ASRS Directline

 Issue Number 7 : September 1995

And You Want to be a Flight Instructor? Flight Instruction Incidents

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 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?
Are You Sure?

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 schedule.

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.

Training Environment

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.


Looking Out

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:

Looking In

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.


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:

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.

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:

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.


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:

And in another report:

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:

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.

And in another report:

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:

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'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:

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.

Another reporter apparently knew all the right procedures, but lack of practice caused him to fail to perform when he needed to.

Conclusions and Recommendations

Flight instruction problems exist in all levels of flying, from beginning instruction through air carrier recurrent training.

  1. 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.

  2. 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.

  3. 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.

  4. 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).

  5. 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."

  6. 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.

  7. 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 and CRM

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, DC 20590.

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