The Human Factor of Death

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For my sins – none of which I admit of course, but which would appear to add up to a satisfyingly disgraceful total – I am part of a working group investigating human factors in air display accidents.

It is a depressing task. At this, our first meeting, we sit in an antiseptic room in the Royal Aeronautical Society in London, trying to get into the heads of dead pilots in an effort to help today’s live pilots not to become more dead pilots.

I can almost feel departed friends crowding round saying, “Okay, wise guy; what are you doing here? You’ve made mistakes, and if it wasn’t for luck, you’d be one of us…”

Which, of course, is true.

Among our number in the (live) group is one Des Barker, Major General in the South African Air Force, long-time fast-jet display pilot, author of a book called  ‘Zero Error Margin’ – the very title of which most aptly sums up the problem – and also archivist extraordinary of display accidents worldwide. Des produces for us an analysis of 500 display accidents going right back to 1908! This collation puts the world’s civil aviation authorities to shame because — to my knowledge — not one of them can produce similar statistics for their own countries, let alone worldwide.

The score of accidents for 2007 was 28…the highest number in the last decade, and a figure which has caused a frisson among display organizations around the globe. Some accidents resulted from mechanical failures and so only count as display accidents on a technicality. But, as we sit here, it is gloomily apparent that ten to a dozen were squarely down to good old pilot error, often on the part of humans highly experienced. Error which frequently involved pull-outs from maneuvers which quite simply did not top-out at sufficient height for recovery above ground level.

Unsurprisingly, at this first meeting, we do not come up with any magic bullets. Given time and inputs from around the world, we may eventually grind out something useful. But there is no magic bullet.

The following, then, are not conclusions of the working group. These are purely my own opinions based on some 2,000 displays…some flown well, some not so well.

They are my personal Display Commandments.

Ego and pressure
All display pilots are egotists or they would not be display pilots. Add to ego a goodly smear of pressure-on-the-day — the cloud base which may or may not be just enough, the fuel bowser which turns up an hour late just before your slot time, the marital problem which keeps sneaking round the back door of your mind – and you have a pilot who is tense and ill-prepared. And that is the pilot who just might make that one uncharacteristic mistake.

Pre-flight briefing
It seems probable that most accident pilots had not adequately pre-briefed themselves for the task ahead. I personally regard thorough pre-briefing – your own briefing, that is, above and beyond the general display brief – as being the last bastion of defense before you go out and do something stupid.

My own rule is to fly the display ten times in my head before I go anywhere near the airplane. And also “walk through” the sequence waving my arms about like a demented tic-tac man. This occasions much mirth among observers – some walk a mile to watch the idiot doing his monkey imitation – but it does serve to focus my tiny brain.

It fixes the wind in my mind, and how I’ll be correcting for it. It casts a leery eye at the upwind cloud base and counsels that I may have to change the three highest-topping maneuvers thus, thus and thus. It reminds me this day is hot and humid; and so my mindset is to take out that flick and that flick and make that vertical 4-point roll a non-hesitation, all to conserve energy.

The pre-brief is even more important if weather indeed threatens to change at about the time you’re due to get airborne. In fact, a lowering cloud base prompts a wise aviator to have two pre-briefs: one for if there’s room for the full display, and one for if there isn’t. Thus, you will not be bereft of ideas if on climb-out you arrive at an 1,800 foot cloud base when you need 2,500 to loop.

Heights, top and bottom
Display accidents are aviation’s snuff movies; there’s always somebody filming it. So, time and again, we see an aircraft mushing down in high G and high alpha as the pilot realizes he’s too low just before he hits the ground. Frequently, this misfortune prompts querulous mutterings about low aerobatic base heights at air displays.

But it’s not at the bottom of the figure where the guy made the mistake. Rather, it’s at the top, where he failed to check his top-height minima before pulling on round. He actually killed himself at 1,000 feet or 2,500 feet or whatever, depending on aircraft type. Having topped-out way too low, the journey to impact was a formality.

Keeping track of energy during the hurly-burly of a performance is THE key to safety.  And having a running check on your topping-out heights during the sequence is THE key to keeping track.

At the top of things, the aircraft will be slow and the altimeter will have caught up. A quick glance just before you reach the apex of (say) a loop will instantly tell you whether you’ve reached your minimum “chicken height” or not.

If you have reached it, you know it’s safe to pull round. If you haven’t, you know you have to escape (usually by lowering the nose about 20 degrees and half-rolling out). There’s no decision involved, no dithering; either you got the height or you ain’t.

All this is “hoss” sense. So what leads a pilot – a good, hitherto prudent pilot – to ignore hoss sense on that fatal day? The probability is that several factors have ganged up to make him hot and bothered: external pressures, rushed preparation, over-confidence, weather, emotional state, simple hubris. We cannot know. But we need to know.

Peer group monitoring
This is quite simply watching each other’s displays and having a discrete word afterwards if you feel disquieted. Being a race of rugged individualists, display pilots don’t do enough of this. Okay, I know why: firstly, nobody wants to be seen as a whinger, and, secondly, you’re too busy with your own things to watch everyone else anyway.

The high performance aerobatic community does set an example. These eccentric souls have come up the competition route where critiquing each other’s performance is routine. So, at a display, it’s natural for one Unlimited guy to say to another, “Can you watch me and give me a crit?”  It may sound like saying, “Watch me dance, luvvy, then tell me how good I was.” But these aviators are about as luvvy as a grizzly bear with a cheese-grater, so you do learn things.

But the fact is that — in the hurly-burly of an air show — people won’t generally watch you closely unless you ask them to. So bloody well ask.

As an off-the-wall suggestion, I wonder if safety might be improved if the pilots’ tent was in front and exactly on centre-point at every display? We are after all our brothers’ keepers.

Display pilot qualifications
All display pilots in the UK have to hold a Display Authorization, for which they are tested by one of a small band of Evaluators (DAEs). The US and other countries have similar systems. And I wonder sometimes whether we are all tough enough initially. For example, how many of us ask for all the top heights to be detailed and for a demo of a flat show as well as a full display?

Also, an unfortunate truism runs throughout aviation examination; that it may be difficult to get a rating in the first place, but thereafter examiners are generally loath to take it away or downgrade it on renewal. Yet renewal is our best chance of spotting sloppiness or over-confidence. Perhaps DAEs should look into their own heads.

Conclusions – or lack thereof
The human factor comes in when, under real or imaginary pressure, a pilot ignores the above basic credos. On our working group, Steve Jarvis, an aviation psychologist from Cranfield University, has words for it such as “Plan Continuation Bias,” meaning that faced with a two-second “Shit, I’m a bit low” decision, your average homo sapiens follows his original plan – flawed or not – because that’s his mindset.

If so, we need to tweak the mindset. We need to make the credos of planning and energy-monitoring so powerful that they block “continuation bias.” We need to change from “Shit, I’m a bit low” to “Too low; plan B NOW”.

We need to get it across that, whoever you are, from nervous first-timer to national air display legend, the credos demand absolute obeisance. All the time. Every time.

Yeah, that’s got it hacked. The only slight problem is…. how?

Write a book? Yeah, cool…except the book won’t be open on the knees of the guy the night before he’s gnawing his lip and about to make his last mistake.  E-mail a regular newsletter? A CRM course especially designed for display pilots?

I confess I don’t know. If anybody out there has any ideas then I for one am listening.

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