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 are inadequate as they typically identify *what* happened but rarely explain *why* pilots made critical decisions or *how* better risk management could have altered outcomes.
• The author's analysis of general aviation fatal accidents found that over three-fourths were attributable to poor risk management, with environmental and pilot-related factors being the most common risks.
• To address a general aviation safety culture that often ignores or tolerates risks, individual pilots are urged to proactively enhance their risk management skills through supplementary training and consistent assessment before and during every flight.

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