To Error is Human

This year’s nationwide FAA Safety Stand Down took a realistic and practical approach to human error by first acknowledging that, because we have a brain, we are susceptible to making unintentional mistakes for a multitude of reasons. The question isn’t “have you ever,” but rather, how many times have you started to go to the store, but when you got to the first intersection, you took the turn to work? How many times have you locked your keys in the car or house? Had trouble finding where you left something? These are little errors with no serious results, but you can make the same kind of simple errors of omission or commission while flying an airplane and the results can be significant or even deadly.

The more important the task, the graver the consequences of an unintentional slip or error can be. Contrary to our desire to think only irresponsible people make mistakes, they can and do happen to the best intended and most highly qualified people as well.

KLM Advertisement

KLM Advertisement

An example used in the Safety Stand Down presentation was of Captain Jacob van Zanten, a KLM Royal Dutch Airline Boeing 747 instructor pilot who was featured in their ads that boasted of the airline’s safety, efficiency and professionalism. Unfortunately, van Zanten was also the captain of the KLM 747 that misunderstood the tower clearance at Tenerife in the Canary Islands, which resulted in what is still considered the aircraft disaster with the greatest loss of life.

How do we avoid making unintentional errors given that we never meant to make the mistake in the first place? We need to understand how our brain lets us make those errors so we can work to prevent situations where we are more prone to them. These conditions are easily recognized when discussed in safety meetings, but they are subtle. And it’s hard to assess their impact on our day-to-day activities as well as while flight planning or in flight. They are brought on by things like hunger, fatigue, medication and stress. Your thought process can be degraded at times due to trance, hallucination or monotony. It’s easier for your mind to wander or be distracted if you are tired, hungry or too cold or too warm. It’s also easy to not pay attention when everything is “just right.”

You have to work to keep your brain in the game when flying. Checklists help, and cockpit discipline is good too. Run all the required checklists for takeoff, climb, cruise, descent, and before and after landing. But on long flights you need to do things to monitor the flight progress between each waypoint in addition to all the checks at each waypoint so you’re ahead of the airplane and ready for any unexpected developments. Actively seek information throughout the flight to help you determine if something might happen or is happening to make things go differently than the flight plan you started with. Do not be committed to completing the flight as you had intended. If the situation dictates, you need to be prepared to take an alternate route or go to an alternate airport. Don’t let external pressures force you into a poor decision.

F-4 on Approach

F-4 on Approach

One Friday evening in December while flying a night instrument training sortie in Germany, my navigator and I started our approach to learn that the weather was worse than forecast and intermittently below minimums. I was scheduled to leave for vacation Saturday morning and planned to drive to Switzerland for a week of skiing. You can guess that the weather gods did not cooperate, and I had to divert to our alternate and spend the night there. Happily, the alternate was on the way from my home base to Switzerland. So on Saturday morning, another pilot from my squadron rode with my wife to the alternate. I gave him the airplane, jumped in the car and headed for Switzerland. Granted, not all weather diverts can work out that well. But being on the ground at the alternate with the opportunity to continue when the weather improves is always better than running out of gas or having an accident trying to fly an approach when the weather is too bad.

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About Rich Martindell

Instrument flight instructor (CFII), rated airline transport pilot (ATP), former military instructor pilot in F-4s and F-15s. Aircraft accident investigator and flight safety consultant. FAA Safety Team Lead Representative.
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