The Human Factor: No Greater Burden

It is one of the great challenges facing those of us dedicated to reducing the accident rate in aviation: How do we help pilots maintain an awareness of the potential negative consequences of taking chances in aviation? One approach is to publish articles about accidents, exhorting pilots not to make the same mistakes. However, there are so many of these articles in almost every aviation magazine, pilots can get numb to them. The fact that there are about 1,500 aviation accidents in this country each year, approximately four per day, makes it obvious this approach is not as effective as we would like it to be.

Another problem is that many of the accidents fall into a few very familiar categories — continuing into IMC without an instrument rating or a clearance, flying low, running out of gas, trying to take off at a high density altitude with tanks and seats full. Most pilots could probably recite the list in their sleep. As the saying goes, familiarity breeds contempt. We open to an accident article, read the title and think, “It’s just another pilot flying too low” or “another pilot continuing on into bad weather.” It doesn’t help that some pilots dismiss articles about accidents, thinking, “I would never do that!”

On the other hand, we don’t want to make people fearful of flying. Most people don’t wake up thinking, “I’m probably going to die today.” This is good, because an overriding fear of death, known as thanatophobia, is often debilitating. It would certainly be very difficult to plan and conduct a flight if you were convinced you were going to die or cause the death of someone else during that flight. So, ultimately, our goal should be to maintain a healthy respect for the risks involved in flying without becoming overly fearful.

Many years ago, I observed a creative approach to making the potential negative consequences of taking unnecessary risks in aviation very real to the pilots involved. I was teaching a two-week Aircrew Coordination Training class to some Navy P-3 Orion instructor pilots. Toward the end of the class, one of the instructors, who was a pilot in the Navy Reserve, told me that in his “day job” he was head of the CRM program at a major airline. He said that since he was going to steal all my good stuff, it was only fair to invite me to attend one of his CRM training sessions to see if there was anything good there that I could use.

When I took him up on his offer, I observed a lot of good CRM training, but the session that had the greatest impact on me was a simple role-playing scenario. Two volunteers were asked to come to the front of the room and sit in chairs facing the class. They represented a pilot and copilot who had been killed in an accident caused by pilot error. They were asked for the names of their spouses and children, and then other pilots played the parts of those family members. The “family members” were given an actual fatal accident scenario. They then asked their father/husband why he made the decisions that led to the accident:

“Dad, we miss you! Why did you continue with the approach even though there was heavy rain and wind shear? Why didn’t you wait for the storm to move on?”

“Honey, it’s so hard to go on without you! Why didn’t you turn around when you saw that squall line up ahead?”

There was hardly a dry eye in the room. In fact, the people representing the family members and the pilots had a hard time completing the exercise. Even today, more than 20 years later, the memory of that exercise still gives me chills.

I took the title for this article from a new Aircraft Owners and Pilots Association Air Safety Foundation video that is seeking to have an impact similar to the airline exercise. The pilot involved in a fatal accident, Russ Jeter, personally provided the funding for this 32-minute video. He speaks forthrightly in the video about how shocked he was that, as an airline transport rated pilot with more than 4,000 hours who always uses a checklist and always does a GUMP check (gas/undercarriage/mixture/prop) on final even in fixed-gear airplanes, he could make the basic mistake of landing an amphibious floatplane on a lake with the landing gear extended.

Jeter talks about the accident, the unsuccessful attempts to rescue his son, the devastating impact the accident and his son’s death had on him and his personal quest to understand what could have led him to make such a basic mistake. Because of Jeter’s willingness to share his story, we get a rare glimpse into some of the subtle but deadly behind-the-scenes factors that are undoubtedly involved in many accidents.

With the help of a specialist in human factors, Jeter realized that the death of his mother only 12 days before the accident had resulted in a sleep deficit. Even though he was spending the same amount of time in bed as he usually did, he was not sleeping well. The morning of the accident, he was aware that he was “a little groggy” and didn’t wake up as quickly as he usually did, but he didn’t think much about it. Yet that lack of sleep, coupled with the distraction of talking with his young son right up to short final, led him to fail to check whether the gear was up before landing on the lake.

It is truly admirable that Jeter was not only willing but anxious to share his story in the hope that it could help other pilots avoid a similar mistake, and the AOPA Air Safety Foundation did a very professional job in presenting his message in a personal and compelling fashion. His accident is important because it illustrates that even safe, professional pilots who stay current, are continually learning and would never think of taking a risk like flying low or trying to push through bad weather can still have an accident due to something as simple as not getting enough sleep.

The stress assessment tool Jeter used is available on the Web page with the video. It lists 43 different events that can be stressful. As you might expect, some very traumatic events make the top of the list with the highest point values — things like death of a spouse, divorce, marital separation or spending time in jail rate from 63 to 100 points. However, almost three-quarters of the events listed as being stressful are situations most people would consider good or beneficial. One example is getting married. Marriage should hopefully be a very exciting and joyful event in a person’s life. On the other hand, it involves huge changes for each person, along with everything that goes into planning a wedding, and thus it is also usually a very stressful time and carries a point value of 50.

Generally, any change is stressful, whether it is considered a negative change like divorce or being fired; a positive change like marital reconciliation; or just a neutral change, such as changing jobs, social activities or eating habits. Even Christmas and taking a vacation make the bottom of the list, with 12 and 13 points respectively. As much as we look forward to those events, we are often also glad when they are over and we can get back to our usual routine. The list on the AOPA website has boxes you can check, and your score is continuously tabulated at the bottom of the list. Studies have shown that the amount of stress in your life over the past year is related to the likelihood you will get sick in the near future. A score of 300 or higher indicates a high risk of becoming ill and is also associated with reduced performance and increased mistakes. A score of less than 150 is associated with only a low to moderate chance of illness and little or no impact on performance. These scores are for anything that happened over the past year. The stress from an event like the death of a family member will be much greater, possibly even debilitating, the first few weeks after it happens.

I encourage each pilot to invest 30 minutes to watch No Greater Burden. After you watch the video, take a few minutes to ponder how your disability or death would affect those around you, and think about the burden you would carry the rest of your life if a mistake you made caused serious injury or death to another person. We all have stressful periods in our lives, and most pilots are occasionally tempted to take off or continue into bad weather or fly low over a friend’s house. I believe the story Russ Jeter shares about his mistake and the burden he will carry for the rest of his life will be a powerful tool to encourage each of us to make the right decision in those circumstances. I’m sure Jeter would be very happy that some good has come out of the death of his son.

To view the video and the stress assessment tool, go to


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