Human Factors in Aviation

• Loss of situational awareness: When dealing with one emergency issue aboard an aircraft it is easy to forget to maintain awareness of other potential issues. For example, the 1978 United Airlines Flight 173 Portland, Oregon crash occurred when the crew was so distracted while attempting to diagnose an issue with the landing gear that they failed to realize they were running out of fuel. This type of pilot error is also present in many controlled flights into terrain, such as the 1995 American Airlines Flight 965 crash where the crew failed to notice their navigational errors and forgot that they had deployed the air brakes, which led the plane to crash into a mountain in Colombia.
  
  The July 6, 2013 crash of Asiana Airlines Flight 214 at SFO is another prime example, a case in which we represent numerous passengers. In this case, the pilots failed to properly monitor the landing approach, became fixated on instruments, did not fully understand how the auto-throttle worked (a potential design defect) and did not notice that the auto-throttle was maintaining too-low airspeed and dangerous deviation below the intended glide slope. The crew failed to look out the cockpit windows to see that they could not safely land, all of which led to a catastrophic crash onto the runway.
• Crew coordination: In the aviation industry, this area is usually referred to as crew resource management or CRM. Captains must respect the first officer and acknowledge mistakes or warnings addressed by the first officer (setting aside their own pride). First officers must not be intimidated by the captain and must call attention to problems. When communication between flight crew members breaks down the results are often devastating. One incident that exemplifies this human error is the 1982 Air Florida Flight 90 crash, in which the co-pilot tried three times to warn the pilot of issues regarding ice on the wings and low speeds but was ignored or told he was incorrect each time. The plane crashed into the 14th Street Bridge over the Potomac River, two miles from the White House.
• Lack of proper training: Airlines are responsible for ensuring their pilots and crew have the training needed to properly operate whatever aircraft they are tasked with operating. Yet, many pilots are not necessarily trained on all aspects of a particular plane. This came up as another human factors issue in the crash of Asiana Airlines Flight 214 at SFO. The NTSB determined the probable cause of the crash stemmed, in large part, from the human factors of pilot error and flight crew mismanagement. Asiana’s training was faulted for contributing to the accident since the airline had a policy to always use full automation, discouraging manual flight operations. This led the pilots of Flight 214 to be over-reliant on the automated system and thus unable to properly diagnose or correct the issue when their plane came in for landing too low and slow. Proper training must ingrain efficient and safe CRM principles.
• Fatigue: Fatigue is one of the most commonly reoccurring human factors in aviation. Yet, it is one of the most difficult to combat, because the solutions tend to impact airline profits. Over the years airlines have consistently pushed pilots and flight crew to work longer hours with shorter turnaround time, often forcing the pilots and crew to have the bare minimum of rest hours available to them between flights. Airlines often close their eyes to the difficulties that flight crews experience in the effort to actually get the needed rest. Even though they know crew members are constantly operating on unusual schedules in different cities and time zones each day, and have tight schedules that provide for minimum rest opportunity, airlines often choose to simply believe that every hour off duty means adequate rest. Many plane crashes officially blamed on pilot error are truly caused by pilot fatigue that led to pilot error.
• Checklists: Checklists are made to be followed. Whenever pre-flight and pre-landing checklists are skimmed or skipped entirely in order to make up time or because the flight crew feels it is unnecessary, the risk for a potential accident grows. In the Southwest Airlines Flight 1455 crash mentioned above, rather than reading the full checklist aloud—as required—the first officer visually acknowledged the checklist items.
• Air traffic controller error: Those flying the plane are not the only people who contribute to aviation accidents caused by human factors. If an air traffic controller is distracted from his or her duties, is fatigued or poorly trained, any one of those conditions can easily lead to airport runway accidents, or mid-air collision, or faulty services provided to pilots with aircraft emergencies that unnecessarily leads to loss of life.
• Human factors in aviation maintenance: Human error can play a part in a crash before the plane is even in the air. When aircraft maintenance is done incorrectly an aircraft part can malfunction without warning, causing catastrophe. In the 2003 crash of Air Midwest Flight 5481 at Charlotte/Douglas International Airport, an inexperienced and unsupervised crew of mechanics mis-rigged the elevator control of a Beechcraft 1900D, thus preventing the pilot from having full capability of lowering the nose if a climb was excessive. During the fatal takeoff in a fully loaded airplane, the airplane climbed very steeply, but because of the negligent maintenance of the elevator, the pilots could not stop the climb, and the airplane stalled and crashed, killing all the passengers and crew.
• Crew negligence: While the actions of flight attendants and other onboard crew members may seem less important, their primary responsibility is to keep passengers safe. If they fail to properly close an overhead bin, luggage can fall on passengers and injure them mid-flight. In an emergency situation, if they do not properly follow escape protocol, passengers can be harmed or killed during those critical moments following a plane crash.

*Ronald Goldman started his career in aviation accident law in 1972. Other principals of the firm began litigating aviation cases in 1985.