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Why are Routine Flight Operations Killing Pilots and their Passengers?

by Robert Baron, The Aviation Consulting Group


Routine flight operations present pilots with a myriad of latent threats. Three accident scenarios are presented that exemplify how a routine flight operation can end in disaster. The pilot's complex and dynamic psycho-cognitive behaviors are analyzed and show that satisfactory technical training alone does not make a safe pilot.

More emphasis needs to be put on the "human system," the most likely system to fail in flight. Recommendations address the areas where intervention and education may mitigate some of these issues.


The crew had just finished recurrent training. The instructor praised both pilots for exemplary performance in the simulator, and attested to that fact with positive comments on both pilot's grade sheets. Both pilots had thousands of hours of flight experience and thousands of hours of combined time in the particular make and model they were flying. They were back on the line the following day.

Their first leg back on the line proved tragic, as both pilots, and 27 passengers were killed when the aircraft descended prematurely on a non-precision approach at night. As usual, the first question asked was "what happened?" How could such an experienced and well-trained crew commit this type of error, especially the day after they received recurrent training and were commended on their skills?

This is but one example of a routine flight operation gone terribly wrong. The pilots had flown into this airport on numerous occasions, albeit during daylight hours. The weather was reported to be good Visual Flight Rules (VFR), the wind was calm, and the runway was 10,000 feet long. Visual Approach Slope Indicators (VASI's) were available to establish a proper glide angle to the runway threshold. But for some reason, the crew descended below the VASI's prematurely, causing the aircraft to impact the ground a few miles from the end of the runway. Another classic Controlled Flight Into Terrain (CFIT) accident has occurred. A perfectly airworthy airplane, under complete control, was flown unintentionally into the ground without any prior awareness by the flight crew.

This example shows us, in its purest form, where technical training ends and human factors begin. This type of accident occurs more frequently than one would be led to believe. The pilots assumed this was a routine flight. After all, the weather was good and there was nothing wrong with their aircraft just minutes before landing.

As it turns out, the captain, who was the pilot flying, was compelled to attempt a night visual approach to the runway, even though the VOR Runway 17 instrument approach was briefed and set up earlier. When the first officer queried the captain on this discrepancy, the captain replied that he "wanted to shoot the visual approach since the weather was good and it would save some time." That was the last discussion recorded on the Cockpit Voice Recorder (CVR) before the sound of impact, approximately two minutes later.

In a macro-analysis of this accident, it was concluded that the aircraft impacted rising terrain approximately 2.3 miles from the runway threshold. Additionally, the aircraft was 800 feet lower than it should have been at that point if the pilots had executed the VOR Runway 17 instrument approach. For a technically proficient crew, which this crew was, the instrument approach alternative would have been routine, and the outcome would likely have had a more successful result.


This scenario might be considered a quintessential example of failure in human performance. A fully trained, experienced, and competent flight crew committed a series of errors that lead to a Controlled Flight Into Terrain accident. Why?

"Why?" as it relates to aviation accidents, is a very complex and challenging question. The attempt to analyze a pilot's cognitive thought processes extends far beyond the scope of this paper. After all, only the pilot can really answer the question, "what were you thinking?" We can however, use deductive reasoning to look at where some of the problems manifest themselves.

For the sake of simplification, we will look at only two distinct areas: (1) training facility weaknesses, and (2) psycho-cognitive threats during routine flight. A breakdown in these areas can pave the way for the highest and most undesirable event, an accident.


Not enough emphasis put on the most unreliable system in the aircraft, (the pilot):
Pilot training on a specific aircraft can last anywhere from a few days, up to a few months, depending on the type of aircraft. Training facilities put a large amount of effort into teaching systems in the shortest amount of time possible. And while the importance of good systems knowledge is undeniably important, the most failure-prone system, the pilot, is often overlooked or disregarded.

Crew Resource Management training is weak or non-existent at many facilities:
Although many training facilities have begun to incorporate a fair amount of CRM training into their programs, some facilities do not have the time or properly trained facilitators to make a significant impact during a normal training period. After a 2 hour training period, a single CRM debriefing comment by the simulator instructor to the affect of "you should speak up more next time," does not adequately address the problem.

Simulator training time is too compressed. Many emergency/abnormal scenarios that are combined to save time are unfounded and are extremely unlikely to occur in real life:
Some facilities, in the interest of time, will combine multiple emergency/abnormal scenarios. It is extremely improbable that a modern airliner or business jet will experience an engine failure and a total hydraulic failure at the same exact time, and that the pilots will have to execute a circle-to-land approach with the weather right at landing minimums. Yet, these are the types of scenarios that some facilities are training and testing pilots on.

"Routine" flight operations are under-emphasized. Yet, routine flight operations claim many more lives than non-routine operations:
Inasmuch as the previous topic depicted an overdose of non-realistic scenarios, this topic highlights a relatively untouched realm of training: Routine flight operations. Realistically, engine failures, hydraulic failures, and popped circuit breakers are not killing pilots and their passengers. The largest number of crashes and fatalities occur when nothing is mechanically wrong with the aircraft.


The next level picks up where the training ends. At this point, the crew has satisfactorily completed recurrent training and is back on the flight line. All incidences referenced from this point forward are considered "in-flight."

Keep in mind that all three-accident scenarios in this report were due to a failure in human performance, and not a mechanical malfunction. In other words, the problems were not easily identifiable in training, but they became blatantly clear later on.

During flight, the pilot's psycho-cognitive system performs like a computer, inputting thousands of bits of information, with the associated action commands performed as an output. Occasionally, there is a "short circuit" in these processes and the stage is set for problems.

The following list breaks down the events for Scenario One into CRM marker clusters, as defined in FAA Advisory Circular 120-51D. The author has incorporated additional clusters for clarity. Refer to the figure below for a graphical flow of the Captain's behavioral patterns.

Scenario One

  • Proficiency Training- The crew was proficient with no training weaknesses noted
  • Illness/Medication-Neither pilot tested positive for alcohol or drugs, including over-the-counter medication.
  • Fatigue-The crew was well rested
  • Distractions-Distractions were not considered a significant factor in the accident.
  • Stress-Stress was low. During the approach phase of flight, stress levels will normally be somewhat elevated.
  • Workload-Workload was considered routine. During the approach phase of flight, workload will normally be highest.
  • Task Management-Management of tasks became somewhat ambiguous. A last minute change of the approach procedure by the Captain was a factor.
  • Communicative Ability-The Captain's decision to change the approach procedure and not re-brief was the beginning of the "red zone."
  • Complacency-The Captain displayed signs of complacency. He considered this a routine approach and the weather was good. He had also been into that airport many times before.
  • Decision Making-Complacency likely influenced the decision making misjudgment.
  • Personality Traits-Ingrained and hard to change. The Captain's personality included a large amount of machismo, according to pilots who had flown with him in the past.
  • Risk Taking-This is the area where decision making and machismo converge. The Captain had decided to "take the risk."
  • Assertiveness-The First Officer may have had the last chance to trap the Captain's bad judgment. However, the F/O did not speak up and challenge the Captain.
  • Situation Awareness-Due to all the previous unmitigated behavior problems, the crew experienced a loss of situation awareness. A perfectly airworthy aircraft was flown into the ground without any prior awareness by the flight crew.


The crew successfully completed all of the training requirements required for an annual pilot proficiency exam. As in the first scenario, the crew, as a whole, was highly experienced both in total flight hours and in the specific aircraft type.

This particular leg was a repositioning flight. Only the pilots were onboard, who were flying the aircraft to another airport to pick up their passengers and fly them to their destination. The repositioning flight was very short in duration, approximately 15 min. There were no known aircraft anomalies and the weather was considered good for the short flight. The airport facilities were well suited for the type of operation being conducted by this flight crew.

For some reason, the crew decided to perform a circle-to-land maneuver (which requires excess maneuvering to line up with the landing runway, as opposed to straight-in). During the circle-to-land, something had gone terribly wrong. A post crash investigation revealed that the aircraft experienced a loss of control at a low altitude and airspeed, indicative of an accelerated stall. Both pilots were killed. The investigation also verified no defects to the aircraft that may have contributed to the loss of control.

The following list breaks down the events for Scenario Two. Refer to the figure below for a graphical flow of the Captain's behavioral patterns.

Scenario Two

  • Proficiency Training- The crew was proficient with no training weaknesses noted.
  • Illness/Medication-Neither pilot tested positive for alcohol or drugs, including over-the-counter medication.
  • Fatigue-The crew was well rested
  • Communicative Ability-The crew had very good communicative ability. Checklists were called for and accomplished at the right time, briefings were thorough, and there was no ambiguity as to what actions were going to be taken next.
  • Risk Taking-The Captain was not a known risk taker. In fact, interviews with other pilots had indicated that he was rather "passive" and "conservative" in his flying skills.
  • Complacency-It did not appear that complacency played an active role in this accident. The fact that a circle-to-land maneuver is not executed that often would likely have raised the pilot's awareness of the extra vigilance required for that particular maneuver.
  • Stress-Stress levels were in a high caution area for two reasons: 1) Pressure for a timely arrival to pick up paying passengers, and 2) An approach that requires a higher amount of monitoring due excessive maneuvering at low altitudes.
  • Workload-The combination of maneuvering the airplane, scanning for other traffic, and properly aligning the airplane with the landing runway significantly increased the workload. This was the beginning of the "red zone."
  • Task Management-Task management became an extremely high threat as the Captain, who was the non-flying pilot, became task-saturated in both monitoring the F/O's performance, scanning for other traffic, and ensuring proper alignment with the landing runway.
  • Distractions-Pervasive distractions during the most critical phase of the approach drew the Captain's attention away from the F/O's dangerously slow airspeed and steep bank angle.
  • Personality Traits-The Captain had a Type-B Personality. Immediate and corrective actions, such as taking the controls of the airplane, may have been hampered by this personality trait.
  • Decision Making-This is the area where distractions and Type-B Personality converge. The Captain decided to let the F/O continue the approach with no apparent intervention.
  • Assertiveness-Assertion on the part of the captain in the form of "callouts" or other verbal warnings were lacking. Additionally, the Captain never made an attempt to take over the controls.
  • Situation Awareness-Due to all the previous unmitigated behavior problems, the crew experienced a loss of situation awareness. A perfectly airworthy aircraft was flown into a dangerous flight regime'an accelerated stall'close to the ground'from which recovery was not possible.


The third and final scenario once again involved a highly experienced crew. In this case a commuter operation. Their last proficiency check included positive remarks on the captain's training record reflecting "good use of CRM," and "excellent Situational Awareness." The first officer's training record had included a notation "excellent flying skills, should be considered for upgrade shortly."

Both pilots were well rested after having the previous four days off. This was their first flight of the day. A routine flight was forecast for the short leg with a passenger manifest of 16 and one flight attendant. The weather would not be a factor. As a matter of fact, it was a remarkably clear spring day. Mechanically, there were no open airworthiness items that could affect the safety of flight.

Approximately one and a half minutes after takeoff, the commuter plane collided with a small general aviation aircraft. Pilots, all 16 passengers, and the flight attendant were killed on the commuter. Additionally, the pilot and two passengers perished in the Piper Cherokee single-engine general aviation aircraft.

The following list breaks down the events for Scenario Three. Refer to the figure below for a graphical flow of the Captain's behavioral patterns.

Scenario Three

  • Proficiency Training- The crew was proficient with no training weaknesses noted.
  • Illness/Medication-Neither pilot tested positive for alcohol or drugs, including over-the-counter medication.
  • Fatigue-The crew was well rested
  • Communicative Ability- The Captain's communicative ability was cause for a moderate amount of caution. In general, he tended to be very impulsive and act without regard to input from previous F/O's that had flown with him.
  • Situation Awareness-Situation awareness was also in a moderate caution area. Pushback and taxi to the active runway was routine and the crew was cognizant of their taxi route, departure clearance, and other potentially conflicting ground traffic.
  • Stress-Stress levels became elevated due to the crew's acceptance of an immediate takeoff clearance before completion of the Before Takeoff Checklist.
  • Complacency-The Captain's decision to be rushed into a takeoff clearance may have been partially influenced by complacency. This can be corroborated by the Captain's comment of "I've done this a thousand times before," captured on the Cockpit Voice Recorder. This was the beginning of the "red zone."
  • Workload-During the rushed takeoff procedure, workload increased to a point where there were so many tasks (checklist procedures) that needed to be accomplished in such a short period of time, that some tasks were omitted.
  • Task Management-Task management was severely degraded due to the reasons stated in the previous cluster.
  • Personality Traits-The Captain's personality traits included a Type-A Personality, which can be classified as a very high caution area. Other pilots who had flown with the Captain described him as a person "always in a rush to get things done."
  • Decision Making-This is the area where task management and Type-A Personality converge. The combination of the Captain's impulsive behavior, coupled with poor task management, led to a spontaneous and risky decision (acceptance of a premature takeoff clearance).
  • Risk Taking-Both the Captain and F/O were willing to assume the risk of an immediate departure based on a repetitive and successful schema ("we've done this so many times before").
  • Assertiveness-The First Officer may have had the last chance to trap the Captain's bad decision. However, the F/O did not speak up and challenge the Captain.
  • Distractions-One of the items omitted on the before takeoff checklist was turning on the Traffic Collision Avoidance System (TCAS). Shortly after becoming airborne, the crew continued to try to "catch up" on the checklist items that should have been completed prior to takeoff. Both pilots were working inside the cockpit and neither was looking outside for conflicting traffic. Due to all the previous unmitigated behavior problems, a perfectly airworthy aircraft was involved in a mid-air collision.


These accident scenarios are a classic representation of human error in its purest form. Human performance is a complex and challenging science. More attention needs to be focused on "why pilots do some of the things they do (or don't do)," and what the associated consequences of those actions might be.

Recommendations for improving the system should address the following areas:

1. Training facilities must put more emphasis on human performance. This might be accomplished with a    stand-alone training module that addresses this area in more detail.

2. CRM training needs to become mandated for all flight operations (currently, the FAA does not require Part 135 on-demand charter pilots to have formal CRM training).

3. CRM Facilitators should have some formal training on proper training and debriefing methods.

4. Simulator training should concentrate on more realistic flight and emergency/abnormal scenarios and avoid simultaneous unrelated systems failures, compounded by the worst possible weather.

5. During ground school and simulator training, an emphasis should be made that "routine flight operations" can become a significant threat and complacency can exacerbate the problem.

6. Pilot selection, particularly below the airline level (i.e., Part 135 charter and corporate aviation) should implement or expand on the use of psychological testing.

7. All pilots should be required to take a formal (credit or non-credit) course on psychology.


In summary, routine flight operations, as benign as it sounds, can and will continue to be a latent threat to flight crews. Training facilities and pilots need to increase their vigilance of this threat and expand on safeguards and awareness training.

On a research level, both NASA and FAA have stepped up investigation into this area. NASA's research on Cognitive Performance in Aviation Training and Operations, and FAA's AAR-100 Human Factors Division, continue to provide valuable data for incorporation into aviation training programs at all levels.


Federal Aviation Administration. AAR-100 Human Factors Division.

National Aeronautics and Space Administration. Research on Cognitive Performance in Aviation Training and Operations. Available at

Presented at the Human Performance, Situation Awareness and Automation Technology Conference (HPSAA), March 24, 2004, Daytona Beach, FL. Mr. Baron and The Aviation Consulting Group can be reached at or 800- 294-0872.

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