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How We Forget

Everyone occasionally forgets to perform some everyday task such as returning a phone call or depositing a check. But if the task is a flight-critical function, such as putting down the landing gear, surely no competent, conscientious pilot would forget, right? Well, no, even if it is a matter of life and death, pilots sometimes forget. For example, several airline catastrophes have occurred when a cockpit crew attempted to take off, forgetting to set flaps. Airline accidents have also occurred when cockpit crews forgot to lower the landing gear, turn on pitot heat, set hydraulic boost pumps to high, etc. The frequency of such oversights in the airline industry is much higher than the accident rate suggests because in most cases, the oversight is caught by a warning system in time for the crew to correct the situation.

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Key Takeaways:

  • Pilots, regardless of competence or conscientiousness, are inherently vulnerable to "prospective memory" lapses—forgetting to perform intended flight-critical tasks—due to the way the brain processes information.
  • These memory lapses typically occur when routine, automatic tasks are disrupted by interruptions or atypical situations, or when non-habitual, deferred tasks are forgotten, often under high workload, due to missed environmental cues.
  • Key countermeasures include recognizing this universal vulnerability, creating explicit "implementation plans" for non-routine or deferred actions, utilizing reminder cues, diligently using checklists while being aware of their own vulnerabilities, and executing tasks deliberately without rushing.
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Everyone occasionally forgets to perform some everyday task such as returning a phone call or depositing a check. But if the task is a flight-critical function, such as putting down the landing gear, surely no competent, conscientious pilot would forget, right? Well, no, even if it is a matter of life and death, pilots sometimes forget. For example, several airline catastrophes have occurred when a cockpit crew attempted to take off, forgetting to set flaps. Airline accidents have also occurred when cockpit crews forgot to lower the landing gear, turn on pitot heat, set hydraulic boost pumps to high, etc. The frequency of such oversights in the airline industry is much higher than the accident rate suggests because in most cases, the oversight is caught by a warning system in time for the crew to correct the situation.

How should we think of the pilots who have an accident because they forgot to perform some flight-critical task? Do they lack competence? Were they not careful or conscientious enough? My NASA research team and I spent several years studying prospective memory: remembering—and sometimes forgetting—to do things we intend to do but at a later time. We concluded that all pilots are vulnerable to these memory lapses as a function of how our brains work and the specific circumstances of the flight. Experience and conscientiousness are of course essential to flight safety but are not, by themselves, adequate to prevent these memory lapses. Not surprisingly, accidents caused by these lapses are more common in personal airplanes, in part because GA pilots typically lack protections such as takeoff configuration warning systems and co-pilots.

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