Accident Case Study Communication Breakdown Led

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In the technological world of modern air travel, there’s a certain irony in the fact that the majority of aviation disasters are caused by human error. And one of the most common forms of error is miscommunication. Even if just one person makes a mistake, the repercussions can be catastrophic.

Air travel is arguably one of the safest forms of transportation, but when airplane crashes do happen, because of their nature, they can take a devastating toll on human life. Here’s our list of the 10 worst air crashes caused by miscommunication.

10. Avianca Flight 52 (1990)

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On January 25, 1990, Avianca Flight 52 was carrying 149 passengers from Bogotá, Colombia to New York. However, because of bad weather conditions and air traffic congestion, the Boeing 707 was forced into a holding pattern off the coast near New York. And after circling for nearly an hour and a half, the aircraft was running low on fuel.

When Flight 52 arrived at Kennedy Airport, due to the fog and wind, only one runway was open for the 33 planes that were attempting to land every hour. What’s more, the flight was delayed again as the aircraft ahead of them failed to touch down. Flight 52’s fuel situation soon became desperate.

Two crucial pieces of miscommunication led to the disaster that was to follow. When the aircraft was passed from regional to local air traffic controllers, the local controllers were not informed that the aircraft had too little fuel to reach its alternative airport. Compounding the problem, crucially the aircraft’s crew did not explicitly declare that there was “fuel emergency” to the local controllers, which would have indicated that the plane was actually in danger of crashing.

As a result, after missing its first attempt to land, the airplane was given a landing pattern that it had too little fuel to execute. While the crew attempted to maneuver the plane, its engines flamed out in quick succession. The Boeing 707 slammed into the village of Cove Neck, Long Island, killing 65 of its 149 passengers and eight out of nine of its crew.

9. Air Florida Flight 90 (1982)

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On January 13, 1982, Air Florida Flight 90 was due to travel from Washington National Airport in Virginia to Hollywood International Airport in Fort Lauderdale, FL, with a layover in Tampa.

Conditions were snowy, and the aircraft had been de-iced improperly. Neither did it have its engine anti-icing system activated. This caused instruments to freeze and fail to register the correct readings. So, while the cabin crew thought that they had throttled up sufficiently for takeoff, in actual fact they didn’t have enough power.

The Boeing 737’s run-up took almost half a mile (800m) longer than it should have done. Even as they set off down the runway, the first officer noticed that something was wrong with the plane’s instruments and that it wasn’t capable of getting airborne. However, his attempts to communicate this were brushed off by the captain, who ordered the takeoff to continue.

The plane crashed into the 14th Street Bridge, killing 78 people, including four motorists. Later, reports showed that there was sufficient space for the aircraft’s takeoff to have been aborted – if only the flight crew had been communicating better.

8. Singapore Airlines Flight 006 (2000)

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It’s not often that an aircraft collides with a bulldozer yet, tragically, that’s exactly what happened in this next accident, involving an airplane schedule to fly from Singapore to Los Angeles via Taipei. On October 31, 2000, Singapore Airlines Flight 006 was taxiing to its takeoff point in stormy weather. Conditions were bad. There was low visibility thanks to the heavy rain. And crewmembers accidentally steered the Boeing 747 into runway 05R, which was closed for repairs.

The runway was cluttered with excavators, concrete barriers and a small bulldozer, but the pilot was unable to see them because of the inclement weather. The pilots had also apparently failed to read a report issued two months earlier that stated that the runway would be closed. As a result, they began takeoff procedures on the wrong runway.

While attempting to take off, the aircraft collided with the heavy equipment and broke apart. Many passengers seated in the middle of the plane were killed when fuel in the wings exploded and sent fireballs through that section. The final death toll amounted to 83 of the 179 on board, including four crewmembers.

7. Linate Airport Disaster (2001)

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On October 8, 2001, miscommunication played a role in a major collision at Linate Airport in Milan, Italy. The runway was obscured by thick fog, effectively reducing visibility to around 656 feet (200 meters), which may also have contributed to the tragedy, together with factors such as high traffic volume.

A Cessna Citation CJ2 business jet was given clearance to taxi to its takeoff point on a route that would avoid the main runway. However, due partly to poor use of radio communications and lack of proper markings and signs, the Cessna misinterpreted the message and turned in the wrong direction, crossing the main runway. Its route led it into the path of Scandinavian Airlines Flight 686, a McDonnell Douglas MD-87 airliner.

The two planes collided, with Flight 686 traveling at about 170 mph (270 kph). The Cessna went up in flames, while the right engine of the MD-87 was destroyed. The pilot of Flight 686, Joakim Gustafsson, managed to get the plane airborne for a brief period. And in an attempt to regain control, he hit the thrust reverser and brakes – noted as a particularly skilful maneuver. Even so, Gustafsson lost control of the plane, and it smashed into a luggage hangar at the end of the runway. In total, 118 people were killed in the disaster.

6. Dan Air Flight 1008 (1980)

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A Dan-Air 727 similar to the accident aircraft

This disaster was caused by a single misheard word. Dan Air Flight 1008 departed from Manchester, England, on the morning of April 25, 1980, en route to Tenerife, one of Spain’s Canary Islands. At 1:21 pm, the plane ploughed into the side of the island’s mount La Esperanza, killing all 146 people on board.

The cause of the disaster was a misinterpretation made by the Boeing 727’s flight crew. The plane was instructed by the control tower to take an unpublished, not officially approved, and potentially dangerous holding pattern above Los Rodeos Airport. But the pilot also seems to have mistaken the word “inbound” for “outbound” in the instructions he received, flying in the opposite direction to which he was supposed to.

This turn in the wrong direction took the plane through an area of exceptionally high ground. And due to the airport’s lack of ground radar, the air traffic controllers were unable to tell the flight crew that the plane was off course.

Heavy clouds obscured the crew’s vision, likely preventing them from seeing the looming threat of the mountain. The first sign they had of any impending danger was when the plane’s ground proximity warning device was triggered. The crew attempted a steep climb, but the aircraft slammed into the mountainside, killing everyone on board instantly.

5. PSA Flight 182 (1978)

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On September 25, 1978, Pacific Southwest Airlines Flight 182 was making a routine trip from Sacramento to San Diego. In the vicinity, an instructor was giving one of his students flying lessons in a private Cessna aircraft.

At some point, the Cessna made an unauthorized change of course, which put it on the same flight path as the much larger Boeing 727. At first, both pilots managed to steer clear of each other. But communication between the crew and airport control sounded nervous prior to the crash.

In the transmissions between air traffic control and Flight 182, the crucial word “passed” appears to have been misheard as “passing,” causing the controllers to believe that the flight crew knew the location of the Cessna. In fact, they had lost sight of the plane.

Less than two minutes after the transmission, the Cessna slammed into the bottom of Flight 182’s right wing. The Cessna broke to pieces, and the Boeing 727’s right wing was shattered. Both aircraft plummeted into a San Diego neighborhood, killing all 135 onboard on Flight 182, seven people on the ground, and both the Cessna pilots.

Witnesses at the crash site reported utter carnage, with blood and pieces of people’s bodies strewn across the entire area. In the end, if the crew of Flight 182 had managed to clearly communicate to air traffic control that they had lost sight of the smaller plane, California’s deadliest ever aircraft disaster might have been averted.

4. American Airlines Flight 965 (1995)

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On December 20, 1995, American Airlines Flight 965 was flying from Miami to Cali, Colombia, carrying 163 passengers and crew. On approach to the airport of Cali, the crew accidentally erased the waypoints that would have allowed them to navigate to the airport.

It was at this point that two miscommunications occurred. First, the captain entered the first “R” on the list of waypoints available, inadvertently sending the plane directly towards Bogotá, through a valley that put it on a collision course with mountainous terrain. Next, the air traffic controller at Cali, Nelson Ramírez, sensed that something was wrong, but he did not know enough English to correct the errant plane.

Flight 965 slammed into the 9,800-foot (3,000-meter) mountain, despite the flight crew’s last-minute efforts to pull out of the collision. In total, 159 people were killed in the crash, leaving only four survivors (initially five), who were all sitting within two rows of each other. A dog was also rescued from the wreckage.

3. Garuda Indonesia Flight 152 (1997)

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On September 26, 1997, Garuda Indonesia Airlines Flight 152 was traveling from Jakarta to Medan. While making its final approach, the pilot called Medan airport for help, complaining of poor visibility due to forest fires burning below.

At the time, the fires had caused delays, and three planes were waiting to land at Medan. Confusion arose because two of the aircraft had the same flight number. And in the chaos, air traffic control allegedly pulled the doomed Garuda Flight 152 off its regular course.

However, it seems that the crucial element of the disaster was a massive failure of communication between the pilot and the airport. Just before the plane – an Airbus A300 – was due to land, air traffic control ordered the pilot to turn right instead of left. A mix-up resulted, and the flight crashed in mountainous terrain, killing all 234 individuals on board. Chillingly, one minute after the plane turned in the wrong direction, the pilots were heard screaming.

2. Charkhi Dadri Mid-Air Collision (1996)

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The Charkhi Dadri mid-air collision the occurred on November 12, 1996 is the worst mid-air crash in the history of aviation. Kazakhstan Airlines Flight 1907 collided with Saudi Arabian Airlines Flight 763 at an altitude of almost 14,000 feet (4,300 meters), killing all 349 people on board both planes.

The cause of the disaster can be traced back to communications difficulties in the Kazakhstani plane. None of the Kazakhstani flight crew, except the radio operator, understood English, so they were completely reliant on him to communicate with air traffic control. The radio operator also lacked his own set of instruments and had to look over the shoulders of the pilots in order to find out information, such as the aircraft’s height.

The result of this was that Flight 1907 descended more than 1,000 feet (300 m) below its assigned altitude of 15,000 feet (4,600 meters), while struggling with turbulence inside a bank of cloud. The radio operator noticed the descent and told the crew to bring the aircraft back up, unfortunately placing them square in the path of the Saudi Arabian Boeing 747.

The resulting collision destroyed the left wing and stabilizer of Saudi Arabian aircraft, sending it spiraling towards Earth, disintegrating as it fell. Flight 1907, meanwhile, crashed into a field. Four survivors were recovered from the wreckage of the Kazakhstani plane, but all of them died soon afterwards.

1. Tenerife Airport Disaster (1977)

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The worst air disaster of all time occurred at Tenerife’s Los Rodeos Airport (now known as Tenerife North Airport) in the Canary Islands. Two Boeing 747s, Pan Am Flight 1736 and KLM Royal Dutch Airline Flight 4805, collided in fog, killing 583 people and leaving only 61 survivors. Unfortunately, the causes of the disaster boil down to possible impatience and a very basic error of communication.

On March 27, 1977, Los Rodeos Airport was covered in heavy fog and was overcrowded due to traffic being diverted from Gran Caneria Airport, where a bomb had exploded. This may also have meant that direction from air traffic control was more muddled than usual.

KLM pilot Jacob van Zanten was eager to leave. Van Zanten and his crew had almost reached the legal limit of their on-duty time and would have to stay in Tenerife overnight unless they got going soon. This may have contributed to the pilot’s fatal mistake when he received the communication “you are clear” from the air traffic control tower.

A second clearance was required before van Zaten could take off, but instead he began to accelerate down the runway. In the meantime, the Pan Am flight, which was attempting to find its assigned taxiway in the heavy fog, was directly in the KLM airplane’s path. The resulting collision obliterated the Dutch plane, sending it some 100 feet into the air before it came crashing down and exploded in a ball of fire. The Pan Am flight was sliced into pieces and also went up in flames.

Pilot error (sometimes called cockpit error) is a term used to describe a decision, action or inaction by a pilot or crew of an aircraft determined to be a cause or contributing factor in an accident or incident. The term includes mistakes, oversights, lapses in judgment, gaps in training, adverse habits, and failures to exercise due diligence in a pilot's duties.

The causes of pilot error include psychological and physiological human limitations, and various forms of threat and error management have been implemented into pilot training programs to teach crew members how to deal with impending situations which arise throughout the course of a flight.[2]

Accounting for the way human factors influence the actions of pilots is now considered standard practice by accident investigators when examining the chain of events that led to an accident.[2][3]


Usually in an accident caused by pilot error, it is assumed that the pilot in command (captain) makes an error unintentionally. However, an intentional disregard for a standard operating procedure (or warning) is still considered to be a pilot error, even if the pilot's actions justified criminal charges.

The pilot may be a factor even during adverse weather conditions if the investigating body deems that the pilot did not exercise due diligence.[citation needed] The responsibility for the accident in such a case would depend upon whether the pilot could reasonably know of the danger and whether he or she took reasonable steps to avoid the weather problem.[citation needed] Flying into a hurricane (for other than legitimate research purposes) would be considered pilot error;[original research?] flying into a microburst would not be considered pilot error if it was not detectable by the pilot, or in the time before this hazard was understood.[original research?] Some weather phenomena (such as clear-air turbulence or mountain waves) are difficult to avoid, especially if the aircraft involved is the first aircraft to encounter the phenomenon in a certain area at a certain time.[original research?]

Placing pilot error as a cause of an aviation accident has often been controversial. For example, the NTSB found that the crash of American Airlines Flight 587 was because of the failure of the rudder, which was caused by "unnecessary and excessive rudder pedal inputs" on the part of the co-pilot who was operating the aircraft at the time. American Airlines' pilots had been improperly trained concerning extreme rudder inputs. The rudder failure was caused by a flaw in the design of the Airbus A300 aircraft and the co-pilot's rudder inputs should not have caused the catastrophic rudder failure that led to the accident that killed 265 people. The NTSB report did not use the term "pilot error" at all.[4]

Modern accident investigators avoid the words "pilot error", as the scope of their work is to determine the cause of an accident, rather than apportion blame. Furthermore, any attempt to blame pilots does not consider that they are part of a broader system, which in turn may be at fault for their fatigue, work pressure or lack of training.[3]ICAO and its member states therefore adopted the Reason Model in 1993 in an effort to better understanding the role of human factors in aviation accidents.[5]

Thus, pilot error is a major cause of air accidents. During 2004, pilot error was pointed to be the primary reason of 78.6% of disastrous GA (general aviation) accidents, and as the major cause of 75.5% of general aviation accidents in the US.[6] Pilot errors are related to multiple causes. Decision errors can be caused by several factors such as tendencies, biases as well as breakdowns when human proceeds the information coming in. For pilot in aviation, these errors are highly to produce not only errors but also fatalities.[7]

Causes of pilot error[edit]

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 massive loss of life. 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 fatigue, workload, and fear as well as cognitive overload, poor interpersonal communications, imperfect information processing, and flawed decision making.”[8] 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.[9]


The term "threat" is defined as any event "external to flight crew's influence which can increase the operational complexity of a flight."[10] 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 weather conditions, hazardous , air traffic control shortcomings, bird strikes, and high terrain."[10] 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 interruptions, ground maintenance errors, and inadequacies of manuals and charts."[10]


The term "error" is defined as any action or inaction leading to deviation from team or organizational intentions.[8] 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 primarily related to operational and behavioural mishaps.[11] Errors can vary from incorrect altimeter setting and deviations from flight course to more severe errors such as exceeding maximum structural speeds or forgetting to put down landing or takeoff flaps.

Decision making[edit]

Reasons for negative reporting of accident 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.[12] Wiegmann and Shappell invented three cognitive models to analyze approximately 4,000 pilot factors associated with more than 2,000 U.S. Naval aviation mishaps. Although the three cognitive models has slight difference in the types of errors all three lead to the same conclusion: judgment errors.[13] There are three steps which are decision-making, goal-setting, and strategy-selection errors. All of those were highly related with primary accidents.[13] For example, on December 28, 2014, AirAsia Flight 8501, which carrying seven crew members and 155 passengers, crashed into Java sea due to several fatal mistakes of the captain in the poor weather condition. in this case, the captain chose to adjust the flight altitude at the high rate which is not acceptable.[14]

Psychological illness[edit]

The psychological treatment and requirements of pilots is always listed in aviation law and enforced by individual airlines. Facing multiple special challenges, pilots must exercise control in complicated environments. Psychological illness is typically defined as an unintended physical, mental, or social injury, harm or complication that results in disability, death, or increased use of health care resources.[15] Due to physiological problems such as jet lag, pilots usually feel uncomfortable after long-hour flights. Psychological illness is regarded as a primary problem for pilots which had also caused several fatal accidents in the past.[16]

SilkAir Flight 185 On 19 December 1997, Flight 185 crashed into the Musi River near Palembang in southern Sumatra. All 97 passengers and seven crew were killed on board. After the investigation of the accident, all the evidence pointed to the captain which was concluded to be a planned suicidal accident.

EgyptAir Flight 990 On 31 October 1999, the Boeing 767 crashed into the Atlantic Ocean south of Nantucket Island, Massachusetts. All 217 people on board were killed. Although the result had never been proved, the crash was considered as a deliberate action by the relief first officer.[17]

Germanwings Flight 9525 On 24 March 2015, the aircraft, flight 9525 crashed in the French Alps. All 144 passengers and six crew members were killed. As the co-pilot of the plane, Andreas Lubitz had been treated for suicidal tendencies and been forbidden to work by a doctor. Lubitz hid this information from his employer. During the flight, the door was locked by Lubitz and the captain could not enter before Lubitz deliberately caused the aircraft to crash into a mountain.

Threat and error management (TEM)[edit]

TEM involves the effective detection and response to internal or external factors that have the potential to degrade the safety of an aircraft's operations.[9] Methods of teaching TEM stress replicability, or reliability of performance across recurring situations.[18] TEM aims to prepare crews with the "coordinative and cognitive ability to handle both routine and unforeseen surprises and anomalies."[18] The desired outcome of TEM training is the development of 'resiliency'. Resiliency, 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 line operations safety audit (LOSA), implementation of crew resource management (CRM), cockpit task management (CTM), and the integrated use of checklists in both commercial and general aviation. Some other resources built into most modern aircraft that help minimize risk and manage threat and error are airborne collision and avoidance systems (ACAS) and ground proximity warning systems (GPWS).[19] 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.

Line operations safety audit (LOSA)[edit]

LOSA is a structured observational program designed to collect data for the development and improvement of countermeasures to operational errors.[20] Through the audit process, trained observers are able to collect information regarding the normal procedures, protocol, and decision making processes 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.[10] Observers on flights which are being audited typically observe the following:[20]

  • Potential threats to safety
  • How the threats are addressed by the crew members
  • The errors the threats generate
  • How crew members manage these errors (action or inaction)
  • Specific behaviors known to be associated with aviation accidents and incidents

LOSA was developed to assist crew resource management practices in reducing human error in complex flight operations.[10] 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 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.[10]

Crew resource management (CRM)[edit]

CRM 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."[21] CRM training has been integrated and mandatory for most pilot training programs, and has been the 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:[21]

  • Decision making – the use of logic and judgement to make decisions based on available information
  • Assertiveness – willingness to participate and state a given position until convinced by facts that another option is more correct
  • Mission analysis – ability to develop short and long term contingency plans
  • Communication – clear and accurate sending and receiving of information, instructions, commands and useful feedback
  • Leadership – ability to direct and coordinate activities of pilots & crew members
  • Adaptability/flexibility – ability to alter course of action due to changing situations or availability of new information
  • Situational awareness – ability to perceive the environment within time and space, and comprehend its meaning

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."[21]

Application and effectiveness of CRM[edit]

Since the implementation of CRM circa 1979, following the need for increased research on resource management by NASA, the aviation industry has seen tremendous evolution of the application of CRM training procedures.[22] The applications of CRM has been developed in a series of generations:

  • First generation: emphasized individual psychology and testing, where corrections could be made to behaviour.
  • Second generation: featured a shift in focus to cockpit group dynamics.
  • Third evolution: diversification of scope and an emphasis on training crews in how they must function both in and out of the cockpit.
  • Fourth generation: CRM integrated procedure into training, allowing organizations to tailor training to their needs.
  • Fifth generation (current): acknowledges that human error is inevitable and provides information to improve safety standards.[23]

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 there is a correlation between CRM programs and better risk management.[23]

Cockpit task management (CTM)[edit]

Cockpit task management (CTM) is the "management level activity pilots perform as they initiate, monitor, prioritize, and terminate cockpit tasks."[24] A 'task' is defined as a process performed to achieve a goal (i.e. fly to a waypoint, descend to a desired altitude).[24] CTM training focuses on teaching crew members how to handle concurrent tasks which compete for their attention. This includes the following processes:

  • Task initiation – when appropriate conditions exist
  • Task monitoring – assessment of task progress and status
  • Task prioritization – relative to the importance and urgency for safety
  • Resource allocation – assignment of human and machine resources to tasks which need completion
  • Task interruption – suspension of lower priority tasks for resources to be allocated to higher priority tasks
  • Task resumption – continuing previously interrupted tasks
  • Task termination – the completion or incompletion of tasks

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.[24] CTM has been integrated 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.


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 a flight.[25] The objectives of checklists include "memory recall, standardization and regulation of processes or methodologies."[25] 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 memory function are a few of the effects of stress and fatigue.[26] 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 incident or crash. Apart from checklists issued by regulatory bodies such as the FAA or ICAO, 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 IM SAFE 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.[25] These checklists, along with a number of other redundancies integrated into most modern aircraft operation systems, ensure the pilot remains vigilant, and in turn, aims to reduce the risk of pilot error.

Notable examples[edit]

One of the most famous incidents of an aircraft disaster attributed to pilot error was the nighttime crash of Eastern Air Lines Flight 401 near Miami, Florida on December 29, 1972. The captain, first officer, and flight engineer had become fixated on a faulty landing gear light and had failed to realize that the flight controls had been bumped by one of the crew, altering the autopilot 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 on the ground visible to act as an external reference), the distracted flight crew did not notice the plane losing height and the aircraft eventually struck the ground in the Everglades, killing 101 out of 176 passengers and crew.

The subsequent National Transportation Safety Board (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.

During 2004 in the United States, pilot error was listed as the primary cause of 78.6% of fatal general aviation accidents, and as the primary cause of 75.5% of general aviation accidents overall.[27] For scheduled air transport, pilot error typically accounts for just over half of worldwide accidents with a known cause.[28]

  • 28 July 1945 – a United States Army Air ForcesB-25 bomber bound for Newark Airport crashed into the 79th floor of the Empire State Building after the pilot became lost in a heavy fog bank situated over Manhattan. All three crewmen were killed as well as eleven office workers in the building.
  • 24 December 1958 – BOACBristol Britannia 312, registration G-AOVD, crashed as a result of a controlled flight into terrain, (CFIT), 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.
  • 3 January 1961 – Aero Flight 311 crashed near Kvevlax, Finland. All twenty-five occupants were killed in the crash, the worst in Finnish history. An investigation later determined that both pilots were intoxicated during the flight, and may have been interrupted by a passenger at the time of the crash.
  • 28 February 1966 – AmericanastronautsElliot See and Charles Bassett were killed when their T-38 Talon crashed into a building at Lambert-St. Louis International Airport during bad weather. A NASA investigation concluded that See had been flying too low on his landing approach.
  • 29 December 1972 – Eastern Air Lines Flight 401 crashed into the Florida Everglades after the flight crew failed to notice the deactivation of the plane's autopilot, having been distracted by their own attempts to solve a problem with the landing gear. Out of 163 occupants, 75 survived the crash.
  • 27 March 1977 – the Tenerife airport disaster; a senior KLM pilot failed to hear, understand or follow tower instructions, causing two Boeing 747s to collide on the runway at Tenerife; 583 people were killed in the worst-ever air disaster.
  • 28 December 1978 – United Airlines Flight 173; a flight simulator instructor Captain allowed his Douglas DC-8 to run out of fuel while investigating a landing gear problem. 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 accident is that an instructor can control the amount of fuel in simulator training so that it never runs out.
  • 13 January 1982 – Air Florida Flight 90, a Boeing 737-200 with 79 passengers and crew, crashed into the 14th Street Bridge and careened into the Potomac River shortly after taking off from Washington National Airport. Seventy-five passengers and crew, and four motorists on the bridge, were killed. The NTSB report blamed the flight crew for not properly employing the plane's de-icing system.
  • 19 February 1985 – above the Pacific Ocean the crew of China Airlines Flight 006 lost control of their Boeing 747SP after the No. 4 engine flamed out. The aircraft fell 10,000 feet in twenty seconds and lost a total of 30,000 feet in two-and-a-half minutes before control was regained. There were no fatalities but the aircraft was badly damaged.
  • 28 August 1988 – the Ramstein airshow disaster; a member of an Italian aerobatic team misjudged a manoeuvre, causing a mid-air collision. Three pilots and 67 spectators on the ground were killed.
  • 31 August 1988 – Delta Air Lines Flight 1141 crashed on takeoff after the crew forgot to deploy the flaps for increased lift. Of the 108 crew and passengers on board, fourteen were killed.
  • 8 January 1989 – in the Kegworth air disaster, a fan blade broke off in the left engine of a new Boeing 737-400, but the pilots mistakenly shut down the right engine. The left engine eventually failed completely and the crew could not 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.
  • 3 September 1989 – The crew of Varig Flight 254 made a series of mistakes so that their Boeing 737 ran out of fuel hundreds of miles off-course above the Amazon jungle. Thirteen died in the ensuing crash landing.
  • 21 October 1989 – Tan-Sahsa Flight 414 crashed into a hill near Toncontin International Airport in Tegucigalpa, Honduras, because of a bad landing procedure by the pilot. 127 people died in the accident.
  • 24 November 1992 – China Southern Airlines Flight 3943 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, but the crew did not notice that the number 2 power lever was at idle. This led to an asymmetrical power condition. It crashed on descent to Guilin Airport, killing all 141 aboard.
  • 23 March 1994 – Aeroflot Flight 593 crashed on its way to Hong Kong. The captain, Yaroslav Kudrinsky, invited his two children into the cockpit, and permitted them to sit at the controls, against airline regulations. His fifteen-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 flat spin. The pilots recovered the plane but it crashed into a forest, killing all 75 people on board.
  • June 24, 1994 – B-52 crashes in Fairchild Air Force Base. The crash was largely attributed to the personality and behavior of Lt Col 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 crash is now used in military and civilian aviation environments as a case study in teaching crew resource management.
  • 30 June 1994 – Airbus Industrie Flight 129, a certification test flight of the Airbus 330-300, crashed at Toulouse-Blagnac Airport. While simulating an engine-out emergency just after takeoff with an extreme center of gravity location, the pilots chose improper manual settings which rendered the autopilot incapable of keeping the plane in the air, and by the time the PIC regained manual control, it was too late. The aircraft was destroyed, killing the flight crew, a test engineer, and four passengers which included Airbus and airline customer VIPs. The investigative board concluded the PIC 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.
  • 2 July 1994 – USAir Flight 1016 crashed to a residential house and the airplane was destroyed. There were 20 passengers and crew injured in that accident.
  • 20 December 1995, American Airlines Flight 965Boeing 757-200 with 155 passengers and a crew of eight, 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 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 cordinates, and the aircraft crashed into the mountains, killing 159 of the 163 people aboard.
  • 6 August 1997 – Korean Air Flight 801, crashed at Nimitz Hill, which was located 3 miles away from Guam International Airport . During the approach to the airport, the captain’s failure to conduct a non-precision approach properly led to this misfortune accident. The National Transportation Safety Board announced that the possible factor of captain’s poor decision was fatigue. Out of 254 passengers and crew members, 228 were killed in the crash.
  • 12 October 1997 – Singer John Denver died when his newly-bought Rutan Long-EZ home-built aircraft crashed into the Pacific Ocean off Pacific Grove, California. The NTSB indicated that Denver lost control of the aircraft while attempting to manipulate the fuel selector handle, which had been placed in a hard-to-reach position by the aircraft's builder. The NTSB cited Denver's unfamiliarity with the aircraft's design as a cause of the crash.
  • 16 July 1999 – John F. Kennedy, Jr.died when his plane, a Piper Saratoga, crashed into the Atlantic Ocean off the coast of Martha's Vineyard, Massachusetts. 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 spatial disorientation". Kennedy did not hold a certification for IFR flight, but did continue to fly after weather conditions obscured visual landmarks.
  • 31 August 1999 – 65 people died after Lineas Aéreas Privadas Argentinas (LAPA) flight 3142 crashed after an attempted take-off with the flaps retracted.
  • 31 October 2000 – Singapore Airlines Flight 006 was a Boeing 747-412 that took off from the wrong runway at the then Chiang Kai-Shek International Airport. It then collided with construction equipment on the runway, bursting into flames and killing 83 of 179 occupants.
  • 12 November 2001 – American Airlines Flight 587 encountered heavy turbulence and the co-pilot over-applied the rudder pedal, turning the Airbus A300 side to side. Due to the excessive stress, the rudder failed. The A300 spun and hit a residential area, crushing 5 houses and killing 265. Contributing factors included wake turbulence and pilot training.
  • 24 November 2001 – Crossair Flight 3597 crashed into a forest on approach to runway 28 at Zurich Airport. This was caused by Captain Lutz descending below the minimum safe altitude of 2400 feet on approach to runway 28 at Zurich.
  • 15 April 2002 – Air China Flight 129, a Boeing 767-200, crashed near Busan, South Korea killing 128 of the 166 people aboard. The co-pilot had been flying too low.
  • 25 October 2002 – eight people, including US SenatorPaul Wellstone, were killed in a crash near Eveleth, Minnesota. The NTSB concluded that "the flight crew did not monitor and maintain minimum speed."
  • 26 February 2004 – a Beech 200 carrying Macedonian President Boris Trajkovski crashed, killing Trajkovski and eight other passengers. The crash investigation ruled that the accident was caused by "procedural mistakes by the crew" during the landing approach.
  • 3 January 2004 – Flash Airlines Flight 604 dived into the Red Sea shortly after take off. All 148 people were killed. The captain had encountered vertigo, his control column was slanted to the right, and the captain did not notice. The 737 banked until it was unable to stay in the air. However, the report was disputed.
  • 14 August 2005 – the pilots of Helios Airways Flight 522 lost consciousness, most likely due to hypoxia caused by failure to switch the cabin pressurization to "Auto" during the pre-flight preparations. The Boeing 737-300 crashed after running out of fuel, killing all on board.
  • 3 May 2006 – Armavia Flight 967 lost control and crashed into the Black Sea while approaching Sochi-Adler Airport in Russia. All 113 people on board were killed. The pilots were fatigued and flying in stress condition. Their stress level were pushed over the limit and causing them to lose their situational awareness.
  • 27 August 2006 – Comair Flight 191 failed to become airborne and crashed at Blue Grass Airport after the flight crew inadvertently attempted takeoff from a much shorter secondary runway rather than the intended takeoff runway. 49 of the 50 on board, including all 47 passengers, were killed.
  • 1 January 2007 – Adam Air Flight 574; The crew's preoccupation with a malfunction of the inertial reference system diverted their attention from the flight instruments and allowed 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 loss of control. This caused the aircraft to hit the water at high speed and a steep angle and disintegrate, killing all 102 people on board.[29]
  • 7 March 2007 – Garuda Indonesia Flight 200; poor Crew Resource Management and the failure to extend the flaps led the aircraft to run off the end of the runway after landing. The aircraft landed at an "unimaginable" speed. Twenty-two of the 140 occupants were killed.
  • 12 February 2009 – Colgan Air Flight 3407 flying as Continental Connection entered a stall and crashed in to 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 in the plane died, along with one person inside the house.
  • 1 June 2009 – Air France Flight 447 entered a stall and crashed into the Atlantic Ocean following pitot tube failure and improper control inputs by the first officer. All 216 passengers and 12 crew members died.
  • 10 April 2010 – 2010 Polish Air Force Tu-154 crash; during a descent towards Russia's Smolensk North Airport, the flight crew of the Polish presidential jet ignored automatic warnings and attempted a risky landing in heavy fog. The Tupolev Tu-154M descended too low and crashed into a nearby forest; all of the occupants were killed, including Polish president Lech Kaczynski, his wife Maria Kaczynska, and numerous government and military officials.
  • 12 May 2010 - Afriqiyah Airways Flight 771 The aircraft crashed about 1,200 metres (1,300 yd) short of Runway 09, outside perimeter of Tripoli International Airport,killing 103 passengers and leaving a sole survivor who was a 10-year-old boy named Ruben Van Assouw, On 28 February 2013, the Libyan Civil Aviation Authority announced that they had determined that the cause of the crash was pilot error. Crew resource management lacked/was insufficient, sensory illusions and the first officer inputs to the aircraft side stick were a contributing factor in the crash. Also fatigue could have played a role in the accident.

The final report stated that the accident resulted from 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 activation of the Terrain Awareness and Warning System, and the flight crew’s lack of monitoring and controlling of the flight path,

  • 22 May 2010 – Air India Express Flight 812; overshot the runway at Mangalore Airport, killing 158 people. The plane touched down 610 metres from the usual touchdown point after a steep descent. CVR recordings showed that the captain of the aircraft was sleeping and woke up just minutes before landing. His lack of alertness made the plane land very fast and steep and it ran off the end of the tabletop runway.
  • 28 July 2010 – Airblue Flight 202; crashed into the Margalla Hills. The Captain became confused with the heading knob and thought that he had done the right thing to turn the plane. However, due to his failure to pull the heading knob, the plane did not turn. The Airbus A321 went astray and slammed into Margalla Hills. All 152 occupants aboard died.
  • 20 June 2011 – RusAir Flight 9605 crashed onto a motorway while on final approach to Petrozavodsk Airport in western Russia, after the intoxicated navigator encouraged the captain to land in heavy fog. Forty-three people died in the crash, while only five survived.
  • 6 July 2013 – Asiana Airlines Flight 214 tail struck the seawall short of runway 28L at San Francisco International Airport. 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 approach path during landing.
  • 23 July 2014 – TransAsia Airways Flight 222 brushed trees and crashed onto six houses in a residential area in Xixi Village, Penghu Island, Taiwan. From 58 people onboard Flight 222, only 10 people survived the crash. The Captain was overconfident with his skill and intentionally descended and rolled the plane to the left. Crew members didn't realize that their altitude was in extreme danger and the plane would impact terrain until 2 seconds before the crash.
  • 6 February 2015 – TransAsia Airways Flight 235; 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 an engine. However, he accidentally shut off the correctly functioning one 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 37 of the 53 on board.

See also[edit]


  1. ^"TENERIFE DISASTER – 27 MARCH 1977: The Utility of the Swiss Cheese Model & other Accident Causation Frameworks". Go Flight Medicine. Retrieved 13 October 2014. 
  2. ^ ab"Risk management handbook"(pdf) (Change 1 ed.). Federal Aviation Administration. January 2016. Chapter 2. Human behavior. Retrieved 24 August 2016. 
  3. ^ abRural and Regional Affairs and Transport References Committee (May 2013). "Aviation Accident Investigations"(pdf). Government of Australia. 
  4. ^"In-Flight Separation of Vertical Stabilizer, American Airlines Flight 587, Airbus Industrie A300-605R, N14053, Belle Harbor, New York, November 12 2001"(PDF). National Transportation Safety Board. October 26, 2004. Retrieved November 16, 2017. 
  5. ^Investigating Human Error: Incidents, Accidents, and Complex Systems. Ashgate Publishing. 2004. ISBN 0754641228. 
  6. ^"Accident statistics". Retrieved 2015-10-21. 
  7. ^Foyle, D. C., & Hooey, B. L. (Eds.). (2007). Human performance modeling in aviation. CRC Press.
  8. ^ abHelmreich, Robert L. (March 18, 2000). "On Error Management: Lessons From Aviation". BMJ: British Medical Journal. 320-7237: 781–785. 
  9. ^ abThomas, Matthew J.W. (2004). "Predictors of Threat and Error Management: Identification of Core Nontechnical Skills and Implications for Training Systems Design". The International Journal of Aviation Psychology (14(2)): 207–231. 
  10. ^ abcdefEarl, Laurie; Bates, Paul R.; Murray, Patrick S.; Glendon, A. Ian; Creed, Peter A. (January 2012). "Developing a Single-Pilot Line Operations Safety Audit". Aviation Psychology and Applied Human Factors. 2: 49–61. doi:10.1027/2192-0923/a000027. ISSN 2192-0923. 
  11. ^Li, Guohua; Baker, Susan P.; Grabowski, Jurek G.; Rebok, George W. (February 2001). "Factors Associated With Pilot Error in Aviation Crashes". Aviation, Space, and Environmental Medicine (72(1)): 52–58. 
  12. ^Stanhope, N.; Crowley-Murphy, M. (1999). "An evaluation of adverse incident reporting". Journal of Evaluation in Clinical Practice: 5–12. 
  13. ^ abWiegmann, D. A., & Shappell, S. A. (2001). Human error perspectives in aviation. The International Journal of Aviation Psychology, 11(4), 341–357.
  14. ^Stacey, Daniel (15 January 2015). "Indonesian Air-Traffic Control Is Unsophisticated, Pilots Say". The Wall Street Journal. Retrieved 26 January 2015
  15. ^Sears, N.; Baker, G.R. (2013). "The incidence of adverse events among home care patients". International Journal for Quality in Health Care: 16–28. 
  16. ^Wickens, C. D. (2002). Situation awareness and workload in aviation. Current directions in psychological science, 11(4), 128–133.
  17. ^Paxson, P (2002). "Have you been injured? The current state of personal injury lawyers' advertising". The Journal of Popular Culture. 36 (2): 191–199. doi:10.1111/1540-5931.00001. 
  18. ^ abDekker, Sidney; Lundström, Johan (May 2007). "From Threat and Error Management (TEM) to Resilience". Journal of Human Factors and Aerospace Safety (260(70)): 1–10. 
  19. ^Maurino, Dan (April 2005). "Threat and Error Management (TEM)". Canadian Aviation Safety Seminar (CASS); Flight Safety and Human Factors Programme – ICAO. 
  20. ^ ab"Line Operations Safety Audit (LOSA)". SKYbrary. Retrieved 24 August 2016. 
  21. ^ abcMyers, Charles; Orndorff, Denise (2013). "Crew Resource Management: Not Just for Aviators Anymore". Journal of Applied Learning Technology. 3 (3): 44–48. 
  22. ^Helmreich, Robert L.; Merritt, Ashleigh C.; Wilhelm, John A. (1999). "The Evolution of Crew Resource Management Training in Commercial Aviation". The International Journal of Aviation Psychology (9(1)): 19–32. 
  23. ^ abSalas, Eduardo; Burke, Shawn C.; Bowers, Clint A.; Wilson, Katherine A. (2001). "Team Training in the Skies: Does Crew Resource Management (CRM) Training Work?". Human Factors. 43 (4): 641–674. doi:10.1518/001872001775870386. ISSN 0018-7208. 
  24. ^ abcChou, Chung-Di; Madhavan, Das; Funk, Ken (1996). "Studies of Cockpit Task Management Errors". The International Journal of Aviation Psychology (6(4)): 307–320. 
  25. ^ abcHales, Brigette M.; Pronovost, Peter J. (2006). "The Checklist -- A Tool for Error Management and Performance". Journal of Critical Care (21): 231–235. 
  26. ^Cavanagh, James F.; Frank, Michael J.; Allen, John J.B. (April 2010). "Social Stress Reactivity Alters Reward and Punishment Learning". Social Cognitive and Affective Neuroscience. 6: 311–320. doi:10.1093/scan/nsq041. 
1994 Fairchild Air Force Base B-52 crash, caused by flying the aircraft beyond its operational limits. Here the aircraft is seen in an unrecoverable bank, moments before the crash. This incident is now used in military and civilian aviation environments as a case study in teaching crew resource management.
Actual flight path (red) of TWA Flight 3 from departure to crash point (controlled flight into terrain). 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.

Maraba Airport

Belem Airport

Location of the crash landing after running out of fuel and departure/destination airports of the Varig Flight 254 (navigational error).
Runway collision 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.
The Tenerife airport disaster now serves as a textbook example.[1] 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 great number of large aircraft, resulting in disruption of the normal use of taxiways.
The 3p design altimeter is one of the most prone to misreading by pilots (a cause of the UA 389 and G-AOVD crashes).
Multiple sources of information can be taken from one interface here. Pilots may get information from the attitude indicator, altitude or airspeed in one scan.
Checklists like these ensure that pilots are able to follow operational procedure and aids in memory recall.
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