Flight Training - August 2024 - 22

PREFLIGHT ACCIDENT ANALYSIS
BY ALICIA HERRON
IT'S ME. HI. I'M THE PROBLEM.
HUMANS CONTINUE TO BE THE PROBLEM IN ACCIDENTS
WE TALK ABOUT HUMAN FACTORS OFTEN
in aviation safety. This makes sense,
because the human element is nearly
always an influence on accidents and
incidents. There are two primary elements
in human factors: the human and
the machine. Of these two, we already
know which one is more reliable.
When it comes to the machine, in our
case we're talking about the whole of the
airplane. Human factor is why you like
(or dislike) the way your glass avionics
look, and what makes the display easy
or difficult to interpret. It's what makes
navigation on your cellphone easy and
intuitive or confusing and frustrating. It's
also when you don't notice that you're
on GPS mode instead of Nav mode, and
when the fuel selector switch is in an
inconvenient area and a pilot moves it
(or doesn't) erroneously, and it's what
makes the yoke or stick comfortable (or
uncomfortable) to hold. It is, essentially,
the accumulation of little things that
make interacting with a machine, in this
case an airplane, easier, safer, and more
intuitive. Good human factor design
forms the machine to our strengths, and
it also informs the way we interact with
that machine based on our weaknesses.
According to peer-reviewed studies,
pilots overestimate their own abilities.
Part of this overestimation relates to our
ability to perform at our best in all phases
of flight. One historically weak component
of the human mind that influences
performance? Memory.
Our memories are frail and changeable-much
more so than you may
think. In fact, each time we access a
memory, there is a chance it can become
corrupted, and then saved again with
that corruption. Do you ever muse on a
particularly happy or sad moment and
with time it seems to become even more
TRAPPED IN ICE
Learn more about the Cirrus accident in this Accident Case Study from the
AOPA Air Safety Institute. airsafetyinstitute.org/ACS/TrappedInIce
22
FLIGHT TRAINING AUGUST 2024
joyous or even more miserable? It is
possible that you are rewriting it with
your rumination, changing it from fact
more and more each time. In many components
of life, this matters little. But in
others, like witness testimony in courtrooms
and relying on memory in flight, it
can make a huge difference.
There are different classifications
of memory, and in flight, we often use
procedural memory and relative position
memory. Procedural memory is knowing
what steps to take to achieve a goal-
IF YOU KEEP USING
CHECKLISTS, THEY'LL HELP
MAKE SURE YOU'RE FOLLOWING
CRITICAL STEPS BOTH BEFORE
AND AFTER FLIGHT.
essentially our flow. And relative position
memory is knowing where to reach for
each step with our eyes closed; we also
use this skill when we know where to
reach for a light switch in the dark or
can walk around a room at night without
hitting any furniture. But like all memory,
without repetition, we lose it.
The weaknesses in our memory are one
of the huge reasons why we use both flows
and checklists in flight, and one of the reasons
why professional pilots must receive
such regular and rigorous training. As GA
pilots, we are not subject to that rigor, and it
is up to us to stay sharp. Even with regular
practice, your memory will fade, possibly
without you even noticing, and you may
omit steps on a flow or even forget to do it.
But if you keep using checklists, they'll help
make sure you're following critical steps
both before and during flight.
In an accident that occurred a few years
ago, checklist usage (or lack thereof) could
have played a critical role. A Cirrus flew
into forecast icing conditions, and after
making the incorrect choice to take off despite
the forecast, the pilot ultimately made
the correct choice to divert. Following
a track consistent with autopilot usage,
it appears that the pilot did not capture
the final approach path at the diversion
airport. At this point, he likely kicked off the
autopilot and tried to turn back toward final
approach. During the turn, he lost control
of the aircraft and crashed, killing both
himself and his nonpilot passenger. He was
above the minimum altitude for the Cirrus
Airframe Parachute System-so why didn't
he pull the chute?
The NTSB's investigation showed that
the pin for the parachute was not removed.
This remove before flight tagged item is on
multiple checklists and on the pin itself-
both during preflight and before takeoff.
Why the pilot did not remove this pin is
impossible for us to say, but it highlights
the importance of relying on checklists
instead of memory, since we can assume
that it was never the pilot's intention to
disable a potentially life-saving device.
While another pilot's lack of checklist
usage might not have such devastating
consequences, and it is also possible the
pilot didn't recognize the danger he was in
and never attempted to deploy the chute, it
is still a stark reminder of the importance
of checking and verifying.
Whether you're a skygod or a
brand-new pilot, all minds are subject to
weaknesses. Remember (if you can...) that
our memories are a weak point and keep
up the flow practice and checklist usage.
If nothing else, it'll create a good habit
and keep you safe. At worst, you could
disable one of your most important tools.
alicia.herron@aopa.org
http://www.airsafetyinstitute.org/ACS/TrappedInIce
Flight Training - August 2024

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