'Pilot error' not always what it seems

Safety first

Posted: Wednesday, February 14, 2001

Pilot error was, for the most part, the largest causal factor sited in the reports that I read. What is pilot error? It seemed to me that anything that leads to an accident where there is not a clear case of mechanical failure is attributed to the catch all phrase 'pilot error.' To the uninitiated it would appear that the pilot caused the accident. Not necessarily true.

I have spent the last several weeks looking up accidents on the National Transportation Safety Board (NTSB) Web site. A couple of things surprised me about the data that I read.

I had expected to see more fatal accidents with private aircraft and the amount of small private helicopters in accidents amazed me. Now, I didn't do a statistical analysis for sure, this was just my perception of what I read. Pilot error was, for the most part, the largest causal factor sited in the reports that I read.

What is pilot error? It seemed to me that anything that leads to an accident where there is not a clear case of mechanical failure is attributed to the catch all phrase "pilot error." To the uninitiated it would appear that the pilot caused the accident. Not necessarily true. Case in point.

I knew a pilot named Ernie many years ago that, although he was on in years, some 80 or so, was probably the best pilot around at the time. He worked for a flight school and also demonstrated and sold airplanes. I swear that he could make an airplane look so fine in flight that a person just had to learn to fly or buy the plane, or both. And so it was that Ernie came to demonstrate a twin Cessna to a couple of men who owned a car dealership in the area.

The plan was to fly to a city a short distance away, have lunch and return with the plane hopefully sold. The twin, with Ernie flying, was about 20 miles away from the departure airport and on an airway when a student pilot in a low-wing single-engine airplane decided to do a Chandell (a climbing, turning maneuver). The student's airplane climbed and turned into the twin-engine plane that Ernie was piloting, taking the left engine nacelle and severing the left control cables in the process.

Ernie made a split second decision based on his experience. He called a mayday and proceeded to the nearest airfield, a military field with a very wide, long runway. The wind was blowing from the left as Ernie turned to final approach, which caused him to drift right. He had no choice in the runway direction because he had limited control of the airplane. Everything would have been fine if a military fighter plane had not been on the side of the runway waiting to be cleared onto the runway.

The wind drifted Ernie's aircraft into the wing of the military plane and the result was that two occupants of the twin, Ernie and the rear seat passenger, suffered fatal injuries. The NTSB determined that a contributing causal factor was pilot error on the part of the twin pilot. Could Ernie have made a different decision that might have changed the outcome of the accident? There were four other airports in the vicinity, perhaps another airport would have had a better choice of runway to compensate for the wind. Who knows, only Ernie and he's not talking.

Pilot decision-making can be as simple as what kind of doughnuts to bring on a trip, or as difficult as which runway is best to land a crippled airplane on. From the preflight action to the successful culmination of every flight the pilot is directly responsible for the safety of those carried on the aircraft as well as the safety of people on the surface.

Each decision that a pilot makes concerning any aspect of a flight needs to be considered carefully and completely. The outcome of any given flight is dependent upon this decision-making process. Emergency procedures, for instance, should be practiced continually so that if or when a genuine emergency occurs, the pilot is prepared.

I encourage you to make the decision-making process a part of your personal preflight prior to your arrival at the airport. Consider every aspect of the flight before you begin the airplane preflight. Think about it.

Patricia Mattison is the safety program manager for the Federal Aviation Administration's Juneau Flight Standards office.



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