A Review of Flightcrew-Involved, Major Accidents of U.S. Air Carriers 1978 Through 1990
NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON DC
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U.S. air carrier operations are extremely safe, and the accident rate has declined in recent years. However, among the wide array of factors cited by the National Transportation Safety Board as causal or contributing to airplane accidents, actions or inactions by the flightcrew have been cited in the majority of fatal air carrier accidents. Recognizing that deficiencies in various aspects of the aviation system may adversely influence flightcrew performance, the Safety Board conducted this study to learn more about flightcrew performance by evaluating characteristics of the operating environment, crewmembers, and errors made in major accidents of U.S. air carriers between 1978 and 1990 in which the flightcrew was cited by the Board. Characteristics of the operating environments and flightcrews were identified from information derived from major investigations of 36 accidents and 1 incident. The errors identified were evaluated in light of the contexts in which they occurred. The safety issues discussed in the report are a performance of flightcrews when the captain is the flying pilot and the first officer is the non-flying pilot b performance of the non-flying pilot in monitoring and challenging errors made by the flying pilot c adequacy and error-tolerance of checklist procedures during the taxi phase of operation d associations between flightcrew performance and crewmember experience, crewmembers familiarity with each other, workrest issues, and flight delays and e adequacy of crew resource management training programs. Safety recommendations concerning flightcrew training and flight operations procedures were made to the Federal Aviation Administration.
- Commercial and General Aviation