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Human Performance Errors
Reporters of incidents in this data set
referenced human errors as shown in
Table 1.
An example of poor judgment is
flight crew failure or reluctance to use
speed brakes to meet descent profile
requirements:
- “Flight plan called for a (SIE CAMRN
2) STAR to JFK. ATC instructed us to
cross CAMRN at 11,000 feet, 250 knots.
At 19,000 feet, I told Captain we would
not make restriction unless he used speed
brake to increase rate of descent. He responded
there would be no problem. I informed
him I would tell ATC we were unable
to comply with restriction. ATC
responded, ‘give us the altitude first and
then the airspeed.’ We crossed CAMRN at
13,000 feet and 290 knots. We were
handed off to Approach for a normal continuation
of flight to JFK with no comments
made to us by ZNY or Approach
Control reference the CAMRN crossing.
The Captain’s comment to me was that
he did not like using the speed brake and
thought he would be able to make the restriction.”
(# 315639)
Flight crews failing to cross-check
data typically resulted in use of the
wrong waypoint:
- “Inbound to SLC at Flight Level 310.
We were cleared the OGDEN 5 Arrival
with a descent clearance to cross BEARR
(25 nm NW Ogden VOR) at 17,000 feet.
STAR path tracks outbound Burley VOR
117 degree radial to Ogden VOR 302 degree
radial, then radar vectors. The STAR
depicts the Ogden VOR very close to the
Salt Lake City VOR. I (Captain) was flying
the aircraft outbound on the Burley
VOR radial, First Officer had switched
his VOR to Salt Lake City for distance to
the field. However, he did not verbally
announce that he had switched to SLC—I
thought he was on Ogden. Because of unfamiliarity
with arrival (only second time
into SLC), I switched over to SLC VOR
inbound (should have been Ogden). We
discussed the fact the outbound and inbound
radials did not match up but nei14
Issue Number 10
Table 2 — Cockpit Workload Issues
Based on 97 Citations from 171 of 172 Reports
Workload Issues CitationsPercent
FMS Programming (automation issues) 18 24.0%
High quantity radio communication with ATC 17 22.7%
Lack of planning on the part of the flight crew that led to
time-compression (such as cabin attendant in cockpit)
17 22.7%
Other (misread altimeter, company com, etc.) 15 20.0%
Flight attendant call or cockpit-cabin interphone
communication
12 16.0%
Achange in clearance 10 13.3%
Weather factors 8 10.7%
TOTALS 97129.4%
Note: Multiple citations are possible in this category, thus the total number
of citations exceeds the number of reports.
ther of us discovered my mistake. I therefore
tracked off course and, because [I
was] looking at the wrong DME, started
the descent too late to make the crossing
restriction.” (# 300912)
Cockpit Workload
Reporters cited cockpit workload on
SIDs and STARs as a factor in 44
percent of reports. The most commonly
noted workload issues are
shown in Table 2.
- “I tried unsuccessfully to enter the
restriction in the FMS. After three attempts,
the Captain tried unsuccessfully
and tried to explain why it wouldn’t take.
Meanwhile, no descent was started…we
are flying an airplane, not a computer.
My focus on the FMS got in the way of
doing a very simple descent profile. I will
be focusing on flying first, programming
second.” (# 259889)
SID and STAR Charts
In 88 percent of reports, there were no
complaints about chart graphic
depiction or procedures. There were,
however, some complaints regarding
chart text narratives, specifically that
the font size was small, and that text
blocks were sometimes not placed
sufficiently close to the appropriate
area of the graphic depiction. In one
event, the flight crew of a turbojet
transport followed instructions specific
to turboprop aircraft, thus deviating
from an altitude requirement.
Event Resolution
Table 3 provides event resolution
information:
Incident Severity
In more than 95 percent of incidents
in the data set, the analysts’ subjective
assessment was that there was minimal
impact on flight safety or efficiency.
While there was no direct
evidence of loss of separation in the
majority of these events, there may
have been implications for ATC, such
as sector penetration, of which the
pilot reporters in this study were
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