Number 7 : September 1995
by Marcia Patten
and ASRS Analysts
"Following a period
in which I had had a total of 4 days off work in the previous 2 months, I was
programmed for a particularly busy 12-hour day. [After landing on] my third
flight...as we cleared the runway, we were told to contact Ground Control, and
the student acknowledged, however we did not change frequency. I immediately
began taxiing and debriefing the landing...Maybe having been cleared to the
ramp so often in the last few days I assumed we were cleared again...and I
taxied [across the active] runway. This was a clear case of tiredness or
fatigue from overwork. Fear of being replaced or losing my status as a 'senior'
instructor if I eased up in a world awash with instructors, and also needing
the money from a poorly paid piecework job were the driving factors."
[Emphasis added.] (# 242730)
You Still Want to Instruct?
- "While giving an ATP/Light
Transport jet-type check-ride, the candidate made a very smooth landing followed
by a rollout with four flat tires. Prior to this landing, we made an aborted
takeoff at 120 knots on an 85 degree day. The apparent problem was that the
tires overheated and blew the wheel fuses which deflated the tires."
Are You Sure?
- "[During takeoff], just as
we reached rotation speed, [the student] raised the nose and for no explainable
reason, he reached down and raised the gear at the same time. The left prop
hit the runway...he yanked back on the yoke to try and climb. I took control...and
my student reduced both throttles to idle in an attempt to abort! In discussing
this with the pilot, after the fact, he was at a total loss as to why he did
what he did." (# 252497)
The Instructor's World
In every instructional situation,
the instructor is faced with multiple performance and cockpit management tasks.
Errors may occur during all levels of instruction, from an instructor's first
flight with a student pilot in a Cessna 172, to a check airman doing upgrade
training with a highly experienced pilot in a large air carrier aircraft.
Instructors may also be under personal
and professional pressures. For a flight school instructor, there may be the
pressure to build flight time, to make a profit for the flight school, or just
to make a living. Air taxi or air carrier instructors may feel pressured to
upgrade their own careers, help upgrade the trainee's career, or cut costs on
additional training. Some air carrier, commuter, or air taxi pilots may also
be expected to maintain their company instructor or check airman status with
the local FAA office on their own time, all while still sustaining a full line
Juggling these personal and professional
performance requirements may cause an instructor to react in ways that result
in instructional accidents or incidents. Instructional incidents are not just
a source of aggravation or embarrassment to the instructor or the company. They
also have the potential for huge economic impact in cases of aircraft damage
or personal injury. There is the additional potential for emotional impact--on
instructors, in FAA investigatory follow-up, or loss of credibility or reputation;
and on students, in fear, loss of confidence in their instructors, or more importantly,
loss of confidence in themselves.
Why do some of these incidents happen?
What human factors and human behaviors contribute to instructional incidents?
How can instructors avoid the mistakes made by some of their unwary colleagues?
To answer these questions, we searched
the Aviation Safety Reporting System (ASRS) database for a representative sample
of incidents that occurred during instructional or check-ride flights. This
article reviews only records in which the action or task of instructing appeared
to contribute directly to the incident, and the aircraft involved was generally
"healthy", i.e., without mechanical problems. The data set includes
78 records from 1988-1993, including all sectors of civil aviation, i.e., general
aviation (GA), air taxi and commuter, and air carrier.
A Student By Any Other Name
More than half of the "students"
involved in the reported incidents were undergoing advanced training (e.g.,
instrument, complex aircraft, commercial, multi-engine, flight instructor, etc.).
These included company pilots undergoing initial operating experience (IOE)
and upgrade training in new aircraft. Only 10 percent of the reports referred
specifically to instruction of student pilots. Instructors indicated that they
were quite vigilant with their student pilots, but tended to relax with their
advanced students due to higher expectations about the advanced students' abilities
to perform various tasks or maneuvers. This was especially so in the case of
air taxi or air carrier instructors doing upgrade training with company pilots.
Most incidents (89 percent) occurred
in VMC weather where most GA flight training would be expected to take place.
Only three incidents are known to have occurred at night--these were commuter
training operations. Half of the incidents occurred in the typically high-density
traffic area of Class D airspace, where the pilots were in contact with ATC.
More than half of the incidents occurred during the approach and landing phase,
which involves numerous and varied tasks, requiring maximum attention to detail
inside the aircraft and maximum vigilance outside.
Distraction due to some aspect of
instructional activity was cited as a contributing factor in 80 percent of the
incident reports, and appeared to be a major cause of near mid-air collisions
(NMACs), the most commonly reported incident by a margin of more than 2-to-1.
These incidents reflected an apparent breakdown in the practice of basic "see
and avoid" principles. In the following case, conversation was the culprit
in distracting the instructor from his usually-thorough scan:
- "As my student and I were
returning after a training flight...we reported downwind abeam and were cleared
to land following the SMA downwind ahead. At this point I got heavily involved
in talking my student through the steps to be followed during the approach,
and after looking for the traffic and not seeing it, I wrongly assumed it
was already on the ground...A couple of moments later I observed the other
SMA take evasive action...Contributing factors to this incident...are: my
lack of concentration on looking and positively identifying our traffic before
landing (as I routinely do) due to the heavy 'question and answer' situation
that my student involved me in. After this incident, I have made it a very
clear point to all my students to minimize the pilot-to-pilot chat during
operation in the traffic pattern." (# 124564)
Another often-cited source of distraction
was the need to be focusing inside the aircraft instead of outside the aircraft:
"...I noticed the shadow of
an airplane headed towards us. We had heard no traffic in the vicinity [of this
uncontrolled airport]. Giving flight instruction to a student under the hood
prevents and/or impedes proper scanning. Although I constantly remind myself
to get my head out of the cockpit on these flights, there are lapses...I must
be looking out so often for traffic that I am unable to evaluate a student's
approach at all." (# 148597)
Did You Hear Something?
Distraction was also cited as a contributing
factor to gear-up and near gear-up landings. Gear-up landings occurred in 8
percent of the reported incidents. Although this is a small percentage of reports,
it probably accounts for a very large cash outlay for repairs. Many reporters
indicated that they were so involved in the instructional situation that they
missed the gear check on their pre-landing checklist, and often didn't even
hear a gear warning-horn.
- "The second day of training
for the trainee...with numerous approaches, both 2 engine and single engine.
The last approach was a single engine, flapless approach...to simulate a flap
problem. The approach was broken off and the circling maneuver was commenced.
Airspeed dropped and this was brought to the attention of the trainee...so
gear was retracted to clean up the aircraft. When the gear was retracted,
the gear warning horn went off because of the simulated single engine condition
of the power lever (retarded). The gear warning horn was canceled and the
circling continued. As we were getting re-established, it seems that at some
point [the trainee] called for final checks, but I don't know when because
my attention was primarily on circling, checking for traffic, proper radio
procedures, and problems inherent in the maneuver...I missed reselecting the
gear down. When the L power lever was retarded for landing, the gear warning
horn did not go off (was not heard at all) again to warn of an impending gear
up landing." (# 145537)
Fatigue was mentioned specifically
in the three reports of night training incidents, and alluded to in many others.
Tired pilots may be unable to divide their attention adequately among many cockpit
tasks. They may ignore standard procedures, or, as in the following report,
forget some basic operating limitations. This reporter apparently was well aware
of his aircraft's gear warning-horn system, but the details slipped his mind
in the wee hours:
- "The student, a First Officer
in upgrade training, was instructed to execute...a simulated single engine,
no flap approach and landing. All items on the checklist were done except
for the gear down call, which was delayed until landing assured. The student
and I forgot to call for gear down and to verify it...The above events occurred
in the early a.m. during training (mostly emergency situations). Both crew
members had been awake since the morning the previous day...for 20 hours"
Another pair of reports from an instructor
and trainee regarding their near gear-up landing reiterate the hazards of late
night or early morning training flights.
- "A definite contributing
factor...was fatigue. Due to the unavailability of aircraft, all flight training
had to take place at night. I got home the night before at 4 a.m. and the
night before that at 3 a.m."(# 182635)
- "The company is not using
flight simulators any longer, I assume to save money. It was late at night
because there are not any aircraft available during the day because all the
aircraft are in revenue service." (# 181978)
The company certainly did not save
any money on the repairs or replacement of two bent props, not to mention the
loss of revenue associated with aircraft down-time!
Inappropriate or unrealistic expectations,
sometimes referred to as complacency, were cited in 50 percent of the reports.
In retrospect, many instructors realized that they had been too relaxed about
operations on a well-known airport or route. Non-adherence to clearances, including
runway and taxiway transgressions, and unauthorized entry into controlled airspace,
were often the result of an instructor's unfulfilled expectations. One instructor
expected too much of the student's command of English:
- "My [foreign] student...had
been training here for 3 months, 30 hours. I assumed he was competent with
taxi instructions. I was distracted in the cockpit. He taxied onto the active
runway...! I then realized that this student understood very little of what
was being said. I [took] the English language for granted. Never again."
Even more common, and more distressing
to many instructors, was the realization that they had placed too high an expectation
on a student's performance. Sometimes this resulted in a costly incident due
to loss of aircraft control.
- "I was giving a Commercial
SEL/MEL instrument rated pilot a...biennial flight review. The pilot had over
700 hours of total time. In flight he did everything above commercial pilot
standards and had a good handle on the aircraft. I brought the throttle to
idle to simulate engine failure. The pilot set up for a landing...As we neared
the ground...I noticed the tailwind. We touched down...the grass was slick...the
airplane swerved...the wingtip contacted the ground and the nose cowling came
to rest against a small pine tree. The pilot was doing an excellent job and
my guard was down compared to someone not so proficient..." (# 258389)
Someone Else's Fault ?
As often happens, a few pilots blamed
ATC for its "failure" to provide advisories. Fortunately, however,
more than a third of the reporters recognized their own unwarranted reliance
on ATC advisories as a contributing factor to the reported incident:
- "I should have been more
vigilant outside [the aircraft] instead of being totally absorbed with my
student's approach. I probably was lulled into a false sense of security by
hearing from FSS that there was no reported traffic in the area" (# 144724)
And in another report:
- "Too much reliance is placed
on...ATC for collision avoidance and traffic advisories in a VFR environment.
The [other] instructor said he never saw us and that ATC never called [us
as] traffic ahead. Lack of understanding of ATC's responsibility by the [other
instructor] contributed to the near miss." (# 158566)
Is Anybody Listening...?
Sometimes pilots forget that controllers
can have their hands full, too. The only report by ATC personnel was from this
controller frantically trying prevent a midair collision:
- "I issued expeditious turn
and climb to [light aircraft] X. There was no reply. I then issued traffic
alert [and descent] to [light aircraft] Y, who continued climbing...There
was no reply from either aircraft. [Follow-up] phone conversations with both
pilots revealed that [light aircraft] X was being flown with a student and
instructor. The instructor apparently was 'busy' in the cockpit. [Light aircraft]
Y apparently thought the climb clearance...was for him." (# 166851)
The Team Approach
Who's In Charge Here?
Usually rank provides a fairly clear
delineation of who does what in a multi-person cockpit. The addition of some
Crew Resource Management (CRM) skills encourages cooperation and assertiveness
among the crewmembers, and a safe flight results. However, there can be a gray
area of responsibilities and of delegation of authority when, for example, a
captain is in a "trainee" position being given a line check by the
company check pilot who is acting as first officer (F/O) for the flight. The
reversal of roles may lead to an incorrect assumption that the "other"
pilot has control of the aircraft, has programmed a flight computer, or is making
a crucial decision about the flight.
- "Aircraft began to show significant
oil loss. The Captain chose to continue to operate the aircraft as if there
was not a problem. He made no contact with the company and made no plans for
a precautionary landing. My role as F/O and check airman giving a regular
line check created a conflict as I began to question the appropriateness of
the Captain's judgment. In the future, when giving line checks, I will do
it from the observer's seat. This will give the Captain the benefit of a complete
crew without conflicting agendas. It will also provide me a single role to
better evaluate the crew." (# 163040)
And in another report:
- "[On approach] the right
hydraulic quantity and pressure went to 0. The landing was uneventful. With
the emergency equipment standing by and maintenance working on the gear doors,
we started the APU to supplement cabin cooling. Once the APU air was selected
on, the cabin began filling with smoke and fumes. We immediately secured the
APU and ventilated the cabin...My gut feeling was not to start the APU...however,
this was a line check by a check airman in the jump seat and my intuition
was influenced by his suggestion to start the APU to save fuel." (# 235103)
Both reporters were uncomfortable
with the actions or suggestions of another cockpit crewmember, but felt unable
to act due to their assigned "roles."
Not all role reversal stories are
problematic. A crew with 2 of its 3 engines running erratically and causing
airframe vibrations pulled it all together and landed safely:
- "From a human factors standpoint,
two Captains were flying plus a very experienced S/O (retired Air Force).
Both Captains...deferred to each other, assessed the situation with the S/O's
input and all agreed how to resolve the problem. It was refreshing to see
cockpit resource management work in an emergency situation." (# 247627)
CRM is not just for air carrier crews.
An instructor and student experiencing a landing gear malfunction put their
heads together to land their aircraft with minimum damage and no injury:
- "I solicited input from my
student, who is also a CFI. We elected to review our checklist...in an effort
to find any items which might aid our effort to land safely...and make decisions
for landing...The student and I planned our landing sequence, and I instructed
the student to secure all objects in the airplane. On downwind, the student
latched the door 'ajar'...All engines, mixtures, fuel selectors, ignition,
electrical system were turned off in accordance with checklists and to prevent
a fire hazard. Calmness prevailed...Flight experience on the part of both
student and instructor contributed to the decisions made during the emergency."
I've Got The Airplane!
Several instructors indicated that
they should have been on the controls sooner than they did, sometimes even at
the start of a maneuver:
- "My student and I had drifted
over another aircraft that was on a simultaneous approach course...I allowed
my student to deviate...instead of taking over the aircraft with a verbal
'my airplane!,' I let my student go too far." (# 146237)
Know Thy Aircraft
Did I Do That?
An instructor's lack of thorough
knowledge of the aircraft often resulted in incorrect or improper use of equipment.
Mistakes included an improper use of gear lever, flap switch, and fire extinguisher.
The following air taxi training incident points to the potential hazards of
not being knowledgeable about all the details of the aircraft.
- "While conducting a training
flight, [I] induced a simulated power plant failure...I had failed to turn
the auto-coarsen off, a standard procedure for simulating engine failure...Before
I could turn off the auto-coarsen computer, the right prop went to full auto-coarsen.
I was concerned about the possibility of an over-torque if I turned off the
computer ...so I elected to shut down the right engine and land single engine."
Another reporter apparently knew
all the right procedures, but lack of practice caused him to fail to perform
when he needed to.
- "[On start] we experienced
an engine fire. I...grabbed the fire extinguisher and exited the plane. I
couldn't make the extinguisher work, but the student was able to use it and
put out the fire. It never occurred to me to read the directions on the fire
extinguisher or to keep cranking the engine starter, even though this is what
we have all been told to do. We have talked about this type of emergency but
never practiced it. Everyone should read directions on the extinguisher [and]
know how to operate it. Walk through the procedure with actual cranking of
the engine, turning off fuel, call for help, etc. Do this like we practice
engine failures." (# 213870)
Conclusions and Recommendations
Flight instruction problems exist
in all levels of flying, from beginning instruction through air carrier recurrent
- Training situations involving
advanced students may be more conducive to instructional incidents than ab-initio
(beginning) flight training, due to the instructor having unwarranted expectations
about an advanced trainee's capabilities and performance. Instructors involved
in providing training to advanced students should remember to maintain vigilance.
- ASRS flight instruction incident
reports and other published incident and accident data support the conclusion
that approach and landing phases of flight are when a large portion of aircraft
accidents occur. Instructors should minimize unnecessary conversation throughout
the flight lesson, and maintain a sterile cockpit (i.e., eliminate non-essential
dialog) during approach and landing.
- Some of the problems associated
with distraction due to cockpit chat can be eliminated by the instructor conducting
a thorough pre-procedure briefing with the trainee prior to the flight, then
by adhering to the planned procedure as much as possible. This will help minimize
conversation, especially during the critical phase of approach and landing.
Another strategy some instructors employ is to have another trainee along
to act as an observer during instrument training flights. The observer can
maintain a nearly full-time scan outside the aircraft, and still listen and
learn from the training experience. Although the instructor is not relieved
of the responsibility for collision avoidance, the extra pair of eyes can
allow the instructor to spend more time monitoring student performance.
- It is difficult for most people
to properly determine their level of fatigue, let alone their level of impairment
due to fatigue. Watch out for uncomfortably long duty days, or periods of
duty with little or no intervening sleep--these are precursors to fatigue-related
errors. Remember that in addition to appropriate duty-time restrictions and
adequate rest, pilots (and everyone else) require adequate and proper nourishment
to perform at required levels (and, no that doesn't mean coffee and a doughnut
for breakfast, with selected items from the four major junk food groups for
lunch and dinner, either).
- Sometimes, in their zeal, instructors
try too hard to coach an overwhelmed or fatigued student just a little bit
too far. Sometimes, it is safest and wisest course just to say, "I've
got the airplane. Let's call it a day."
- Apply Crew Resource Management
concepts and skills. General aviation instructors should include these decision-making
and communication skills as part of basic student instruction, and reinforce
them throughout advanced or upgrade training. (See the sidebar on General
Aviation Instructors and CRM.) Air carrier and commuter instructors and check
airmen should recognize that the decision-making and crew-coordination skills
are even more important during training and check-rides, when role delegation
is not routine, e.g., a line captain is acting as a first officer.
- Know your aircraft. Instructors
should decline to provide instruction in an aircraft unless they are thoroughly
trained and current in that make and model. A training session for the student
should not be an initial or recurrent training session for the instructor.
General Aviation Instructors
How do General Aviation flight instructors
learn about CRM? A good starting point is the FAA Advisory Circular AC120-51A,
"Crew Resource Management Training," available free by writing to
the U.S. Department of Transportation, General Services Section, M-443.2, Washington,
and redistribution of ASRS Directline articles is not only permitted--it
is encouraged. We ask that you give attibution to ASRS Directline, to the
Aviation Safety Reporting System (ASRS), and of course, to the authors of