Knowledge

Pilot error

Source πŸ“

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to pilot training and goes hand in hand with CRM. Some aircraft operating systems have made progress in aiding CTM by combining instrument gauges into one screen. An example of this is a digital attitude indicator, which simultaneously shows the pilot the heading, airspeed, descent or ascent rate and a plethora of other pertinent information. Implementations such as these allow crews to gather multiple sources of information quickly and accurately, which frees up mental capacity to be focused on other, more prominent tasks.
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aircraft side stick; fatigue could also have played a role in the accident. The final report cited the following causes: the pilots' lack of a common action plan during the approach, the final approach being continued below the Minimum Decision Altitude without ground visual reference being acquired; the inappropriate application of flight control inputs during the go-around and after the Terrain Awareness and Warning System had been activated; and the flight crew's failure to monitor and control the flight path.
462: 121: 134: 1383:: one of the ATR 72's engines experienced a flameout. As airplanes are able to fly on one engine alone, the pilot then shut down one of the engines. However, he accidentally shut off the engine that was functioning correctly and left the plane powerless, at which point he unsuccessfully tried to restart both engines. The plane then clipped a bridge and plummeted into the Keelung river as the pilot tried to avoid city terrain, killing 43 of the 58 on board. 298:"coordinative and cognitive ability to handle both routine and unforeseen surprises and anomalies." The desired outcome of TEM training is the development of 'resilience'. Resilience, in this context, is the ability to recognize and act adaptively to disruptions which may be encountered during flight operations. TEM training occurs in various forms, with varying levels of success. Some of these training methods include data collection using the 87: 22: 514:
a flight. The objectives of checklists include "memory recall, standardization and regulation of processes or methodologies." The use of checklists in aviation has become an industry standard practice, and the completion of checklists from memory is considered a violation of protocol and pilot error. Studies have shown that increased errors in judgement and cognitive function of the brain, along with changes in
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flight crews undertake when faced with threats and errors during normal operation. This data driven analysis of threat and error management is useful for examining pilot behavior in relation to situational analysis. It provides a basis for further implementation of safety procedures or training to help mitigate errors and risks. Observers on flights which are being audited typically observe the following:
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4,000 pilot factors associated with more than 2,000 U.S. Navy aviation mishaps. Although the three cognitive models have slight differences in the types of errors, all three lead to the same conclusion: errors in judgment. The three steps are decision-making, goal-setting, and strategy-selection errors, all of which were highly related to primary accidents. For example, on 28 December 2014,
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their location in relation to a radio beacon in Tulua. The aircraft was equipped to provide that information electronically, but according to sources familiar with the investigation, the pilot apparently did not know how to access the information. The captain input the wrong coordinates, and the aircraft crashed into the mountains, killing 159 of the 163 people on board.
865:. The captain, Yaroslav Kudrinsky, invited his two children into the cockpit, and permitted them to sit at the controls, against airline regulations. His sixteen-year-old son, Eldar Kudrinsky, accidentally disconnected the autopilot, causing the plane to bank to the right before diving. The co-pilot brought up the plane too far, causing it to stall and start a 33: 1254:(flying as Continental Connection) entered a stall and crashed into a house in Clarence Center, New York, due to lack of situational awareness of air speed by the captain and first officer and the captain's improper reaction to the plane's stick-shaker stall warning system. All 49 people on board the plane died, as well as one person inside the house. 1323:, killing 158 people. The plane touched down 610 meters (670 yd) from the usual touchdown point after a steep descent. CVR recordings showed that the captain had been sleeping and had woken up just minutes before the landing. His lack of alertness made the plane land very quickly and steeply and it ran off the end of the tabletop runway. 360:
accepted standard for developing human factors skills for air crews and airlines. Although there is no universal CRM program, airlines usually customize their training to best suit the needs of the organization. The principles of each program are usually closely aligned. According to the U.S. Navy, there are seven critical CRM skills:
286:, which was carrying seven crew members and 155 passengers, crashed into the Java Sea due to several fatal mistakes made by the captain in the poor weather conditions. In this case, the captain chose to exceed the maximum climb rate for a commercial aircraft, which caused a critical stall from which he was unable to recover. 812:, but the pilots mistakenly shut down the right engine. The left engine eventually failed completely and the crew were unable to restart the right engine before the aircraft crashed. Instrumentation on the 737-400 was different from earlier models, but no flight simulator for the new model was available in Britain. 208:. There are multiple factors that can cause pilot error; mistakes in the decision-making process can be due to habitual tendencies, biases, as well as a breakdown in the processing of the information coming in. For aircraft pilots, in extreme circumstances these errors are highly likely to result in fatalities. 1364:
brushed trees and crashed into six houses in a residential area in Xixi Village, Penghu Island, Taiwan. Of the 58 people on board the flight, only ten people survived the crash. The captain was overconfident with his skill and intentionally descended and rolled the plane to the left. Crew members did
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was a 9-year-old boy named Ruben Van Assouw. On 28 February 2013, the Libyan Civil Aviation Authority announced that the crash was caused by pilot error. Factors that contributed to the crash were lacking/insufficient crew resource management, sensory illusions, and the first officer's inputs to the
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Arthur "Bud" Holland, the pilot in command, and delayed reactions to the earlier incidents involving this pilot. After past histories, Lt Col Mark McGeehan, a USAF squadron commander, refused to allow any of his squadron members to fly with Holland unless he (McGeehan) was also on the aircraft. This
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are a few of the effects of stress and fatigue. Both of these are inevitable human factors encountered in the commercial aviation industry. The use of checklists in emergency situations also contributes to troubleshooting and reverse examining the chain of events which may have led to the particular
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The use of checklists before, during and after flights has established a strong presence in all types of aviation as a means of managing error and reducing the possibility of risk. Checklists are highly regulated and consist of protocols and procedures for the majority of the actions required during
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The need for CTM training is a result of the capacity of human attentional facilities and the limitations of working memory. Crew members may devote more mental or physical resources to a particular task which demands priority or requires the immediate safety of the aircraft. CTM has been integrated
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with 155 passengers and eight crew members, departed Miami approximately two hours behind schedule at 1835 Eastern Standard Time (EST). The investigators believe that the pilot's unfamiliarity with the modern technology installed in the Boeing 757-200 may have played a role. The pilots did not know
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crashed into a golf course short of the runway near Hindustan Airport, Bangalore, India. The flight crew failed to pull up after radio callouts of how close they were into the ground. The plane struck a golf course and an embankment, bursting into flames. Of the 146 occupants on the plane, 92 died,
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is the "effective use of all available resources by individuals and crews to safely and effectively accomplish a mission or task, as well as identifying and managing the conditions that lead to error." CRM training has been integrated and mandatory for most pilot training programs, and has been the
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to run out of fuel while investigating a landing gear problem, causing a crash that killed ten of those on board. United Airlines subsequently changed their policy to disallow "simulator instructor time" in calculating a pilot's "total flight time". It was thought that a contributory factor to the
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Cockpit task management (CTM) is the "management level activity pilots perform as they initiate, monitor, prioritize, and terminate cockpit tasks." A 'task' is defined as a process performed to achieve a goal (i.e. fly to a waypoint, descend to a desired altitude). CTM training focuses on teaching
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Reasons for negative reporting of accidents include staff being too busy, confusing data entry forms, lack of training and less education, lack of feedback to staff on reported data and punitive organizational cultures. Wiegmann and Shappell invented three cognitive models to analyze approximately
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The term "error" is defined as any action or inaction leading to deviation from team or organizational intentions. Error stems from physiological and psychological human limitations such as illness, medication, stress, alcohol/drug abuse, fatigue, emotion, etc. Error is inevitable in humans and is
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checklist (illness, medication, stress, alcohol, fatigue/food, emotion) and a number of other qualitative assessments which pilots may perform before or during a flight to ensure the safety of the aircraft and passengers. These checklists, along with a number of other redundancies integrated into
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Today, CRM is implemented through pilot and crew training sessions, simulations, and through interactions with senior ranked personnel and flight instructors such as briefing and debriefing flights. Although it is difficult to measure the success of CRM programs, studies have been conclusive that
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LOSA was developed to assist crew resource management practices in reducing human error in complex flight operations. LOSA produces beneficial data that reveals how many errors or threats are encountered per flight, the number of errors which could have resulted in a serious threat to safety, and
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shortcomings, bird strikes, and high terrain." Conversely, airline threats are not manageable by the flight crew, but may be controlled by the airline's management. These threats include "aircraft malfunctions, cabin interruptions, operational pressure, ground/ramp errors/events, cabin events and
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settings from level flight to a slow descent. Told by ATC to hold over a sparsely populated area away from the airport while they dealt with the problem (with, as a result, very few lights visible on the ground to act as an external reference), the distracted flight crew did not notice the plane
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departed Guangzhou on a 55-minute flight to Guilin. During the descent towards Guilin, at an altitude of 7,000 feet (2,100 m), the captain attempted to level off the plane by raising the nose and the plane's auto-throttle was engaged for descent. However, the crew failed to notice that the
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LOSA is a structured observational program designed to collect data for the development and improvement of countermeasures to operational errors. Through the audit process, trained observers are able to collect information regarding the normal procedures, protocol, and decision making processes
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involves the effective detection and response to internal or external factors that have the potential to degrade the safety of an aircraft's operations. Methods of teaching TEM stress replicability, or reliability of performance across recurring situations. TEM aims to prepare crews with the
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Pilots work in complex environments and are routinely exposed to high amounts of situational stress in the workplace, inducing pilot error which may result in a threat to flight safety. While aircraft accidents are infrequent, they are highly visible and often involve significant numbers of
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Modern accident investigators avoid the words "pilot error", as the scope of their work is to determine the cause of an accident, rather than to apportion blame. Furthermore, any attempt to incriminate the pilots does not consider that they are part of a broader system, which in turn may be
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location, the pilots chose improper manual settings which rendered the autopilot incapable of keeping the plane in the air, and by the time the captain regained manual control, it was too late. The aircraft was destroyed, killing the flight crew, a test engineer, and four passengers. The
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The causes of pilot error include psychological and physiological human limitations. Various forms of threat and error management have been implemented into pilot training programs to teach crew members how to deal with impending situations that arise throughout the course of a flight.
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became confused with the heading knob and thought that he had carried out the correct action to turn the plane. However, due to his failure to pull the heading knob, the turn was not executed. The Airbus A321 went astray and slammed into the Margalla Hills, killing all 152 people on
245:'s influence which can increase the operational complexity of a flight." Threats may further be broken down into environmental threats and airline threats. Environmental threats are ultimately out of the hands of crew members and the airline, as they hold no influence on "adverse 404:
These seven skills comprise the critical foundation for effective aircrew coordination. With the development and use of these core skills, flight crews "highlight the importance of identifying human factors and team dynamics to reduce human errors that lead to aviation mishaps."
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lost control and crashed into the Black Sea while approaching Sochi-Adler Airport in Russia, killing all 113 people on board. The pilots were fatigued and flying under stressful conditions. Their stress levels were pushed over the limit, causing them to lose their situational
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now serves as a textbook example. Due to several misunderstandings, the KLM flight tried to take off while the Pan Am flight was still on the runway. The airport was accommodating an unusually large number of commercial airliners, resulting in disruption of the normal use of
28:, caused by flying the aircraft beyond its operational limits. Here the aircraft is seen in an unrecoverable bank, a split second before the crash. This accident is now used in military and civilian aviation environments as a case study in teaching crew resource management. 1175:, causing it to enter a stall. The situation was incorrectly handled by the crew, with the captain believing that the engines had flamed out, while the first officer, who was aware of the stall, attempted to correct him. The aircraft crashed into the ground near 1213:, which diverted their attention from the flight instruments, allowing the increasing descent and bank angle to go unnoticed. Appearing to have become spatially disoriented, the pilots did not detect and appropriately arrest the descent soon enough to prevent 217:
fatalities. For this reason, research on causal factors and methodologies of mitigating risk associated with pilot error is exhaustive. Pilot error results from physiological and psychological limitations inherent in humans. "Causes of error include
562:(NTSB) report on the incident blamed the flight crew for failing to monitor the aircraft's instruments properly. Details of the incident are now frequently used as a case study in training exercises by aircrews and air traffic controllers. 233:, and flawed decision making." Throughout the course of every flight, crews are intrinsically subjected to a variety of external threats and commit a range of errors that have the potential to negatively impact the safety of the aircraft. 901:
investigative board concluded that the captain was overworked from earlier flight testing that day, and was unable to devote sufficient time to the preflight briefing. As a result, Airbus had to revise the engine-out emergency procedures.
1357:. Of the 307 passengers and crew, three people died and 187 were injured when the aircraft slid down the runway. Investigators said the accident was caused by lower than normal approach speed and incorrect approach path during landing. 618:), near Winkton, England, while on a test flight. The crash was caused by a combination of bad weather and a failure on the part of both pilots to read the altimeter correctly. The first officer and two other people survived the crash. 1239:
was jammed. Although both crew members were aware, the captain used an outdated braking procedure, and the aircraft overshot the runway and crashed into a building, killing all 187 people on board, as well as 12 people on the
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on 29 December 1972. The captain, first officer, and flight engineer had become fixated on a faulty landing gear light and had failed to realize that one of the crew had accidentally bumped the flight controls, altering the
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Pilot error is nevertheless a major cause of air accidents. In 2004, it was identified as the primary reason for 78.6% of disastrous general aviation (GA) accidents, and as the major cause of 75.5% of GA accidents in the
768:, after the No. 4 engine flamed out. The aircraft descended 30,000 feet in two-and-a-half minutes before control was regained. There were no fatalities but there were several injuries, and the aircraft was badly damaged. 969:
concluded that the crash was caused when the pilots turned the aircraft in the wrong direction, along with ATC error. Low visibility and failure of the GPWS to activate were cited as contributing factors to the
318:(GPWS). With the consolidation of onboard computer systems and the implementation of proper pilot training, airlines and crew members look to mitigate the inherent risks associated with human factors. 1307:
The aircraft crashed about 1,200 meters (1,300 yd; 3,900 ft) short of Runway 09, outside the perimeter of Tripoli International Airport, killing all but one of the 104 people on board. The
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that took off from the wrong runway at the then Chiang Kai-Shek International Airport. It collided with construction equipment on the runway, bursting into flames and killing 83 of its 179 occupants.
44:). Blue line shows the nominal Las Vegas course, while green is a typical course from Boulder. The pilot inadvertently used the Boulder outbound course instead of the appropriate Las Vegas course. 676:
crashed into Mount Longa after the flight crew did not adhere to approach procedures established by ATC. All 115 occupants perished. This is the worst single-aircraft disaster in Italian history.
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and had not noticed that his control column was slanted to the right. The Boeing 737 banked until it was no longer able to stay in the air. However, the investigation report was disputed.
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from side to side. The excessive stress caused the rudder to fail. The A300 spun and hit a residential area, crushing five houses and killing 265 people. Contributing factors included
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but had initiated a go-around due to the bad weather conditions. However, the pilots accidentally disengaged the autopilot and did not notice for 11 seconds. When they did notice, the
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crashed, killing the president and eight other passengers. The crash investigation ruled that the accident was caused by "procedural mistakes by the crew" during the landing approach.
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Multiple sources of information can be taken from one interface here, known as the PFD, or primary flight display from which pilots receive all of the most important data readings
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correctness of crew action or inaction. This data has proven to be useful in the development of CRM techniques and identification of what issues need to be addressed in training.
527:, or checklists made by aircraft manufacturers, pilots also have personal qualitative checklists aimed to ensure their fitness and ability to fly the aircraft. An example is the 2297: 1026:. The NTSB officially declared that the crash was caused by "the pilot's failure to maintain control of his airplane during a descent over water at night, which was a result of 1565: 1228:
and the failure to extend the flaps led the aircraft to land at an "unimaginable" speed and run off the end of the runway after landing. Of the 140 occupants, 22 were killed.
417:, the aviation industry has seen tremendous evolution of the application of CRM training procedures. The applications of CRM has been developed in a series of generations: 103:(major navigational error leading to fuel exhaustion). The flight plan was later shown to 21 pilots of major airlines. No fewer than 15 pilots committed the same mistake. 164:
It also includes a pilot's failure to make a correct decision or take proper action. Errors are intentional actions that fail to achieve their intended outcomes. The
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A military pilot reads the pre-flight checklist prior the mission. Checklists ensure that pilots are able to follow operational procedure and aids in memory recall.
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Thomas, Matthew J.W. (2004). "Predictors of Threat and Error Management: Identification of Core Nontechnical Skills and Implications for Training Systems Design".
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Salas, Eduardo; Burke, Shawn C.; Bowers, Clint A.; Wilson, Katherine A. (2001). "Team Training in the Skies: Does Crew Resource Management (CRM) Training Work?".
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had entered a stall. The aircraft crashed into a highway and residential area, and exploded, killing all 196 people on board, as well as six people on the ground.
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Earl, Laurie; Bates, Paul R.; Murray, Patrick S.; Glendon, A. Ian; Creed, Peter A. (January 2012). "Developing a Single-Pilot Line Operations Safety Audit".
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during the crew's second go-around attempt, killing 35 of the 74 people on board. The crew had unknowingly violated landing procedures, due to heavy weather.
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did not gain enough lift on takeoff and crashed into the ground, killing all but one of the 155 people on board, as well as two people on the ground. The
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influence the actions of pilots is now considered standard practice by accident investigators when examining the chain of events that led to an accident.
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number 2 power lever was at idle, which led to an asymmetrical power condition. The plane crashed on descent to Guilin Airport, killing all 141 on board.
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and deviations from flight course, to more severe errors such as exceeding maximum structural speeds or forgetting to put down landing or takeoff flaps.
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due to pilot error. The aircraft exceeded the climb rate, way beyond its operational limits. All 155 passengers and 7 crew members on board were killed.
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caused by taking the wrong taxiing route (red instead of green), as control tower had not given clear instructions. The accident occurred in thick fog.
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Stacey, Daniel (15 January 2015). "Indonesian Air-Traffic Control Is Unsophisticated, Pilots Say". The Wall Street Journal. Retrieved 26 January 2015
790:: a member of an Italian aerobatic team misjudged a maneuver, causing a mid-air collision. Three pilots and 67 spectators on the ground were killed. 2009:
Helmreich, Robert L.; Merritt, Ashleigh C.; Wilhelm, John A. (1999). "The Evolution of Crew Resource Management Training in Commercial Aviation".
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Pilot’s Handbook of Aeronautical Knowledge (2016). U.S. Department of Transportation. Federal Aviation Administration, Flight Standards Service
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defines the term "accident" as "an occurrence associated with the operation of an aircraft in which a person is fatally or seriously injured
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Li, Guohua; Baker, Susan P.; Grabowski, Jurek G.; Rebok, George W. (February 2001). "Factors Associated With Pilot Error in Aviation Crashes".
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crashed after an attempted take-off with the flaps retracted, killing 63 of the 100 occupants on the plane as well as two people on the ground.
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failed to deploy the MD-82's flaps and slats. The flight crashed after takeoff, killing 154 out of the 172 passengers and crew on board.
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Mizzi, Andrew; Mccarthy, Pete (2023). "Resilience Engineering's synergy with Threat and Error Management - an operationalised model".
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not realize that they were at a dangerously low altitude and the plane was about to impact terrain until two seconds before the crash.
302:(LOSA), implementation of crew resource management (CRM), cockpit task management (CTM), and the integrated use of checklists in both 691:, having been distracted by their own attempts to solve a problem with the landing gear. Out of 176 occupants, 75 survived the crash. 524: 193: 1494: 2258: 966: 943: 928: 873: 25: 1403: 1320: 532:
most modern aircraft operation systems, ensure the pilot remains vigilant, and in turn, aims to reduce the risk of pilot error.
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Hence the definition of "pilot error" does not include deliberate crashing (and such crashes are not classified as accidents).
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crashed into a residential house due to spatial disorientation. 37 passengers were killed and the airplane was destroyed.
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One of the most famous examples of an aircraft disaster that was attributed to pilot error was the night-time crash of
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crash is now used in military and civilian aviation environments as a case study in teaching crew resource management.
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in Tegucigalpa, Honduras, because of a bad landing procedure by the pilot, killing 131 of the 146 passengers and crew.
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crew members how to handle concurrent tasks which compete for their attention. This includes the following processes:
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diversification of scope and an emphasis on training crews in how they must function both in and out of the cockpit.
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descended too low and crashed into a nearby forest; all of the occupants were killed, including Polish president
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ran out of fuel hundreds of miles off-course above the Amazon jungle. Thirteen died in the ensuing crash landing.
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Hales, Brigette M.; Pronovost, Peter J. (2006). "The Checklist -- A Tool for Error Management and Performance".
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Since the implementation of CRM circa 1979, following the need for increased research on resource management by
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accident is that an instructor can control the amount of fuel in simulator training so that it never runs out.
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Task interruption – suspension of lower priority tasks for resources to be allocated to higher priority tasks
283: 1217:. This caused the aircraft to break up in mid air and crash into the water, killing all 102 people on board. 634: 1380: 1361: 1316: 1304: 1060: 912: 680: 582: 541: 95: 1960: 869:. The pilots eventually recovered the plane, but it crashed into a forest, killing all 75 people on board. 1443: 1221: 958: 885: 794: 746: 515: 294: 226: 137:
The "three-pointer" design altimeter is one of the most prone to being misread by pilots (a cause of the
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caused by failure to switch the cabin pressurization to "Auto" during the pre-flight preparations. The
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Dekker, Sidney; LundstrΓΆm, Johan (May 2007). "From Threat and Error Management (TEM) to Resilience".
1210: 1153: 1138: 1123: 989: 982: 787: 757: 695: 382:– clear and accurate sending and receiving of information, instructions, commands and useful feedback 125: 1990:
Myers, Charles; Orndorff, Denise (2013). "Crew Resource Management: Not Just for Aviators Anymore".
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omitted their taxi checklist and failed to deploy the aircraft's flaps and slats. Subsequently, the
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Foyle, D. C., & Hooey, B. L. (Eds.). (2007). Human performance modeling in aviation. CRC Press.
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in Fairchild Air Force Base. The crash was largely attributed to the personality and behavior of
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acknowledges that human error is inevitable and provides information to improve safety standards.
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CRM integrated procedure into training, allowing organizations to tailor training to their needs.
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Aircraft Accident Investigation Report of Indonesian's National Transportation Safety Committee
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Chou, Chung-Di; Madhavan, Das; Funk, Ken (1996). "Studies of Cockpit Task Management Errors".
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Resource allocation – assignment of human and machine resources to tasks which need completion
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pilot failed to hear, understand or follow instructions from the control tower, causing two
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perspectives in aviation. The International Journal of Aviation Psychology, 11(4), 341–357.
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in 1993 in an effort to better understand the role of human factors in aviation accidents.
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shortly after takeoff, killing all 148 people on board. The captain had been experiencing
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emphasized individual psychology and testing, where corrections could be made to behavior.
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Canadian Aviation Safety Seminar (CASS); Flight Safety and Human Factors Programme – ICAO
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encountered heavy turbulence and the co-pilot over-applied the rudder pedal, turning the
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during the flight, and may have been interrupted by a passenger at the time of the crash.
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Stanhope, N.; Crowley-Murphy, M. (1999). "An evaluation of adverse incident reporting".
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accidents, and as the primary cause of 75.5% of general aviation accidents overall. For
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primarily related to operational and behavioral mishaps. Errors can vary from incorrect
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killing 128 of the 166 people on board. The pilot and co-pilot had been flying too low.
684: 400:– ability to perceive the environment within time and space, and comprehend its meaning 246: 222: 157: 1119:. The NTSB concluded that "the flight crew did not monitor and maintain minimum speed. 500: 2201: 2152: 2072: 2064: 2026: 1837: 1833: 1802: 1775: 1681: 1594: 1413: 1373: 1157: 1131: 905: 897: 607: 2084: 1723: 2226: 2191: 2183: 2144: 2112: 2056: 2018: 1903: 1829: 1765: 1757: 1711: 1671: 1663: 1285: 1146: 1042: 816: 718: 570: 307: 254:
interruptions, ground maintenance errors, and inadequacies of manuals and charts."
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for increased lift. Of the 108 passengers and crew on board, fourteen were killed.
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investigation concluded that See had been flying too low on his landing approach.
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incident or crash. Apart from checklists issued by regulatory bodies such as the
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Specific behaviors known to be associated with aviation accidents and incidents
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Error Management (OGHFA BN). Operator's Guide to Human Factors in Aviation.
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ignored automatic warnings and attempted a risky landing in heavy fog. The
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Mission analysis – ability to develop short and long term contingency plans
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Rural and Regional Affairs and Transport References Committee (May 2013).
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was a four-year-old girl named Cecelia Cichan, who was seriously injured.
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there is a correlation between CRM programs and better risk management.
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after the flight crew failed to notice the deactivation of the plane's
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Task prioritization – relative to the importance and urgency for safety
385: 192:
accountable for their fatigue, work pressure, or lack of training. The
2170:
Cavanagh, James F.; Frank, Michael J.; Allen, John J.B. (April 2010).
133: 1180: 1176: 862: 688: 641: 597: 550: 264: 1590:
Investigating Human Error: Incidents, Accidents, and Complex Systems
21: 750: 707: 554:
losing height and the aircraft eventually struck the ground in the
150: 1518:
How exactly should I understand the term "accidental hull loss"?.
1034:
flight, but did continue to fly after weather conditions obscured
1418: 1127: 630: 626: 2172:"Social Stress Reactivity Alters Reward and Punishment Learning" 1942:
Maurino, Dan (April 2005). "Threat and Error Management (TEM)".
569:, pilot error was listed as the primary cause of 78.6% of fatal 196:(ICAO), and its member states, therefore adopted James Reason's 1343: 611: 965:, crashed into a ravine, killing all 234 people on board. The 1098: 558:, killing 101 of the 176 passengers and crew. The subsequent 2252:"Aircraft Accident Investigation Report KNKT/07.01/08.01.36" 842:
including both flight crew. 54 occupants survived the crash.
666: 615: 614:, crashed as a result of a controlled flight into terrain ( 604: 414: 492:
Task termination – the completion or incompletion of tasks
170:
except when the injuries are inflicted by other persons."
99:
Departure/destination airports and crash site location of
1171:
unknowingly (and dangerously) decreased the speed of the
699: 489:
Task resumption – continuing previously interrupted tasks
340:
How crew members manage these errors (action or inaction)
1164:
crashed after running out of fuel, killing all on board.
477:
Task monitoring – assessment of task progress and status
160:
that is a substantial contributing factor leading to an
2008: 1338:
crashed onto a motorway while on its final approach to
981:
home-built aircraft crashed into the Pacific Ocean off
797:
crashed on takeoff after the crew forgot to deploy the
408: 241:
The term "threat" is defined as any event "external to
32: 2298:
Airliner accidents and incidents caused by pilot error
2046: 1819: 1747: 321: 1792: 596:
after the pilot became lost in a heavy fog bank over
808:, a fan blade broke off in the left engine of a new 430:
featured a shift in focus to cockpit group dynamics.
289: 156:
generally refers to an action or decision made by a
1041:31 August 1999 – Lineas AΓ©reas Privadas Argentinas 474:
Task initiation – when appropriate conditions exist
2169: 1273:. All 216 passengers and twelve crew members died. 1082:crashed into a forest on approach to runway 28 at 16:Decision, action, or inaction by an aircraft pilot 1300:, and numerous government and military officials. 1235:: the thrust reverser on the right engine of the 351: 334:How the threats are addressed by the crew members 2289: 2105:The International Journal of Aviation Psychology 2102: 2011:The International Journal of Aviation Psychology 1704:The International Journal of Aviation Psychology 1612: 1610: 456: 1882: 1857:Wiegmann, D. A., & Shappell, S. A. (2001). 1353:tail struck the seawall short of runway 28L at 581:28 July 1945 – A United States Army Air Forces 2134: 737:with 79 passengers and crew, crashed into the 1989: 1901: 1885:Journal of Human Factors and Aerospace Safety 1750:Aviation Psychology and Applied Human Factors 1607: 942:, crashed into Nimitz Hill, three miles from 1656:"On Error Management: Lessons From Aviation" 1372:crashed into the Java Sea as a result of an 1269:failures and improper control inputs by the 1030:". Kennedy did not hold a certification for 2176:Social Cognitive and Affective Neuroscience 1795:Aviation, Space, and Environmental Medicine 1209:were preoccupied with a malfunction of the 1822:Journal of Evaluation in Clinical Practice 1108:25 October 2002 – Eight people, including 2195: 1769: 1675: 1653: 1544:. January 2016. Chapter 2. Human behavior 1198:failed to become airborne and crashed at 194:International Civil Aviation Organization 2259:National Transportation Safety Committee 819:made a series of mistakes so that their 499: 460: 312:airborne collision and avoidance systems 211: 132: 119: 107: 31: 26:1994 Fairchild Air Force Base B-52 crash 20: 1941: 1404:Environmental causes of aviation stress 1156:lost consciousness, most likely due to 663:Lambert–St. Louis International Airport 2290: 2042: 2040: 1992:Journal of Applied Learning Technology 1701: 1654:Helmreich, Robert L. (18 March 2000). 58: 2263:Indonesian Ministry of Transportation 2130: 2128: 2126: 2098: 2096: 2094: 1985: 1983: 1981: 1961:"Line Operations Safety Audit (LOSA)" 1955: 1953: 1878: 1876: 1853: 1851: 1743: 1741: 1739: 1737: 1735: 1733: 1697: 1695: 1649: 1647: 1561: 1559: 1529: 1527: 1261:entered a stall and crashed into the 994:Chiang Kai-Shek International Airport 888:, a certification test flight of the 72: 1280:: during a descent towards Russia's 560:National Transportation Safety Board 409:Application and effectiveness of CRM 2037: 1355:San Francisco International Airport 925:China Southern Airlines Flight 3456 847:China Southern Airlines Flight 3943 535: 322:Line operations safety audit (LOSA) 86: 13: 2123: 2091: 1978: 1950: 1873: 1848: 1730: 1692: 1644: 1568:"Aviation Accident Investigations" 1556: 1524: 1278:2010 Polish Air Force Tu-154 crash 1183:, killing all 160 people on board. 270: 14: 2314: 1169:West Caribbean Airways Flight 708 290:Threat and error management (TEM) 2265:. 1 January 2007. Archived from 1834:10.1046/j.1365-2753.1999.00146.x 1409:Human factors in aviation safety 1284:, the flight crew of the Polish 316:ground proximity warning systems 221:, workload, and fear as well as 85: 71: 57: 50: 2244: 2212: 2163: 2002: 1935: 1895: 1864: 1813: 1786: 1542:Federal Aviation Administration 1439:Stress in the aviation industry 1152:14 August 2005 – The pilots of 832:Toncontin International Airport 815:3 September 1989 – The crew of 756:19 February 1985 – The crew of 721:instructor captain allowed his 337:The errors the threats generate 40:from departure to crash point ( 1635: 1581: 1512: 1500: 1487: 1465: 1399:Controlled flight into terrain 1326:28 July 2010 – The captain of 1115:, were killed in a crash near 745:shortly after taking off from 352:Crew resource management (CRM) 186: 42:controlled flight into terrain 1: 1459: 1429:Sensory illusions in aviation 1370:Indonesia AirAsia Flight 8501 1243:20 August 2008 – The crew of 1205:1 January 2007 – The crew of 1167:16 August 2005 – The crew of 1050:Singapore Airlines Flight 006 977:died when his newly-acquired 773:Northwest Airlines Flight 255 771:16 August 1987 – The crew of 508: 457:Cockpit task management (CTM) 2220:"2005 Joseph T. Nall Report" 1908:10.1007/978-3-031-35392-5_36 1662:. 320–7237 (7237): 781–785. 1660:BMJ: British Medical Journal 1593:. Ashgate Publishing. 2004. 1381:TransAsia Airways Flight 235 1362:TransAsia Airways Flight 222 1317:Air India Express Flight 812 1305:Afriqiyah Airways Flight 771 1061:American Airlines Flight 587 913:American Airlines Flight 965 706:to collide on the runway at 681:Eastern Air Lines Flight 401 542:Eastern Air Lines Flight 401 300:line operations safety audit 227:interpersonal communications 36:Actual flight path (red) of 7: 2117:10.1207/s15327108ijap0604_1 2023:10.1207/s15327108ijap0901_2 1716:10.1207/s15327108ijap1402_6 1444:Threat and error management 1387: 1222:Garuda Indonesia Flight 200 959:Garuda Indonesia Flight 152 927:crashed into the runway at 886:Airbus Industrie Flight 129 795:Delta Air Lines Flight 1141 747:Washington National Airport 592:into the 79th floor of the 446:Fifth generation (current): 331:Potential threats to safety 10: 2321: 2149:10.1016/j.jcrc.2006.06.002 2061:10.1518/001872001775870386 1535:"Risk management handbook" 1351:Asiana Airlines Flight 214 992:was attempting to land at 944:Guam International Airport 929:Shenzhen Huangtian Airport 839:Indian Airlines Flight 605 715:United Airlines Flight 173 274: 236: 1762:10.1027/2192-0923/a000027 1211:inertial reference system 1154:Helios Airways Flight 522 1124:Flash Airlines Flight 604 990:China Airlines Flight 676 983:Pacific Grove, California 973:12 October 1997 – Singer 830:crashed into a hill near 788:Ramstein airshow disaster 758:China Airlines Flight 006 696:Tenerife airport disaster 257: 126:Tenerife airport disaster 2137:Journal of Critical Care 1668:10.1136/bmj.320.7237.781 1454:Kenya Airways Flight 507 1233:TAM Airlines Flight 3054 1226:crew resource management 894:Toulouse-Blagnac Airport 861:, crashed on its way to 804:8 January 1989 – In the 1575:Government of Australia 1520:Aviation stack overflow 1319:overshot the runway at 1173:McDonnell Douglas MD-82 777:McDonnell Douglas MD-82 659:crashed into a building 654:were killed when their 575:scheduled air transport 179:Accounting for the way 114:Linate Airport disaster 1923:Cite journal requires 1622:www.planecrashinfo.com 1434:Spatial disorientation 1282:Smolensk North Airport 1252:Colgan Air Flight 3407 1028:spatial disorientation 954:was a possible factor. 760:lost control of their 741:and careened into the 665:during bad weather. A 505: 466: 231:information processing 146: 130: 117: 45: 29: 1618:"Accident statistics" 1540:(Change 1 ed.). 1259:Air France Flight 447 1137:26 February 2004 – A 936:Korean Air Flight 801 806:Kegworth air disaster 786:28 August 1988 – The 731:Air Florida Flight 90 594:Empire State Building 503: 464: 398:Situational awareness 277:Pilot decision making 212:Causes of pilot error 136: 123: 111: 35: 24: 1475:. Go Flight Medicine 1340:Petrozavodsk Airport 1091:Air China Flight 129 1080:Crossair Flight 3597 1005:John F. Kennedy, Jr. 957:26 September 1997 - 828:Tan-Sahsa Flight 414 694:27 March 1977 – The 96:class=notpageimage| 2188:10.1093/scan/nsq041 1368:28 December 2014 - 1250:12 February 2009 – 1245:Spanair Flight 5022 1207:Adam Air Flight 574 1078:24 November 2001 – 1059:12 November 2001 – 1014:, crashed into the 988:16 February 1998 – 911:20 December 1995 – 855:Aeroflot Flight 593 845:24 November 1992 – 837:14 February 1990 – 713:28 December 1978 – 679:29 December 1972 – 674:Alitalia Flight 112 640:28 February 1966 – 603:24 December 1958 – 565:During 2004 in the 284:AirAsia Flight 8501 251:air traffic control 2232:on 2 February 2007 1379:6 February 2015 – 1336:RusAir Flight 9605 1328:Airblue Flight 202 1200:Blue Grass Airport 1196:Comair Flight 5191 1188:Armavia Flight 967 1117:Eveleth, Minnesota 1048:31 October 2000 – 1043:(LAPA) flight 3142 1010:when his plane, a 826:21 October 1989 – 739:14th Street Bridge 729:13 January 1982 – 685:Florida Everglades 610:312, registration 506: 467: 440:Fourth generation: 428:Second generation: 247:weather conditions 223:cognitive overload 198:model of causation 166:Chicago Convention 162:aviation accident. 147: 131: 118: 46: 30: 1414:Human reliability 1374:aerodynamic stall 1321:Mangalore Airport 1194:27 August 2006 – 1122:3 January 2004 – 1020:Martha's Vineyard 1018:off the coast of 906:USAir Flight 1016 898:center of gravity 793:31 August 1988 – 683:crashed into the 621:3 January 1961 – 608:Bristol Britannia 422:First generation: 265:altimeter setting 2310: 2283: 2281: 2279: 2277: 2271: 2256: 2248: 2242: 2241: 2239: 2237: 2231: 2225:. Archived from 2224: 2216: 2210: 2209: 2199: 2167: 2161: 2160: 2132: 2121: 2120: 2100: 2089: 2088: 2044: 2035: 2034: 2006: 2000: 1999: 1987: 1976: 1975: 1973: 1971: 1957: 1948: 1947: 1939: 1933: 1932: 1926: 1921: 1919: 1911: 1899: 1893: 1892: 1880: 1871: 1868: 1862: 1855: 1846: 1845: 1817: 1811: 1810: 1790: 1784: 1783: 1773: 1745: 1728: 1727: 1699: 1690: 1689: 1679: 1651: 1642: 1639: 1633: 1632: 1630: 1628: 1614: 1605: 1604: 1585: 1579: 1578: 1572: 1563: 1554: 1553: 1551: 1549: 1539: 1531: 1522: 1516: 1510: 1504: 1498: 1491: 1485: 1484: 1482: 1480: 1469: 1286:presidential jet 1276:10 April 2010 – 1147:Boris Trajkovski 1089:15 April 2002 – 1036:visual landmarks 934:6 August 1997 – 853:23 March 1994 – 817:Varig Flight 254 719:flight simulator 635:were intoxicated 571:general aviation 536:Notable examples 434:Third evolution: 308:general aviation 101:Varig Flight 254 89: 88: 75: 74: 61: 60: 54: 2320: 2319: 2313: 2312: 2311: 2309: 2308: 2307: 2288: 2287: 2286: 2275: 2273: 2272:on 16 July 2011 2269: 2254: 2250: 2249: 2245: 2235: 2233: 2229: 2222: 2218: 2217: 2213: 2168: 2164: 2133: 2124: 2101: 2092: 2045: 2038: 2007: 2003: 1988: 1979: 1969: 1967: 1959: 1958: 1951: 1940: 1936: 1924: 1922: 1913: 1912: 1900: 1896: 1881: 1874: 1869: 1865: 1856: 1849: 1818: 1814: 1791: 1787: 1746: 1731: 1700: 1693: 1652: 1645: 1640: 1636: 1626: 1624: 1616: 1615: 1608: 1601: 1587: 1586: 1582: 1570: 1564: 1557: 1547: 1545: 1537: 1533: 1532: 1525: 1517: 1513: 1505: 1501: 1492: 1488: 1478: 1476: 1471: 1470: 1466: 1462: 1390: 1360:23 July 2014 – 1334:20 June 2011 – 1298:Maria Kaczynska 1290:Tupolev Tu-154M 1231:17 July 2007 – 1220:7 March 2007 – 1215:loss of control 1126:dived into the 1097:, crashed near 1069:wake turbulence 1003:16 July 1999 – 890:Airbus A330-300 884:30 June 1994 – 872:24 June 1994 – 859:Airbus A310-300 652:Charles Bassett 623:Aero Flight 311 538: 516:memory function 511: 459: 411: 365:Decision making 354: 324: 292: 279: 273: 271:Decision making 260: 239: 214: 189: 106: 105: 104: 98: 92: 91: 90: 82: 81: 80: 76: 68: 67: 66: 62: 17: 12: 11: 5: 2318: 2317: 2306: 2305: 2303:Aviation risks 2300: 2285: 2284: 2243: 2211: 2182:(3): 311–320. 2162: 2143:(3): 231–235. 2122: 2111:(4): 307–320. 2090: 2055:(4): 641–674. 2036: 2001: 1977: 1949: 1934: 1925:|journal= 1894: 1872: 1863: 1847: 1812: 1785: 1729: 1710:(2): 207–231. 1691: 1643: 1634: 1606: 1599: 1580: 1555: 1523: 1511: 1499: 1486: 1463: 1461: 1458: 1457: 1456: 1451: 1446: 1441: 1436: 1431: 1426: 1421: 1416: 1411: 1406: 1401: 1396: 1389: 1386: 1385: 1384: 1377: 1366: 1358: 1349:6 July 2013 – 1347: 1332: 1324: 1315:22 May 2010 – 1313: 1303:12 May 2010 – 1301: 1294:Lech Kaczynski 1274: 1263:Atlantic Ocean 1257:1 June 2009 – 1255: 1248: 1241: 1229: 1218: 1203: 1192: 1184: 1165: 1162:Boeing 737-300 1150: 1135: 1120: 1113:Paul Wellstone 1106: 1095:Boeing 767-200 1087: 1084:Zurich Airport 1076: 1073:pilot training 1057: 1054:Boeing 747-412 1046: 1039: 1016:Atlantic Ocean 1012:Piper Saratoga 1001: 986: 971: 955: 940:Boeing 747-300 932: 921: 917:Boeing 757-200 909: 904:2 July 1994 – 902: 882: 870: 851: 843: 835: 824: 813: 810:Boeing 737-400 802: 791: 784: 769: 754: 735:Boeing 737-200 727: 711: 692: 677: 670: 638: 619: 601: 587:Newark Airport 546:Miami, Florida 537: 534: 510: 507: 494: 493: 490: 487: 484: 481: 478: 475: 458: 455: 450: 449: 443: 437: 431: 425: 410: 407: 402: 401: 395: 389: 383: 377: 374: 368: 353: 350: 345: 344: 341: 338: 335: 332: 323: 320: 291: 288: 275:Main article: 272: 269: 259: 256: 238: 235: 213: 210: 188: 185: 94: 93: 84: 83: 78: 77: 70: 69: 65:Maraba Airport 64: 63: 56: 55: 49: 48: 47: 15: 9: 6: 4: 3: 2: 2316: 2315: 2304: 2301: 2299: 2296: 2295: 2293: 2268: 2264: 2260: 2253: 2247: 2228: 2221: 2215: 2207: 2203: 2198: 2193: 2189: 2185: 2181: 2177: 2173: 2166: 2158: 2154: 2150: 2146: 2142: 2138: 2131: 2129: 2127: 2118: 2114: 2110: 2106: 2099: 2097: 2095: 2086: 2082: 2078: 2074: 2070: 2066: 2062: 2058: 2054: 2050: 2049:Human Factors 2043: 2041: 2032: 2028: 2024: 2020: 2016: 2012: 2005: 1997: 1993: 1986: 1984: 1982: 1966: 1962: 1956: 1954: 1945: 1938: 1930: 1917: 1909: 1905: 1898: 1890: 1886: 1879: 1877: 1867: 1860: 1854: 1852: 1843: 1839: 1835: 1831: 1827: 1823: 1816: 1808: 1804: 1800: 1796: 1789: 1781: 1777: 1772: 1767: 1763: 1759: 1755: 1751: 1744: 1742: 1740: 1738: 1736: 1734: 1725: 1721: 1717: 1713: 1709: 1705: 1698: 1696: 1687: 1683: 1678: 1673: 1669: 1665: 1661: 1657: 1650: 1648: 1638: 1623: 1619: 1613: 1611: 1602: 1596: 1592: 1591: 1584: 1576: 1569: 1562: 1560: 1543: 1536: 1530: 1528: 1521: 1515: 1509: 1503: 1496: 1490: 1474: 1468: 1464: 1455: 1452: 1450: 1447: 1445: 1442: 1440: 1437: 1435: 1432: 1430: 1427: 1425: 1424:Pilot fatigue 1422: 1420: 1417: 1415: 1412: 1410: 1407: 1405: 1402: 1400: 1397: 1395: 1392: 1391: 1382: 1378: 1375: 1371: 1367: 1363: 1359: 1356: 1352: 1348: 1345: 1341: 1337: 1333: 1329: 1325: 1322: 1318: 1314: 1310: 1309:sole survivor 1306: 1302: 1299: 1295: 1291: 1287: 1283: 1279: 1275: 1272: 1271:first officer 1268: 1264: 1260: 1256: 1253: 1249: 1246: 1242: 1238: 1234: 1230: 1227: 1223: 1219: 1216: 1212: 1208: 1204: 1201: 1197: 1193: 1189: 1186:3 May 2006 – 1185: 1182: 1178: 1174: 1170: 1166: 1163: 1159: 1155: 1151: 1148: 1144: 1140: 1136: 1133: 1129: 1125: 1121: 1118: 1114: 1111: 1107: 1104: 1100: 1096: 1092: 1088: 1085: 1081: 1077: 1074: 1070: 1066: 1062: 1058: 1055: 1051: 1047: 1044: 1040: 1037: 1033: 1029: 1025: 1024:Massachusetts 1021: 1017: 1013: 1009: 1006: 1002: 999: 995: 991: 987: 984: 980: 979:Rutan Long-EZ 976: 972: 968: 964: 960: 956: 953: 952:pilot fatigue 949: 945: 941: 937: 933: 930: 926: 923:8 May 1997 – 922: 918: 914: 910: 907: 903: 899: 895: 892:, crashed at 891: 887: 883: 879: 875: 871: 868: 864: 860: 856: 852: 848: 844: 840: 836: 833: 829: 825: 822: 818: 814: 811: 807: 803: 800: 796: 792: 789: 785: 782: 781:sole survivor 778: 774: 770: 767: 766:Pacific Ocean 763: 759: 755: 752: 748: 744: 743:Potomac River 740: 736: 732: 728: 724: 720: 716: 712: 709: 705: 701: 697: 693: 690: 686: 682: 678: 675: 672:5 May 1972 - 671: 668: 664: 660: 657: 653: 649: 646: 643: 639: 636: 632: 628: 625:crashed near 624: 620: 617: 613: 609: 606: 602: 599: 595: 591: 588: 584: 580: 579: 578: 576: 572: 568: 567:United States 563: 561: 557: 552: 547: 543: 533: 530: 526: 522: 517: 502: 498: 491: 488: 485: 482: 479: 476: 473: 472: 471: 463: 454: 447: 444: 441: 438: 435: 432: 429: 426: 423: 420: 419: 418: 416: 406: 399: 396: 393: 390: 387: 384: 381: 380:Communication 378: 375: 372: 371:Assertiveness 369: 366: 363: 362: 361: 358: 349: 342: 339: 336: 333: 330: 329: 328: 319: 317: 313: 309: 305: 301: 296: 287: 285: 278: 268: 266: 255: 252: 248: 244: 234: 232: 228: 224: 220: 209: 207: 206:United States 201: 199: 195: 184: 182: 181:human factors 177: 173: 171: 167: 163: 159: 155: 154:, pilot error 152: 144: 140: 135: 127: 122: 115: 110: 102: 97: 79:Belem Airport 53: 43: 39: 34: 27: 23: 19: 2274:. Retrieved 2267:the original 2246: 2234:. Retrieved 2227:the original 2214: 2179: 2175: 2165: 2140: 2136: 2108: 2104: 2052: 2048: 2017:(1): 19–32. 2014: 2010: 2004: 1995: 1991: 1968:. Retrieved 1964: 1943: 1937: 1916:cite journal 1897: 1888: 1884: 1866: 1825: 1821: 1815: 1801:(1): 52–58. 1798: 1794: 1788: 1756:(2): 49–61. 1753: 1749: 1707: 1703: 1659: 1637: 1625:. Retrieved 1621: 1589: 1583: 1546:. Retrieved 1514: 1502: 1489: 1477:. Retrieved 1467: 1110:U.S. Senator 874:B-52 crashes 762:Boeing 747SP 723:Douglas DC-8 564: 539: 528: 512: 495: 468: 451: 445: 439: 433: 427: 421: 412: 403: 392:Adaptability 355: 346: 325: 299: 293: 280: 261: 240: 229:, imperfect 215: 202: 190: 178: 174: 169: 153: 148: 38:TWA Flight 3 18: 2236:12 February 1998:(3): 44–48. 1891:(70): 1–10. 1859:Human error 1828:(1): 5–12. 1771:10072/49214 1548:16 November 1342:in western 1296:, his wife 1237:Airbus A320 1103:South Korea 1065:Airbus A300 998:Airbus A300 975:John Denver 963:Airbus A300 704:Boeing 747s 698:: a senior 583:B-25 bomber 314:(ACAS) and 243:flight crew 187:Description 139:UA 389 112:Map of the 2292:Categories 1627:21 October 1600:0754641228 1479:13 October 1460:References 1449:User error 1394:Airmanship 1267:pitot tube 1265:following 1191:awareness. 1145:President 1143:Macedonian 821:Boeing 737 656:T-38 Talon 648:Elliot See 645:astronauts 585:bound for 556:Everglades 509:Checklists 386:Leadership 304:commercial 2069:0018-7208 1970:24 August 1780:2192-0923 1181:Venezuela 1177:Machiques 1141:carrying 1139:Beech 200 970:accident. 867:flat spin 863:Hong Kong 764:over the 689:autopilot 598:Manhattan 551:autopilot 145:crashes). 129:taxiways. 2206:20453038 2157:16990087 2085:23109802 2077:12002012 2031:11541445 1965:SKYbrary 1842:10468379 1807:11194994 1724:15271960 1686:10720367 1508:Skybrary 1388:See also 751:de-icing 708:Tenerife 642:American 151:aviation 2197:3110431 1677:1117774 1419:Jet lag 1240:ground. 1224:: poor 1158:hypoxia 1132:vertigo 1128:Red Sea 753:system. 631:Finland 627:Kvevlax 590:crashed 529:IM SAFE 237:Threats 225:, poor 219:fatigue 2276:8 June 2204:  2194:  2155:  2083:  2075:  2067:  2029:  1840:  1805:  1778:  1722:  1684:  1674:  1597:  1344:Russia 1331:board. 1052:was a 878:Lt Col 612:G-AOVD 258:Errors 143:G-AOVD 2270:(PDF) 2255:(PDF) 2230:(PDF) 2223:(PDF) 2081:S2CID 1720:S2CID 1571:(PDF) 1538:(PDF) 1099:Busan 961:, an 950:said 857:, an 799:flaps 544:near 158:pilot 2278:2013 2238:2007 2202:PMID 2153:PMID 2073:PMID 2065:ISSN 2027:PMID 1972:2016 1929:help 1838:PMID 1803:PMID 1776:ISSN 1682:PMID 1629:2015 1595:ISBN 1550:2018 1481:2014 1093:, a 1071:and 1008:died 967:NTSC 948:NTSB 938:, a 915:, a 733:, a 717:: a 667:NASA 650:and 616:CFIT 605:BOAC 525:ICAO 415:NASA 306:and 141:and 124:The 2192:PMC 2184:doi 2145:doi 2113:doi 2057:doi 2019:doi 1904:doi 1889:260 1830:doi 1766:hdl 1758:doi 1712:doi 1672:PMC 1664:doi 1495:pdf 1032:IFR 700:KLM 661:at 523:or 521:FAA 357:CRM 295:TEM 149:In 2294:: 2261:, 2257:. 2200:. 2190:. 2178:. 2174:. 2151:. 2141:21 2139:. 2125:^ 2107:. 2093:^ 2079:. 2071:. 2063:. 2053:43 2051:. 2039:^ 2025:. 2013:. 1994:. 1980:^ 1963:. 1952:^ 1920:: 1918:}} 1914:{{ 1887:. 1875:^ 1850:^ 1836:. 1824:. 1799:72 1797:. 1774:. 1764:. 1752:. 1732:^ 1718:. 1708:14 1706:. 1694:^ 1680:. 1670:. 1658:. 1646:^ 1620:. 1609:^ 1573:. 1558:^ 1526:^ 1179:, 1101:, 1022:, 629:, 249:, 2280:. 2240:. 2208:. 2186:: 2180:6 2159:. 2147:: 2119:. 2115:: 2109:6 2087:. 2059:: 2033:. 2021:: 2015:9 1996:3 1974:. 1946:. 1931:) 1927:( 1910:. 1906:: 1844:. 1832:: 1826:5 1809:. 1782:. 1768:: 1760:: 1754:2 1726:. 1714:: 1688:. 1666:: 1631:. 1603:. 1577:. 1552:. 1497:. 1483:. 1075:. 1038:.

Index


1994 Fairchild Air Force Base B-52 crash

TWA Flight 3
controlled flight into terrain
The locations of the accident and departure airports shown on a map of Brazil.
class=notpageimage|
Varig Flight 254

Linate Airport disaster

Tenerife airport disaster

UA 389
G-AOVD
aviation
pilot
aviation accident.
Chicago Convention
human factors
International Civil Aviation Organization
model of causation
United States
fatigue
cognitive overload
interpersonal communications
information processing
flight crew
weather conditions
air traffic control

Text is available under the Creative Commons Attribution-ShareAlike License. Additional terms may apply.

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