There are many ways to analyze accidents. One of those is to try to mentally put yourself in the place of the pilot at different stages of the flight, from flight planning through the end of the accident sequence. Part of that is to imagine the pilot’s state of mind as the situation deteriorates so that you can try to formulate actions that might have saved the day.

I can imagine that in many, if not most cases, at least for a fleeting moment, the pilot asks the rhetorical question, “What am I doing here?” Obviously, that is not a strategy to avoid the accident at that point, but it is helpful for us to study the accident and ask, “How did the pilot get into that situation.”

We know about the error chain and that usually a series of errors, rather than a single mistake, leads up to a crash. We also know that if the error chain had been broken somewhere along the way, the accident might have been avoided. So let’s look at some risk factors, commonly found as links in error chains, that we might be able to mitigate. Usually more than one of these risk factors work together or in sequence to answer our question, “How did the pilot get into that situation.” These are not presented in a particular order because they can all range from a minor, contributing factor to a major causal factor.

Proficiency  Pilots need to be proficient for any operations they might reasonably have to perform. The lower the pilot’s capability curve the lower the margin of safety. Of course capability must be measured against the task load for the particular operation. The pilot who always operates a Cessna 172 from a 6,000 foot paved runway with no obstacles at either end, has little need to practice short or soft field operations from a 1,500 foot turf runway with trees at each end. That might be true except when something does not go as planned. Unexpected adverse weather, or a mechanical problem might necessitate an unplanned landing at, guess what, the 1,500 foot turf runway with trees at each end.

But there are areas in which a pilot might not need to maintain proficiency providing there is no chance that the particular skill will be needed. An example might be the professional pilot who is multiengine rated but is retired and only flies single engine airplanes. There is no need to be proficient in multiengine, engine-out operations providing the pilot has the resolve to stay with just single engine airplanes. A common problem befalls the non-current, non-proficient instrument rated pilot. Needing to get home to go to work with IFR conditions and access to an IFR equipped airplane often provides too much temptation to think, “It will be OK just this once.”

Aircraft Maintenance The first link in the error chain often is put in place long before the flight occurs and sometimes that involves aircraft maintenance. An inflight mechanical problem, can range from catastrophic such as a control failure to a minor one such as the loss of an alternator during day VFR flight. But even a minor mechanical problem, increases the pilot’s task load and thereby decreases the safety margin. A well-maintained aircraft does not eliminate the possibility of a mechanical problem inflight, but it reduces the probability.

Fatigue Just about every high-stakes or mission-critical industry has come to recognize the risk posed by a fatigued operator. Of course that includes pilots. Fatigue is common in our society and of course varies in severity. The FAA has determined that being awake for 17 hours has the same effect on performance as having a blood alcohol level in the 0.05 to 0.10 range. The only way to reduce fatigue is to sleep. So the pilot who is otherwise very proficient and fit to fly, but who has been up most of the night, perhaps with an ill child, works a long day, then embarks on a long, cross country flight is adding a link to the error chain. That pilot will have decreased capability and therefore the a reduced margin of safety.

Impairment  Most pilots are well aware of risk of flying after consuming alcohol and refrain from doing so. Most pilots do not use illicit drugs and those who do mostly do not fly while they are under the influence. Unfortunately, we are seeing more cases of impairing, illicit drugs in toxicology reports of fatal accident pilots.  But many pilots are actively flying while being unknowingly impaired. That impairment comes from a variety of prescription and over-the-counter medications. Space here does not permit a detailed discussion, but a general rule that works most of the time is to read the label and ask a pharmacist. If the label says not to drive or operate machinery, that should be a big red flag. Interactions are also a factor, and that is where advice from a pharmacist comes into play. Any degree of impairment reduces capability and therefore the safety margin. Impaired flying presents a big link in the error chain.


External Factors In the human factors world we call this pressure. It is simply something that causes us to press the envelope and go into a situation which is ill-advised. External factors often add the deciding link to the error chain. Common sources of this pressure are a need to conduct a flight to get back to work the next day, provide a promised flight to another person, attend an important meeting, get a child back to college for exams, and many more. Our cognitive biases work on our unconscious mind to make us believe that the risks are lower than they really are.

Of course there are more of these factors and more possible scenarios for each. Below are links to a couple of accidents in the Accident Analysis section. Read through them and see if you can apply some of the factors above to determine how the error chain developed. Try to answer the question, “How did the pilot get into that situation.”

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About the author 

David St. George (Lifetime Member)

David St. George learned to fly at Flanders Valley Airport in 1970. Proving that everyone is eventually trainable, he became an FAA Gold Seal Flight Instructor for airplanes (single and multi, instrument, and glider) and serves the Rochester FSDO as an FAA Designated Pilot Examiner. In this capacity, he gives flight tests at any level from sport pilot to ATP and CFI. For 25 years David was East Hill Flying Club's 141 Chief Instructor and manager. David holds multi and single engine ATP pilot certificates, with pilot ratings for glider and seaplane and several jet type ratings. He recently earned his 13th renewal as a Master Instructor and owns an Aeronca Champ so he can build hours for that airline job!

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