M2.3 Pilot Error

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Embry-Riddle Aeronautical University *

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330

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Mechanical Engineering

Date

Dec 6, 2023

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docx

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Uploaded by samroth787

Answer the following questions. Your response should contain what you learned from all your reading material; keep it succinct, but apply as much knowledge as possible to answer the questions fully: 1. Does the phrase "pilot error" truly define causation within the accident error chain? 2. Compare and contrast the difference between cause or blame. 3. Explain the value of the model concepts relative to detecting organizational factors or elements of the error chain on accidents such as Zonk Air or other mishaps. Hi all, I think a lot of the reading material from the past two weeks is continuously reinforcing that ‘pilot error’ does not define causation in a chain of errors resulting in an accident. Rather, the combination of errors is the cause of the accident. Although the pilot may have been the last influence in a line of others, this does not make them the cause of the accident since absent of the factors occurring before the pilot’s action, the accident would not have happened. Understandably, people like to blame one source of error (person, condition, etc.) because that makes it easier to tackle the problem and hold individuals accountable. It takes much more mental effort to understand the nuances of an aircraft accident and the range of factors contributing to the final occurrence. As mentioned, accidents result from a chain of events. Cause would refer to the factors assisting the accident in happening – in other words, “causing” it. Blame would refer to the person or factor deemed responsible for the accident, or being “blamed” for it. Acknowledging that accidents result from a chain of events does not mean no one is responsible, despite no single factor being the reason for the accident. For example, in the Peak 1680 accident reviewed this week, the pilot chose to continue the approach after being notified of the wind gusting 45 knots. Assuming everything else occurred within the scope of company rules, if the company allows landings in that condition perhaps the rules need further analysis and updating. However, simply stating pilot error is the cause because the pilot is the one to perform the action helps no one except the uninformed masses looking to feel better by assigning blame. Now for the fun part: accident investigation models. Any of the concepts we look at concern themselves with the chain of events leading to the accident, not only one cause, further proving that simply tossing out “pilot error” gets us nowhere when it comes to making aviation safer by preventing similar future events. Each model has its own way of focusing on the factors leading up to the accident, such as training, environment, and culture.  The 5M model determines that analyses of 5 elements (or 6 in some places) will allow investigators to identify the different factors taking part in causing the accident. Each element is tied to multiple factors. For example, the Medium component looks at weather, runway conditions, and topographic design.

 The HFACS model focuses more on identifying human factors playing a role in the causes of the accident. This model detects defective operational human factors that may contribute to the accident by organizing the factors into four main sources: organizational influences, supervisory factors, preconditions for unsafe acts, and unsafe acts.  The SHELL model, somewhat similar to the 5M model, emphasizes four (or five) main elements. Unlike the 5M model, SHELL concentrates on the interaction between humans and machines. For example, the H in SHELL stands for hardware. This refers to a factor in which the human interacted with the hardware and it became a cause in an accident error chain, like a defective lighting design in the flight deck. References

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