Human Factors

Previous studies of aviation safety have found that pilot performance is a major contributor to airline accidents. Some airlines have provided training in crew resource management since the early 1980s, and the Federal Aviation Administration (FAA) will require all airlines to have implemented this training for pilots by March 1998. Crew resource management is an approach to improving pilots' performance that stresses better coordination--among members of the cockpit crew, flight attendants, dispatchers, and air traffic controllers--to handle routine and emergency situations. This report answers the following questions: What are the types and frequency of accidents in which an airline pilot's performance was cited as a contributing factor, including that in which failure to use crew resource management principles was identified? How adequate is FAA's guidance for and oversight of the airlines' implementation of pilot training in crew resource management?

GAO noted that: (1) of the 169 accidents that involved the major airlines and that were investigated and reported on in detail by the National Transportation Safety Board (NTSB) from 1983 through 1995, about 30 percent were caused in part by the pilots' performance; (2) in at least one-third of these accidents, GAO determined that the pilots did not correctly use CRM principles; (3) for example, according to NTSB, just before the 1994 crash in Charlotte, North Carolina, which killed 37 people, the aircraft had encountered a sudden change in wind direction and the captain gave an incorrect order to the first officer, who did not question the order, as CRM principles would require; (4) during the same period, of the nearly 4,000 incidents, GAO found that about one-fifth were caused in part by the pilots' performance; (5) FAA's guidance for and oversight of training in CRM does not ensure the adequacy of this training under part 121 of the federal aviation regulations, while they do under the new Advanced Qualification Program (AQP); (6) FAA's guidance for the implementation of AQP specifies a process for curriculum development that the airlines must follow in order to integrate CRM training with technical flying skills; (7) FAA inspectors overseeing this training assess the curriculum to see if FAA's process has been followed, enabling them to determine whether the pilots' training under this curriculum is adequate; (8) although FAA requires airlines to teach CRM in their traditional part 121 training, the guidance it provides on how to develop the curriculum for this training is ambiguous and does not provide standards that inspectors can use to evaluate airlines' CRM training; (9) because AQP training generally differs from traditional part 121 training in how it develops a curriculum for training CRM, the guidance for this training in AQP may not be applicable to CRM training under part 121; (10) FAA needs to develop guidance for teaching CRM under traditional part 121 training; (11) and although 8 of the 10 major airlines plan to train all their pilots under AQP, the need for guidance on CRM training under part 121 remains--both for those airlines that have opted not to enter AQP as well as for those that participate in the program but will nonetheless continue to have some of their pilots trained under part 121 for up to 8 years as they make the transition to AQP.

Recommendations

Our recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.

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