I want to thank Neil for putting my book, "Pilot Judgment and Crew Resource
Management" up as the September book of the month. The book is primarily
written from my personal experiences with CRM courses, flying in GA,
research on decision making, and teaching human factors to pilots. Some of
the content is airline based, but most is based on my experience in GA
including an attempt to develop a CRM course for single pilot air carrier
operations in Alaska. With this in mine, let me offer an example of
automation induced pilot error in GA that occurred in my flying club just
two days ago. This example also concerns decision making in flight. Here is
the example:
A relatively new private private pilot was flying a Cessna 172 (N64333 the
same airplane shown on the cover of my book) with his wife and in his own
words, this is what happened:
An off-airport landing occurred at approximately noon today (9/8/97). The
pilot and his wife had already been flying for around a half-hour, and the
pilot decided to make a practice landing at Union County (I78) airport. He
then taxied back and departed on Rwy 9. At approximately 500 ft agl the
pilot indicates that he "felt a click" and the "controls locked."
At that point the pilot explains that he had no elevator, nor aileron
control. He indicated that he was only able to use the rudder to turn.
He continued in a left turn and decided he didn't wish to fly over the
city of Marysville to get back to the airport, as he didn't feel he
could make it. He continued further north, towards farm land, and
picked a field in which to set down. The pilot then made a landing that,
according to his wife, seemed quite normal, other than the fact that they
ended up in the middle of a soybean field! Their location was
approximately 1.5 miles north of SR 33, on the west side of SR 31. They
landed safely, with absolutely no harm to them, and what appears to be
no harm to the airplane. The pilot kept his cool and safely brought the
airplane down. Shortly after the landing the pilot found that the controls
moved freely.
After the incident the controls were examined thoroughly and it was
determined that there was no control malfunction. It was determined that the
only way to explain this incident is that the autopilot had been
inadvertantly turned on, either by the pilot's hand on the throttle (which
is located near the autopilot) or with his knee (as others have had happen
in this aircraft).
My point is that automation induced error occurs in small, single-engined
aircraft also and pilots of these aircraft need to be trained in how to deal
with it just as we train the so-called high-tech pilots.
On decison making this pilot was not very experienced. He says that he had
never turned on the autopilot and did not know what it felt like in the
controls. It was a novel situation that required problem solving in flight.
This pilot had not been trained in problem solving in flight either and made
a quick conclusion that there was a control malfunction (without thinking
that he might have caused it). He also made a decision to put it down in a
field (near an airport) which could have had disasterous results but
fortunately worked out ok.
To me this pilot exercised bad judgment in several ways: 1) flying without
knowledge of one of the cockpit systems, 2) kneejerk decision that something
had gone wrong without checking further, 3) kneejerk decision to put it into
a field instead of the airport, 4) little or no further diagnosis of the
problem.
Each of these elements of the situation is open to modification through
training. We at OSU are developing seminars, videos and CBTs to apply this
type of training. Your input and ideas on how to teach these important
aspects of the flying task would be appreciated.
Dick Jensen