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The theme of this monthly column is the interaction between the pilot and the environment, and the influence of this relationship on safe flight. In the previous column we looked at the impact of some basic human emotions on pilot performance. While the small glimpse was by no means exhaustive, hopefully it has started you wandering and wondering along the right road, realising that humans are poorly equipped to deal with the "human factors" in flight. Perhaps it also provided a couple of tips on how to avoid some of the pitfalls.

In the previous column I also mentioned that humans are also subject to physical limitations. Let us briefly analyse the following few accidents to see how these limitations can lead to an incident or tragedy:

The pilot of a light twin is cleared to Flight Level 100, but hears and reads back Flight Level 110. ATC notices the problem and intervenes shortly before there is an accident.

The stop lights of Runway 18 are situated almost on the beach. Soon after a night takeoff the pilot reported to ATC that his gear would not retract and requested a return to the airfield. The wreckage of the C210 was found 1nm out to sea.

The pilot of a PA32 was commissioned to deliver his passengers to a game farm in the bush. He obtained the coordinates of the game farm airfield from the farm manager and planned a late afternoon arrival. He arrived overhead the short grass strip just before sunset and noticed a game viewing vehicle and waving ranger at the end of the runway. He completed the circuit pattern and touched down very close to the threshold. The nosewheel impacted an anthill about halfway down the runway and the aircraft left the strip and stopped some 50m off the runway in a large pond. There were no injuries. The game viewing vehicle "rescued" the pilot and passengers and the ranger told the pilot that the airfield was some 2nm east of the strip (which had been abandoned because of the problem of anthills), and that he was trying to tell him not to land.

What can you find that is common in all of the above accidents? Probably a number of things, but we will concentrate on the physical limitations of the human being(s) behind the controls, and how the environment influenced the operation of the aircraft. Before we start our analysis let us look briefly at one of the recent additions to the "toolbox" of the CRM (Crew Resource Management) courses – Error Management. This will give us a good platform from which to look at the causes and find solutions (or tools to use).

Error management

Error Management is what we should be doing every time we fly. Because we are human, we are going to make mistakes – some small and unimportant, other potentially fatal. We hate making mistakes, but we also know that making mistakes is also a valuable source of information that can be used to prevent further error and also stop other people making the same mistakes.

If we accept that making errors is inevitable, then we must learn a set of "error counter-measures" with three lines of defence:

The first, naturally, is the avoidance of error.

The second is trapping errors before or as they are committed.

The third and last is alleviating or mitigating the consequences of those errors which occur and are not trapped.

For example, consider the Private Pilot of a light aircraft preparing for a long cross-country flight to ABC. She obtains a comprehensive weather forecast, including upper winds. She then prepares an accurate flight log and fuel plan, also building in contingency fuel in case the aircraft uses more fuel than advertised or the plan goes awry. Although her flight planning does not give her too much extra fuel to play with, she is happy that the flight can proceed safely. This constitutes error avoidance.

En route the weather is not quite as forecast (surprised?) and about half-way she notices that the high ground ahead is obscured by cloud. She decides to route around the weather and adjusts her track accordingly. The track will take her a long way off track and she busies herself with map reading and basic navigation. After a time she realises that she is so far off track that unless she heads direct to ABC she might not have enough fuel. ATC advises that the weather at ABC is clear. She elects to climb above the cloud and route direct to ABC. After a few minutes she realises that the ground is obscured and she has no way of knowing where she is, or where she would do a forced landing if her engine failed. She does a 180 degree turn and heads back in the direction of home base. This is "error trapping".

Now, realising she is in a fix, she "confesses" to ATC that she has turned around, but is unsure of her position and may run short of fuel. ATC assists her in finding her position and advises on a nearby suitable airport where she can refuel before continuing back to base. She lands safely. This is "error mitigation" – she has alleviated the consequences of the errors made.

Fortunately, most errors are alleviated in one of the three phases. Some, unfortunately are not. Using the "countermeasures" let us look at the physical limitations encountered by the pilots and look for tools to use to alleviate them.

In the first incident the pilot climbed through his assigned level. Using the error management model we can attempt to minimise the physical "hearing" problem. Often what is heard is not what is understood, and often what is understood is not what was said! The model deals with the 3 error-management counter-measures in turn.

Error avoidance

Learn the "danger" words, this will allow you to anticipate problems associated with "hearing" problems. For example, "five" and "nine", the sequential problems of headings and flight levels, (110 and 100, also 220, 200, 330, 300, etc.) and aircraft numbers and callsigns (BAC vs ABC, or Swiftwings 112 vs 122).

Anticipate routing, flight level or altitude changes and ATC clearances. Have your pen ready!

Wear headsets! Also get your front-seat passenger (or other crew member) to wear headsets and get them to listen in as well.

Error trapping

Write down all your clearances. Even simple headings, altitudes, flight levels and frequencies should be jotted down on your clipboard as this may prevent you from making a "hearing" mistake.

Listen carefully, read back clearly. Read back all clearances, being careful to enunciate clearly the "danger" words above.

Question! If you are not sure you heard the clearance correctly, or if it sounds strange, or if it is unusual, check with ATC. Always confirm, never assume!

Develop situational awareness. Let the autopilot do the work if you are busy, listen out carefully for other traffic

Error mitigation

Confess. If you make a mistake, confess this to ATC immediately

Rectify: If you can rectify the problem, do so, letting ATC know what you are doing.

Remember what happened, store the memory away and spread the word – let someone else learn from your mistakes

Great truth #1: We are never at our best in an aircraft! It is easy to mistake a "one one zero" for "one zero zero" at the best of times, especially if we are expecting to hear 110! If the aircraft is noisy and we are busy the probability of making an error is increased dramatically. Be alert, your country needs lerts.

In the next accident, the pilot of a C210 crashed into the sea after a night takeoff. What are the physical limitations that contributed to the accident? Do some thinking before you look at the model below.

During summer evenings in this area the sea is cooler than the land, so there is inevitably a gentle sea breeze. Takeoffs are thus out to sea and the haze that is ever present in the area makes the horizon difficult to see. The pilot of the Cessna 210 filed a VFR flight plan to his airfield 30 minutes further inland, expecting CAVOK weather conditions all the way.

Spatial disorientation can easily occur when the horizon is not clear, even if the pilot is experienced and well trained. A climbing turn is one of the manoeuvres that can easily disorientate a pilot who is not following his instruments, as the sensations produced by the inner ear are quite misleading. As any instrument rated pilot will tell you, it takes great discipline to trust the instruments and not your body! If the head is moved around, the problem is aggravated. If you look away from the instruments, even for a short time, lots of things can happen unexpectedly!

Error avoidance

Pre-flight planning will alert you to the fact that the horizon might not be readily identifiable after takeoff. Talk to the local pilots if you are unfamiliar with the airfield.

A night takeoff out to sea inevitably is a "black hole" takeoff, and it is vital that you brief yourself to stay on instruments until well above the ground (preferably after the cross-wind turn). Revise your briefing just before takeoff as a reminder. The fact that CAVOK conditions prevail must not mislead you into believing you will always be able to fly visually at night.

Make sure you are not rushed into taking off. Have all your ducks in a row, and test yourself for stress. Make sure your checks are done correctly, as you must focus on accurate flying after takeoff.

Error trapping

Aviate! After takeoff, do nothing except fly until you are well above the ground and climbing well. If you are tempted to look out of the window, don’t! Definitely no actions below 300’ AGL.

If there is an aircraft problem, decide if it can wait. If it can (e.g. gear remains down) then wait until you are well above the ground and can spare the attention. If not (engine failure), then revert back to your emergency training but keep control of the aircraft – priority number 1!

If the ATC calls you soon after takeoff, don’t answer. Respond to the instructions (if any), if required, but wait until you are well above the ground before communicating. Tell ATC you were very busy and could not answer!

Error mitigation

If you have broken any of the above rules, then quickly come back to your instruments (not your senses!). Trust the instruments!

If your gut feel tells you something is not right, then your gut is probably right. Get right back on instruments, keep the wings level and make sure you are climbing. Only then take a systematic look around the panel to see what is worrying your gut.

Great Truth # 2: Do a proper pre-takeoff briefing! Use this opportunity to commit to short-term memory what you are expecting to do during the takeoff and initial climb. Include anything unusual or different. This is especially important with night takeoffs.

This last scenario looks at the pilot who landed up in a pond! While this accident was not caused entirely by physical limitations, it is easy to see the interaction of visual inadequacies and psychological pressure. See if you can develop the model by yourself and then add your ideas to mine.

Error avoidance

Once again preflight planning left a lot to be desired. Cross-checking landmarks with coordinates will give a more accurate position. Talking to pilots or passengers who have been there before may save the day. Don’t trust your eyes!

Planning the flight to arrive with the sun high in the sky will improve the probability of seeing obstructions on the runway. In addition, the pressure to land immediately will not be there.

Have a master plan that will allow you to change your mind about landing! An alternative airfield is a good idea. How about returning to base? Have a "fallback" plan, especially in remote areas.

Your flight training syllabus calls for you to master a "precautionary" landing circuit with a fly past. What happened to all that good stuff?

Today it may be possible to contact the farm manager on his cell phone for directions!

Error trapping

One danger of a pilot under stress and time pressure is that any solution will do. This is called "satisficing" and the first runway that appears under the nose is often assumed to be the right one. Fly around a bit, improving your situational awareness. What’s the rush! If the runway does not look right, it probably isn’t!

If your flypast shows an unsatisfactory surface, go elsewhere! Don’t respond to the urging of the passengers, the farm manager who is waving at you (waving you away?) or the pressure of the company to deliver.

Error mitigation

So your planning has been poor, the airfield is not correct and now what do you do? Problem solve. See what options are available - another airfield, a main center, return to base, a night flight away from the farm? Take your time. Climb up a bit, settle down, do some thinking, ask around for suggestions.

Keep your eyes especially if the light is poor. Be prepared to go-around even after touchdown – don’t relax until the aircraft is tied down!

If you decide to divert, communicate your intentions to ATC if possible

Notify the company of the unsuitability of the field, or the danger of mistaking the strip for the correct airfield.

Great truth #3: It is never too late to change your mind. Be cautious and very suspicious from the start! It is much easier to fix an error before you make it!

Great truth #4: You can always take care of the paperwork on the ground after the event. Incident reports are no big deal, accident reports are.

In summary:

Remember that to err is human! We all make mistakes, and we make lots of them. However, there are many safeguards built into flying that should minimise the effects of error. Maintaining good situational awareness is crucial and this comes primarily from good training - don’t be prepared to accept half-baked training! Ask lots of questions, think through procedures on your own with a lot of question-marks written all over your notes, magazines or books. Above all, use your common sense! This is called "airmanship".

When reviewing these accident reports and others that you might see or hear about, you might find it fairly obvious that in many instances the pilot is at fault. In fact, most light aircraft accidents can be attributed to "pilot error" in some way or another. However, try to remember that it is a real live person involved in the accident – it is a living, breathing human being, just like you, behind the controls! Once you realise that it could have been you there, then one would tend to view the circumstances with more sympathy and less clinically. This is one reason why I have been reviewing these accidents – to make you realise that there is always more to the accident that you can see on the surface.

Good Flying!

Mike Malherbe

I will be happy to receive and respond to comments.

Email: mikemal

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