In the aftermath of two recent disasters, were crew actions – or the lack of same – has been mentioned as crucial factors, there is need to look at what is commonly a misused phrase called ‘pilot error’.
When a well trained pilot makes a mistake there is normally at least one colleague around to correct it. Thats the main reason for a minimum of two pilots on passenger airliners. The reason for a mistake can be a lot of things, but mistakes are naturally not made on purpose. Humans makes mistakes. In the pre-CRM* era a captain could make a fatal mistake unchallenged by his fellow crew members. The worst catastrophe so far was made by a well trained captain – in fact he was an instructor – when he did not listen to his engineer, who had serious doubt wether or not they were cleared for take-off – which they were not -, followed his faulty mindset that they were, and smashed his 747 into another 747 taxiing on the runway, killing 582 people. That was a pilot error if there ever was one.
* CRM – the acronym for using all resources already on your payroll – Crew Resource Management. That catastrophe brought about an important change in the running of things. In short both (or all three) pilots have to agree on everything, and if they don’t, the reason has to be established why not. Co-pilots have to interfere with what the captain is doing wrong, which was unheard of before – and still is a problem in some cultures. It the above accident CRM would have worked like this:
Pre-CRM: ”Are we really cleared for take-off?” ”What?” ”Are we really cleared for take-off?” ”YES”. 582 killed. Post-CRM: ”Are we really cleared for take-off?” ”What?” ”Are we really cleared for take-off?” Aircraft ”Tower, confirm we are cleared for take-off!” Tower ”Negative, hold your position”. Everybody happy.
There are other pilot errors, not yet quite that fatal, happening when well-trained crews are challenged with situations beyond their ability to control. Here ‘pilot error’ is not that obvious. If competent people by complacency or over-ambition end up in a fatal situation it is definitely a simple human error. Then again, if pilots too tired to think straight, or with limited training for what they are required to handle, make mistakes while doing the best they can, an incident or an accident cannot be blamed on ‘pilot error’. It is a sad management error. The difference between pilot error and management error is that the former is a simple – but sometimes fatal – involuntary mistake by one or two human beings, whereas the latter is a deliberate, albeit sometimes unwitting, acceptance of ways to operate.
The worst accident ever, that did not happen, was a management error, that – if the disaster had not been adverted in the very last moment – would have been blamed on pilot error. A fatigued crew (check previous chapter in this blog on ”Fighting Fatigue”) with inadequate information (check previous chapter in this blog on ”Notams”) about the state of runways at their destination, was a few seconds – or feet – away from landing on top of four airliners waiting for take-off on a taxiway.
In the economic squeeze brought on the industry by low-cost airlines, regular airlines have to cut corner as well. Extended duty times is one way. Insufficient pilot training is another one. Sloppy maintenance and insufficient fuel reserves are two more. In the latest two disasters pilot errors have been introduced as a reason for what happened. These crews did the best they could, just as the crews in four the latest accidents, the most renowned being Air France 447, where crew actions have been blamed. The major part of the responsibility in all those accidents lands in the lap of the involved airline managements.
In the latest two accidents, an aircraft construction fault was also a contributing factor, and proper training was not provided. Pilot errors have in the past caused a lot of fatal accidents. In the future, management errors and cost-cutting will be responsible for most of those, most likely by one or more of the four recent hazards listed above.