Analyzing Fatals

The NTSB (or FAA when delegated by NTSB) investigates fatal accidents and the Board issues reports on the probable cause of the accident. The reports also list contributing factors to the accident. Typically, the final reports are peppered with words such as loss of control, controlled flight into terrain (CFIT) and other language describing the final event in the accident sequence and attributing it to one or more other events. But rarely does the report explain the “why” of the accident or the “how” of the pilot’s or other participants’ actions relating to the “why.” For example, in a loss-of-control accident, why did the pilot lose control of the aircraft and how did he or she place themselves in that predicament?

Key Takeaways:

• Current aviation accident investigations often explain *what* happened but rarely delve into *why* pilots made critical decisions or *how* they failed to manage risks effectively.
• The author's analysis of general aviation fatal accidents revealed that over three-quarters were directly attributable to failures in risk management, frequently involving blatant disregard for obvious hazards.
• This widespread issue is compounded by a misleading general aviation safety culture, false claims about aviation danger, and a lack of comprehensive risk management training for pilots.
• To improve safety, individual pilots are encouraged to proactively supplement their training with risk management courses and consistently assess and mitigate risks before and during every flight.

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