Time does not wait: common mistakes of pilots. Pilot error is not the only cause of disasters
Patrick R. VAILETT
Today you completed four flights. Bad weather has blanketed the North East and flight delays have put you 90 minutes behind schedule. While you're taxiing to the FBO, you get a message that a fifth flight has been added to your flight that you were supposed to have departed 10 minutes ago.
As soon as you turn off the engines, you ask the co-pilot to prepare the cabin while you go to the FBO to order refueling and grab food for the passengers. It is at the moment when it turns out that the food has been delivered to another FBO that you meet your passengers already showing noticeable signs of impatience. It's time to fly! The main passenger, without waiting for you to introduce yourself, irritably reminds you of the departure time. You quickly slam the plane door shut, climb into the cockpit, start the engines and focus on taxiing, finding yourself at the end of a long line of planes waiting to take off. During the pre-flight report, one of the passengers is already pestering you with a question where to find a bottle opener. The pace at which air traffic controllers issue takeoff clearances only adds to the tension.
Another busy day in the life of business aviation. And we all know that such developments lead to unfortunate errors, such as forgotten luggage or deviation from specified altitudes during the notorious fifth flight pattern from Teterboro (which carries the risk of colliding with planes landing at international Airport Newark. - Approx. ATO). Most of these mistakes can be survived. Most, but not all.
The most serious accident ever to occur in aviation - the collision of two Boeing 747s in fog on the runway of Tenerife Airport (Canary Islands) in March 1977 - was directly related to the problem of lack of time. The crew of the KLM airliner was concerned about the need to return to Amsterdam before the end of their mission. work shift, and the fog could thicken. The most experienced PIC, KLM chief pilot Jacob van Zanten, urged his subordinates: “Hurry up, otherwise the weather will worsen again, this time completely.” The ensuing collision between the takeoff plane and a Pan American Boeing 747 taxiing on the runway claimed the lives of 583 people.
A National Transportation Safety Board (NTSB) study of 37 major U.S. airline crashes between 1978 and 1990 found that more than half of the planes involved were late or behind schedule before the fatal flight. The NTSB concluded: "Pilots should be cautioned that as pressure and speed increase in order to stay on schedule, the likelihood of making an error may increase."
In the report "Human Factors and Pre-Flight Inspection," published in 1990 by the NASA-Ames Research Center, Earl Wiener, a former military pilot and president of the Human Factors Society, argues that the desire to stay on schedule at all costs creates many errors. prompting the crew to take incorrect actions when the pilots are trying to quickly complete the pre-flight check of the machine. In addition, attempts to save time often push this check into the background; some pilots may simply skip part of the check procedure.
Christopher Wickens, former head of the human factors department at the University of Illinois at Urbana-Champaign, found a very clear relationship between reaction time and error rate. When pilots, due to lack of time, take only a quick glance at the instrument panels, the accuracy of their perception is reduced, which increases the likelihood of errors. Moreover, James Reason, a world-renowned human error researcher, found that lack of time increases the likelihood of an error by approximately 11 times. If we consider the most important factors, increasing the likelihood of human error, then haste will come in second place, second only to general ignorance of the task.
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In a review of 250 ASRS preflight inspection reports, I found that preflight inspection violations due to time constraints were second only to those due to inattention or multi-tasking.
There is no doubt that pilot haste is a potentially dangerous hazard that must be properly controlled.
According to the collection of ASRS reports I have from charter and business pilots, busy flight schedules appear as the main reason for rushing, as it leaves insufficient time for all ground operations. Many reports provided examples of how pre-existing reasons for rushing were exacerbated by the condensation of traffic from ground services that typically occurs during sporting events. high level or on popular holiday destinations during the appropriate season. At such times, ground services prepared in advance for work can be literally worth their weight in gold.
The vast majority of reports indicate that pilots find themselves under time pressure for several reasons, in particular due to problems associated with serving passengers, such as their being late, changes in the flight route or type of cargo carried, and excess baggage.
The air traffic control system is responsible for approximately a third of all incidents that occur due to lack of time. Sometimes problems arise from changes in departure intervals, intersecting takeoff requests, fast taxis, refined clearances, or complex clearances that require spending a lot of time with your head down to program the FMS (flight management system).
The consequences of a lack of time can be varied, and reports often highlight several at once. For example, sometimes the crew of an airplane does not comply with the altitude prescribed in the departure pattern, and also discovers that in the pre-flight rush one of the dispatcher’s messages went unnoticed. So the number of impacts exceeds the 250 events recorded by ASRS.
Of all the undesirable consequences of rushing, the most common is deviation from ATC instructions. Very often this takes the form of deviation from given height during takeoff. Thus, 57 of the 159 noted deviations from ATC recommendations included an incorrect climb, and 38 - a deviation from the assigned route.
The second, most unpleasant consequence of haste is the careless study of the relevant flight documentation. While fairly common, this deficiency is associated with critical operational issues, including flying outside of MEL (Minimum Equipment List) restrictions. Such violations include entering RVSM airspace with an inoperative autopilot or planning a flight to an airport with an icy runway with the reverse control blocked. This also includes insufficiently careful study and assessment of weather conditions along the route and at the point of arrival, as well as the possible impact of thunderstorms, lightning and icing on the flight. Some errors in this category involve crews who discover only after takeoff that the weather conditions at the destination airport are below the established weather minimum or that the airport is closed for an air show; or it turns out that the runway on which the landing was planned is closed, and none of the crew members bothered to read the NOTAM telegrams before departure. Finally, mention should be made of incidents where the documentation sent contained errors - such as incorrect aircraft number, incorrect weight and balance, or incorrect crew names - that went unnoticed in a hurry.
The "Other errors" section includes forgotten in-flight meals or coffee cups, obtaining permission to take off an aircraft that had been forgotten to refuel, or, as has happened on several embarrassing occasions, attempting to take off while the airfield launch unit was still connected to the aircraft. Other mistakes made in haste are failure to set the flaps to the takeoff position and/or use of the wrong takeoff mode, resulting in undesirable aircraft behavior during takeoff. Despite the fact that none of these errors, admitted by the pilots themselves, led to tragedy, they were quite capable of causing it.
Many of the survey participants reported errors, the results of which became evident much later than when they were made—already during the flight. The most typical of these is the crew programming the wrong waypoint into the FMS while still on the ground; The crew learns about the mistake made only when they hear the dispatcher’s voice: “Airplane so-and-so, where are you flying?”
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Flight phase |
Number of aircraft |
Number of incidents |
|---|---|---|
| Pre-flight preparation | ||
| Taxiing | ||
| Takeoff | ||
| Climb | ||
| Cruise flight | ||
| Decline | ||
| Approach | ||
| Landing | ||
| Taxiing | ||
| Post-flight check |
After studying errors made by flight crews, Loukia Loukopoulos, a Navy aviation specialist, and Kay Dismukes, a senior researcher in the Human Factors Research Group at Ames, noticed that most tasks in flight are performed sequentially, meaning one task always follows another. For example, switching the engines to takeoff mode is accompanied by its control using sensors.
Pre-flight preparation, on the contrary, does not have a clearly defined sequence of actions and tasks. Thus, food can arrive on board simultaneously with the delivery of fuel. At the same time, you may need to check the latest weather data, make amendments to the flight plan, quickly resolve the issue of taking on board additional fuel in case of possible delays in transit, contact control specialists Maintenance regarding its implementation, discuss MEL restrictions with the chief pilot, etc. All these events occur again and again in a completely chaotic manner, and their unpredictability largely determines the occurrence of time pressure.
Developing a standard sequence of actions to rank similar tasks and correct placement priorities is an almost impossible task; As Drs. Loukopoulos and Dr. Dismukes note, it is extremely rare that one problem that arises during preflight preparation would require that some other problem be addressed first. This state of affairs greatly contributes to the occurrence of errors.
Battelle Institute staff McElhetton and Drew put forward another reason why errors occur much more often during pre-flight preparation; in their opinion, the division of the crew is to blame. “During a flight, the crew sits in the same cabin and has unlimited communication with each other; people are close to each other and can easily come into contact. This facilitates the practice of crew resource management (CRM),” they note. “However, during During pre-flight preparation, the physical isolation of crew members from each other and the diversion of their attention to various constantly changing external sources of information can reduce the intensity and effectiveness of interpersonal communication." In addition, McElhetton and Drew note that external distractions and fear of falling behind schedule significantly predispose crews to make errors, which are most pronounced during pre-flight preparation.
The crews who submitted the reports included in the sample admitted making errors in 176 cases while taxiing the aircraft onto the runway, and 78 of these directly led to the aircraft being in an undesirable condition. By the way, some of mistakes made resulted in potentially very serious incidents on the runway.
As noted earlier, most crews make not one, but several errors (on average 2.3 errors per crew), and in some cases the number of errors reaches five. There is a clear connection: the more the crew rushes, the more mistakes they make.
In 64% of the 125 reports McElhetton and Drew analyzed, a “mental or emotional predisposition to rush” was found to be the main cause of errors. The study authors further note that flight crew often allow themselves to succumb to pressure from company dispatchers, ground services and technical personnel or agents working with passengers; in turn, these people themselves are subject to various external pressure aimed at the timely completion of all pre-flight and in-flight operations.
So, now that we know our main enemy, what can we advise the crew to do to better deal with this problem? In their study, McElhetton and Drew recommend that airlines make pre-flight operations more structured. However, as far as business aviation is concerned, it is quite difficult to implement these recommendations.
Of course, it is best not to give in to haste, although it is quite difficult to work steadily and methodically when the big boss arrives at the plane late and demands that it take off immediately! In fact, many pilots who file reports with ASRS note how they feel that if they don't hurry up with their lunch, their jobs will be in jeopardy. While airline crews are spared pressure from passengers thanks to union rules and closed door cockpit, pilots working in business aviation are generally deprived of any protection in this regard. Air ambulance pilots have it worst of all, because they know that someone’s life depends on the speed of their actions.
The rest of the recommendations developed based on the results of a study by representatives of the Battelle Institute are much easier to apply in business aviation. These include being constantly aware of the possibility of rush syndrome during pre-flight preparation and taxiing to the runway. Pilots must be especially careful if they are under time pressure during these stages. In such a situation, they must have enough time to reassess their actions and prioritize tasks. Crew must employ sound relationship management techniques to prevent potential errors by strictly adhering to check procedures during pre-flight preparation and taxiing to the runway. Work related to documentation and other non-essential operations should be performed at less busy stages of work.
All the research points to a very clear conclusion: when we are in a hurry, we are prone to making mistakes. As aviation becomes increasingly time-constrained these days, undue haste is a threat that requires careful consideration by the pilot, his superiors, and flight operations managers.
Any plane crash immediately raises questions about the safety of airliners and the threat of terrorism. But until their causes are officially established, it is unreasonable to speculate about what could have caused the failure. However, there are several causes of airliner crashes that are more likely than others.
1. Pilot error
Over time, airplanes become more and more reliable, but at the same time, the number of accidents caused by pilot error is increasing. Currently it is about 4%. Aircraft are complex machines and require real skill to fly them. Because the pilot is actively interacting with the aircraft at every stage of flight, there are many opportunities for things to go wrong, from an incorrectly programmed computer to misjudging the amount of fuel for a climb.
Sometimes only a pilot can save your life
And while such mistakes are unforgivable, it is important to remember that the pilot may also be your last hope when the situation turns dire. For example, in January 2009, an Airbus A320 crashed into a flock of geese over New York. The ship's captain had to weigh all options and act very quickly. Using his extensive flying experience and knowledge of aircraft handling, he directed the aircraft into the Hudson River. Thus, the lives of 150 people were saved not thanks to computers or any automated systems. They were rescued by two pilots, although many fans of technological progress claim that people can be replaced by computers and dispatchers. 
2. Mechanical problems with the airliner
Equipment failure still accounts for 20% of aircraft losses, despite improvements in manufacturing quality and design updates. Even though engines are more reliable than they were half a century ago, they still sometimes create catastrophic situations.
In 1989, a disintegrating fan blade caused the left engine to fail on a British airliner. Difficulty reading indicators measuring instruments led to the pilots turning off the right engine instead of the damaged left one. Due to the lack of working engines, the plane crashed on the airport runway, which led to the death and injury of many passengers and the captain of the ship himself. 
Just recently, one of the Indonesian airliners also began to crash due to engine failure. It was only thanks to the skill of the pilots that he landed safely.
Sometimes new technologies also cause disruptions. In the 1950s, for example, jet aircraft faced a new threat with the introduction of high flying. Because of overpressure The metal on the body was wearing away. After several crashes, some aircraft models were taken out of service pending changes to their designs.
3. Bad weather conditions
Bad weather conditions lead to 10% of aircraft losses. Despite many electronic aids such as hydroscopic compasses, satellite navigation and the availability of weather data, aircraft are still caught in storms, snow and fog. In December 2005, one of the planes in America tried to land in a snowstorm. He left the runway and crashed into a row of standing cars. A small child was injured. 
One of the most famous incidents due to bad weather occurred in 1958, when a British twin-engine passenger plane crashed while attempting to take off. Researchers determined that the ship was slowed down by runway contamination and was unable to reach the required speed. Surprisingly, lightning does not pose a threat to airliners, despite the fact that fear of it is quite common among passengers. 
4. Terrorism
About 10% of aircraft losses are caused by sabotage. As with lightning, the risk associated with terrorism is much less than many people think. However, there were numerous shocking attacks on aircraft. In September 1970, three passenger jets were hijacked in Jordan. This marked a watershed moment in aviation history and prompted greater safety awareness. Hijacked by representatives of the Popular Front for the Liberation of Palestine, these three planes were blown up in front of the world press. Despite all the security improvements, it is still possible for terrorists to board an airplane. Fortunately, this happens very rarely indeed.
5. Other human factors
The remaining losses are attributed to other types of human error. They may be authorized by air traffic controllers, dispatchers, forklift operators, gas tankers or maintenance engineers. Sometimes you have to work long shifts, and all these people can theoretically make catastrophic mistakes.
In 1990, a blowout windshield on a British airliner nearly cost the life of the plane's captain. Almost all 90 windshield bolts were smaller than the required diameter, according to the Air Accident Investigation Branch. But instead of being held accountable for the discrepancy between the bolts and countersunk holes, the maintenance engineer responsible for installing the new windshield blamed it on the oversized countersinks. In fact, this event was preceded a sleepless night, and because the engineer was very tired, he was unable to install the windshield correctly.
It is expected that the location of the Tu-154 that crashed in Sochi, killing 92 people on board, will be discovered today. The bodies of the victims are already being delivered to Moscow for identification. According to Minister Maxim Sokolov, who heads the investigation into the disaster, the version of the terrorist attack is not the main one. However, Tu-154 pilots interviewed by Gazeta.Ru do not agree with this and claim that the plane fell apart in the air.
The search continues
On Monday morning, the first plane arrived in Moscow from Sochi with the remains of the bodies of those killed after the crash of the TU-154 plane. This was announced by Deputy Minister of Defense Pavel Popov. According to him, as a result of the search and rescue operation, 11 bodies and 154 fragments of the bodies of those killed in the plane crash were found. IL-76 aircraft are used for transportation.
Identification of the dead will take place only in Moscow, said Transport Minister Maxim Sokolov, who headed the government commission created on the instructions of the president to investigate the causes of the disaster in Sochi. According to him, other legal significant actions will be carried out in the capital, including with specialists from the Investigative Committee of the Russian Federation, representatives of the Social Insurance Fund and other departments.
As the Ministry of Defense reported earlier, the search operation in the area of the plane crash lasted all night and did not stop for a minute.
Experts carefully analyzed objective monitoring data from radar equipment. The flight path of the Tu-154 has already been determined, the search for debris is being carried out 6 kilometers from the coast, the military department said.
At the same time, the group involved in search work, reported the Southern Regional Center of the Ministry of Emergency Situations. Its total number exceeds 3.5 thousand people and 200 pieces of equipment. These are the forces and means of the Ministry of Emergency Situations of Russia, the Ministry of Defense, the Federal Air Transport Agency, Rosmorrechflot, the Border Directorate of the FSB of Russia, the Ministry of Health, law enforcement agencies and authorities state power Krasnodar region. Ships, divers and aircraft continue to arrive in the operation area.
The Ministry of Defense expects that the location of the crashed plane will be discovered today.
In particular, the Commander-in-Chief of the Russian Aerospace Forces, Colonel General Viktor Bondarev, said that the military already knows where the black boxes are located.
"IN mandatory when an aircraft is detected at the bottom of the sea, information storage devices will be raised, we know where they are - in the keel, I am sure that it was the keel that suffered the least damage,” Bondarev said.
He also said that there are enough forces and means to detect the Tu-154. “A huge number of personnel have been allocated, technical means, aviation equipment, forces involved Black Sea Fleet. Plus, the Ministry of Transport, the Ministry of Emergency Situations and the enormous assistance are provided by the forces and resources of the Russian Geographical Society.
I think today is the day when we will be able to locate the aircraft at the bottom of the Black Sea,” the general said.
According to Maxim Sokolov, who heads the investigation into what happened, the terrorist attack is not included in the main versions of the causes of the disaster. It could have been a technical malfunction or pilot error, the minister said. The reasons are being established by the investigation, as well as by a special technical commission of the Ministry of Defense. It is not yet advisable to introduce additional security measures at Russian airports, Sokolov noted.
Pilot versions
The Tu-154 has an air pressure receiver, which is designed to measure speed, a specialist close to the Tupolev Design Bureau told Gazeta.Ru. According to him, this so-called receiver must be warmed up before departure, otherwise it shows the wrong speed.
“After takeoff, the Tu-154 was supposed to gain altitude in circles in the Sochi area. Two minutes after takeoff, its altitude should have been 800 meters. And if the air pressure receiver showed the wrong speed, then the plane could easily go into a tailspin, get caught in the water and fall to pieces,” the interlocutor explained.
There could be no piloting error, the commander of the Tu-154 ship, first class pilot, holder of the Order of Courage Nikolai Vinogradov, is sure. He also notes that the plane that crashed near Sochi is quite young.
“The plane is supposed to fly 35-40 thousand hours, the plane only flew about 7 thousand. In my park in Vnukovo there were airliners that had already flown 30 thousand, and they can still fly,” Vinogradov told Gazeta.Ru. According to him, the plane fell apart in the air.
“The cause of the disaster is what happened in Sinai: the plane began to fall apart in the air. For what reason - it will be clear when the boxes are lifted. Maybe it's some kind of corrosion or something else. But what is noteworthy is the fact that people are found on the shore, pieces of the plane are found 1.5 km from the coastline, and the main part of the ship lies 6 km away. That is, it turns out that parts of the plane flew into reverse side from it, and people swam ashore and died there,” says the pilot.
Here half were thrown ashore, the rest drowned 6 km away.”
The pilot explained that when a plane falls into the sea and hits the water, the debris cannot fly in the opposite direction, but, on the contrary, will fly by inertia along the wind in which the plane was traveling.
Tragedy of Tu-154
According to the Ministry of Defense, a military transport plane took off from Chkalovsk near Moscow to Syria at the Khmeimim airbase on Sunday at 1:38 Moscow time. There were 92 people on board. Among them are the crew of the aircraft, military personnel, journalists from the Zvezda, NTV and Channel One TV channels, as well as artists from the Alexandrov Ensemble, who were supposed to give a New Year's concert in Syria, as well as the famous philanthropist Elizaveta Glinka.
On the way to Syria, the plane was supposed to land for refueling in Mozdok, but due to weather conditions the airfield was changed to Sochi, the military clarifies. Two minutes after takeoff from Adler airport near the city of Sochi, the plane disappeared from radar. This happened at 5.25 Moscow time, according to the official statement of the Ministry of Defense.
As for me, I think that version of the terrorist attack more than likely for the sole reason that Lubyanka immediately and immediately threw a scarf over every mouth reporting to her. And they all unanimously and confidently deny this version. How can you deny, and even so confidently, if there are not even black boxes?
Well, actually, these boxes can “appear” in public only in one case – if they deny this version. But if they confirm it, then they are guaranteed “not to be found.” It is no coincidence that the entire area, even the coastline, is blocked by security forces. Intermediate option - Lubyanka will state that the boxes have been found, and that they confirm one of official versions. But these boxes will not be shown to anyone.
Well, here it is, read:
Tu-154 recorder deciphered: piloting error confirmed
The conversation is interrupted by one of the pilots exclaiming: “Flaps, bitch!” And then a cry is heard: “Commander, we are falling!”
The Russian Ministry of Defense conducted a preliminary analysis of the recordings of one of the flight recorders of the Tu-154 aircraft that crashed into the Black Sea near Sochi on Sunday. The findings confirm the version of pilot error. Interfax reports this with reference to a source.
“The preliminary analysis of the recorder readings has been completed. It allows us to conclude that the version of the disaster associated with an error in the piloting of the aircraft is a priority,” the agency’s interlocutor said.
He did not provide any details related to the black box recording.
Shortly before this, another agency source reported that the plane, according to preliminary data, crashed due to a “stall” with insufficient wing lift for takeoff.
According to him, the flaps of the Tu-154 worked out of coordination, as a result of their failure, the lifting force was lost, and the speed was not sufficient to gain altitude. For what reason the flaps may have worked abnormally has not yet been established.
There is no official confirmation or refutation of this version yet.
“The conversation is interrupted by one of the pilots exclaiming: “Flaps, bitch!” And then a cry is heard: “Commander, we are falling!” the source said.
A Russian Ministry of Defense Tu-154 plane crashed early in the morning of December 25 in the Black Sea, near Sochi. On board were Russian military personnel, journalists from pro-Kremlin channels, artists, as well as Elizaveta Glinka (Doctor Lisa), the head of the Fair Aid Foundation, who illegally smuggled children from the occupied Donbass to Russia.
The plane was heading to Syria, where the artists of the Russian Army Song and Dance Ensemble planned to give a New Year's concert for the Russian military contingent.
There were 92 people on board. According to official data, they all died.
The investigation is considering several versions of the plane crash, including a technical malfunction and human error. The version of the terrorist attack is considered unlikely.
I don’t know about you, but I was overwhelmed with this “information” to confirm that it was a terrorist attack.
And I can imagine how Lubyanka is now lying at the feet of the Pentagon, so that the results of space reconnaissance are not published! You can bargain for a lot...
But here's what's interesting to me. What will they do if the Americans wait until they get bogged down in their nonsense with recorders, and then take and publish satellite images? This will be fun!
The main causes of plane crashes include:
Failure to comply with ATS recommendations. Thus, on March 28, 1969, the UGA An-2 airliner, en route from Dushanbe to Kalai-Khumb, crashed due to the crew violating flight rules);
deviation from a given route, altitude. On December 25, 2016, a Tu-154 airliner flying from Moscow to Latakia crashed after 70 seconds in the air. The reason is the pilot’s disorientation, which led to the fact that instead of continuing to climb, the pilot began to descend;
partial familiarization with the documentation, including technical instructions, instructions, etc., their failure to comply. So, an example would be the Boeing 757 crash near Lima on October 2, 1996. One of the reasons for the plane crash was the taping of the speed-altitude sensor systems by E. Chakalias, who was temporarily acting as an auditor, and did not know the full importance of the standard procedure entrusted to him. He simply forgot to remove the insulating tape;
errors in FMS programming systems. Such a failure occurred in the iPad tablets used by the crews. This led to the delay of 20 flights. After analyzing the situation, security specialists confirmed that errors in software Boeing 787 aircraft would definitely lead to a complete loss of control of the aircraft.
In terms of frequency, such violations of aircraft operation are second only to errors caused by the need for the pilot to simultaneously perform several duties. Numerous ASRS reports indicate that pilots are responsible for 1/3 of all airborne incidents that occur. main reason such statistics - lack of time.
