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Causes of Accidents - Pilot Induced

The five most common specific causes of pilotinduced accidents, in order of frequency, are:

•Loss of directional control

•Poor judgement

•Airspeed not maintained

•Poor preflight planning and preflight decision making

•Not maintaining ground clearance

The phases of flight most prone to accidents are, in order of precedence:

•Intermediate and Final Approach

•Landing

•Take-off

• Descent

Figure 1.3 Causes of accidents

Flight Safety

Roles Played by theVarious Aviation Participants in Flight Safety

Air transport is a huge system employing millions of people in thousands of different capacities. Those having a direct influence on flight safety are noted below together with their possible limitations:

National and International Authorities (ICAO, IATA, EASA, CAA, FAA etc.)

These organizations have, among their responsibilities those of setting , implementing and monitoring flight safety standards. They are also charged with developing the aviation industry within their field of influence. The two requirements sometimes conflict and, on many occasions, responsible compromises have to be found. This conflict necessitates limitations which, in many cases, are based on either financial or political considerations.

Commercial Organizations

Commercial organizations can suffer from a similar dilemma. The financial position of the organization may drive flight safety parameters. Smaller companies can be particularly vulnerable to cash problems.

The outward signs could include:

•Stretched crew duty times

•Poor rostering

•Unserviceabilities carried

•Weaknesses and short-cutting in maintenance and operational procedures

•Poor communications

•Lip service to minimum equipment lists

•Shortcomings and non-standardization of cockpit layouts

•Lack of passengers and aviation facilities

•Absenteeism

•Poor industrial relations

•Rise in accident rate

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Management

A minor change of policy may have far-reaching effects. For example a change in the utilization of an aircraft may effect workload, servicing schedules, rostering and render procedures invalid. The ripple effect is normally felt throughout the organisation and can have a direct influence on flight safety. In-depth consultation is a prerequisite to effective aviation management.

Training Staff

Training staff are at the coal face of flight safety. The interface and feedback between management and technical/flight personnel often takes place at this level. The professionalism, motivation, flexibility and communication abilities of training personnel are all fundamental to the augmentation of flight safety standards.

Technical/Flight Personnel

At the end of the line are the technical/flight personnel. On their shoulders lie the ultimate conflict. Should job security be put at risk because of flight safety considerations? Should a pilot, for example, agree to fly after extended duty times in order to satisfy a valued contract? Equally should an engineer submit to managerial pressures in order to satisfy serviceability demands? Sadly, this quandary has been faced many times in the past and will continue to be confronted in the future.

The Most Significant Flight Safety Equipment

It is generally considered that the most significant item of technical equipment that has been introduced in the 1980s and 1990s which has contributed most to the reduction of accidents is the Ground Proximity Warning System (GPWS) and later the Enhanced Ground Proximity Warning System (EGPWS).

Safety Culture

An active safety culture is considered to be the heart of and vital to the continuing success of a safety management system.

It has been described as “The safety culture of an organization is the product of individual and group values, attitudes, perceptions, competencies and patterns of behaviour that determine the commitment to, and the style and proficiency of, an organization’s health and safety management.”

Definition

Safety culture is defined as the enduring value and prioritization of worker and public safety by each member of each group and in every level of an organization.

It refers to the extent to which individuals and groups will commit to personal responsibility for safety and to:

•act to preserve

•enhance and communicate safety concerns

•strive to actively learn

•adapt and modify (both individual and organizational) behaviour based on lessons learned from mistakes

and

•strive to be honoured in association with these values

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Open Culture

Where all levels of an organization play an active part in the improvement of the safety culture.

Closed Culture

Where an organization is reluctant to release information on threats, errors or undesired aircraft states to other agencies.

National Culture

Both government and ethnic factors influence attitudes towards safety culture.

Factors that Promote a Good Safety Culture

•Leadership

•Commitment

•Good example

Reason’s Swiss Cheese Model

Likens human systems to multiple slices of Swiss cheese, stacked together, side by side.

An organization’s defences against failure are modelled as a series of barriers (the Swiss cheese slices). The holes in the cheese slices represent individual weaknesses in each part of the system and are continually varying in position and size in each slice.

Figure 1.4 The Swiss Cheese Model - by James Reason

The system as a whole will produce failures when all of the holes in each slice momentarily align. A hazard will pass through all of the holes in all of the defences leading to a failure.

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The Five Elements of Safety Culture

1.An informed culture

2.A reporting culture

3.A learning culture

4.A just culture

5.A flexible culture

Just Culture

Errors and unsafe acts will not be punished if the error was unintentional. Those who act recklessly or take deliberate and unjustifiable risks will be subject to disciplinary action.

Non Punitive Culture

Errors and unsafe acts will not be punished thus encouraging an atmosphere where people have the confidence to report safety concerns.

Flight Safety/Threat and Error Management

The three components of threat and error management (TEM) are:

1.Threats

2.Errors

3.Undesired aircraft states

Threats

LatentThreats

Not immediately obvious to, or observable by flight crews, e.g. poor equipment design, visual illusions or quick turn-around schedules.

EnvironmentalThreats

Those occurring during actual operations, e.g. weather, terrain, ATC, airport.

OrganizationalThreats

Operational pressure, aircraft type, cabin design, maintenance, dispatch, documentation.

Errors

Defined as:

Actions or lack of actions by the flight crew that lead to deviations from organisational or flight crew intentions or expectations.

Aircraft Handling Errors

Manual handling, automatic systems, ground navigation.

Procedural Errors

SOPs, checklists, briefing documentation.

Communication Errors

Crew to external, pilot to pilot.

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