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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 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—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.

If you keep using checklists, they'll help make sure you're following critical steps both before and after flight.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.

[email protected]

Alyssa J. Miller
Alicia Herron
Publications Content Producer
Publications Content Producer Alicia Herron joined AOPA in 2018. She is a multiengine-rated commercial pilot with advanced ground and instrument flight instructor certificates. She is based in Los Angeles and enjoys tailwheel flying best.

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