“the Board”). These reports should be filed with the field office of the Board nearest to the accident or incident.
Aviation Safety Reporting System
References: 14 CFR 91.25, AIM 7-7-1
The Aviation Safety Reporting System (ASRS) receives, processes, and analyzes incident reports involving aviation operations. Reports submitted to ASRS may describe both unsafe occurrences and hazardous situations.
All ASRS submissions are voluntary and are held in strict confidence. Names and other identifying information are removed before going into the ASRS database.
Link: http://asrs.arc.nasa.gov
Uses of ASRS Information
The FAA does not use ASRS information in enforcement actions, except information concerning accidents or criminal offenses, which are excluded from the program.
ASRS data is used to:
- Identify deficiencies and discrepancies in the National Airspace System (NAS) so that they can be remedied.
- Support policy formulation and planning for improvements to the NAS.
- Strengthen the foundation of aviation human factors safety research.
Incentives to Make ASRS Reports
The FAA waives fines and penalties, subject to certain limitations, for unintentional violations of regulations that are reported to ASRS.
The waiver of penalties is subject to the following limitations:
- The violation must be inadvertent and not deliberate.
- The violation did not involve a criminal offense, accident, or action under 49 U.S. Code 44709, which discloses a lack of qualification or competency.
- The reporter must not have been found guilty of a violation during the preceding five years.
- The ASRS report must be submitted within 10 days of the event or date when the person became aware or should have been aware of the violation.
Operational Pitfalls
Peer Pressure: Poor decision-making may be based on an emotional response to peers, rather than evaluating a situation objectively.
Mindset: A pilot displays a mindset through an inability to recognize and cope with changes in a given situation.
Plan Continuation Bias (“Get-There-Itis”): This disposition impairs pilot judgment through a fixation on the original goal or destination, combined with a disregard for an alternative course of action.
Duck-Under Syndrome: A pilot may be tempted to make it into an airport by descending below minimums during an approach.
Scud Running: This occurs when a pilot tries to maintain visual contact with the terrain at low altitudes while instrument conditions exist.
Continuing Visual Flight into Instrument Conditions: Spatial disorientation or collision with ground/obstacles may occur when a pilot continues VFR into instrument conditions.
Getting Behind the Aircraft: This pitfall can be caused by allowing events to control pilot actions. A constant state of surprise at what happens next may be exhibited when the pilot is getting behind the aircraft.
Loss of Positional or Situational Awareness: When a pilot gets behind the aircraft, a loss of positional or situational awareness may result.
Operating Without Adequate Fuel Reserves: Ignoring minimum fuel reserve requirements is generally the result of overconfidence, lack of flight planning, or disregarding applicable regulations.
Descent Below the Minimum En Route Altitude: The duck-under syndrome, as mentioned above, can also occur during the en route portion of an IFR flight.
Flying Outside the Envelope: The assumed high-performance capability of a particular aircraft may cause a mistaken belief that it can meet the demands imposed by a pilot’s overestimated flying skills.
Neglect of Flight Planning, Preflight Inspections, and Checklists: A pilot may rely on short- and long-term memory, regular flying skills, and familiar routes instead of established procedures and published checklists.
The Poor Judgment Chain
Most accidents have multiple causal factors, which can be thought of as links in a chain. The poor judgment chain (PJC) describes the series of mistakes that lead to accidents and incidents related to human factors.
Basic principles of the PJC:
- One bad decision often leads to another.
- As the string of bad decisions grows, the number of safe alternatives available to the pilot diminishes.
- Breaking one link in the chain is all that is usually necessary to change the outcome.
Biases in Aviation
A bias is to feel an inclination or prejudice toward or against someone or something. Pilots must be aware of them to prevent them.
Confirmation Bias
Confirmation bias is the tendency to favor information that supports one’s beliefs or values. It occurs when a person seeks to confirm a decision that has already been made instead of objectively following the decision-making process.
Example: A pilot may ignore information from a weather update that contradicts the preflight briefing.
Dunning–Kruger Effect
People mistakenly assess their knowledge or ability as greater than it is. This cognitive bias is known as the Dunning–Kruger effect.
The incompetent are often blessed with an inappropriate confidence, buoyed by something that feels to them like knowledge.
David Dunning
Expectation Bias
Expectation bias is the tendency to see or hear something that is expected rather than what is occurring. The expectation often is driven by experience or repetition.
Example: A pilot may readback an expected taxi clearance instead of the ATC assigned route.
Framing Bias
Framing bias is the tendency to evaluate options in terms of gains (positive) and losses (negative):
- Risks framed positively are more likely to be accepted than equivalent risks framed negatively.
- Under positive terms, a definite gain is favored over a less probable but greater gain.
- Under negative terms, a less probable but more disastrous loss is favored over a definite loss.
Example: A 75% chance of surviving is usually preferred over a 25% of dying.
Hindsight Bias
Hindsight bias is the tendency, upon learning the outcome of an event, to overestimate one’s ability to have foreseen the outcome. Errors are seen as obvious and preventable.
Hindsight is 20/20.
Example: When reading an accident report, it is easy to spot where a mistake was made and regard the outcome as something that could “never happen to me.”
Plan Continuation Bias (“Get-There-Itis”)
Plan continuation bias is the tendency to continue with the original plan despite changing conditions.
Newton's "4th Law":
A pilot in motion tends to stay in motion. It is easier to say "no" before acting than to stop during an action.
The PAVE Checklist
Pilots should proactively detect (perceive) hazards before and during a flight. The PAVE checklist divides each flight component into four categories or “buckets” for hazard identification
- Pilot
- Aircraft
- enVironment
- External pressures.
Case Study Worksheet
Aircraft Type: | Souls on Board: |
Aircraft ID/Flight Number: | Injuries: |
Date and Location: | Fatalities: |
Instructions
This worksheet guides you through a comprehensive analysis of an aviation accident or incident report. Read the report carefully and consider the following sections to deepen your understanding of the events.
1. NTSB Reporting Requirements
- Review the NTSB’s accident and incident reporting requirements under 49 CFR Part 830.
- Determine if and when the operator is required to notify the NTSB or to submit an accident or incident report.
2. Broad Analysis
- Determine the type of flight plan (IFR or VFR), type of operation (e.g., commercial, private, instructional), time of day, route, and any other general aspects of the flight.
3. Probable Cause and Contributing Factors
- Using the PAVE checklist, analyze the causal and contributing factors to the accident or incident.
Pilot
- Evaluate the pilot’s background, experience, and decision-making process.
- Look for human factors, including signs of arrogance, ignorance, complacency, distractions, and personal biases.
- Determine if and how the pilot contributed to the accident or incident.
Aircraft
- Investigate the aircraft’s design, maintenance history, and any technical issues reported.
- Determine if and how the aircraft’s condition and maintenance contributed to the accident or incident.
Environment
- Analyze the environmental conditions at the time of the accident, including weather, terrain, and airspace.
- Determine if and how the environmental conditions contributed to the accident or incident.
External Pressures
- Consider operational demands, regulatory compliance issues, and passenger influences.
- Determine if and how external pressures contributed to the accident or incident.
4. Poor Judgment Chain
- Trace the sequence of events leading to the accident or incident.
- Identify the points at which intervention could have “broken” the chain.
5. Safety Recommendation
- Evaluate key issues in the accident or incident that pose a risk to future flights.
- Propose safety measures to mitigate the risks.