Pilot error in air carrier mishaps: longitudinal trends among 558 reports, 1983-2002.
BACKGROUND
Many interventions have been implemented in recent decades to reduce pilot error in flight operations. This study aims to identify longitudinal trends in the prevalence and patterns of pilot error and other factors in U.S. air carrier mishaps.


METHODS
National Transportation Safety Board investigation reports were examined for 558 air carrier mishaps during 1983-2002. Pilot errors and circumstances of mishaps were described and categorized. Rates were calculated per 10 million flights.


RESULTS
The overall mishap rate remained fairly stable, but the proportion of mishaps involving pilot error decreased from 42% in 1983-87 to 25% in 1998-2002, a 40% reduction. The rate of mishaps related to poor decisions declined from 6.2 to 1.8 per 10 million flights, a 71% reduction; much of this decrease was due to a 76% reduction in poor decisions related to weather. Mishandling wind or runway conditions declined by 78%. The rate of mishaps involving poor crew interaction declined by 68%. Mishaps during takeoff declined by 70%, from 5.3 to 1.6 per 10 million flights. The latter reduction was offset by an increase in mishaps while the aircraft was standing, from 2.5 to 6.0 per 10 million flights, and during pushback, which increased from 0 to 3.1 per 10 million flights.


CONCLUSIONS
Reductions in pilot errors involving decision making and crew coordination are important trends that may reflect improvements in training and technological advances that facilitate good decisions. Mishaps while aircraft are standing and during pushback have increased and deserve special attention.
Baker
Susan P
SP
Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA. sbaker@jhsph.edu
Qiang
Yandong
Y
Rebok
George W
GW
Li
Guohua
G
D000060:Accidents, Aviation / Q000401:mortality / Q000706:statistics & numerical data / Q000639:trends*; D000062:Accidents, Occupational / Q000401:mortality / Q000706:statistics & numerical data / Q000639:trends*; D000401:Aircraft; D003299:Cooperative Behavior; D004868:Equipment Failure / Q000706:statistics & numerical data; D006801:Humans; D012189:Retrospective Studies; D017751:Safety Management; D013647:Task Performance and Analysis; D014481:United States; D014887:Weather