Pilots are not the Problem: A Qualitative Analysis of Human Factors in Part 135 Pilot Training Programs and Aviation Accidents that Goes Beyond Pilot Error

This qualitative research paper evaluates which Commercial Pilot-ACS tasks and risk management elements are the most prevalent and require more emphasis in pilot training. The intent is to categorize each task as either skill or knowledge-based using HFACS methodologies and compare with previous accident data to determine if the changes to pilot training were effective. The research question answered is, “Which tasks and risk management elements in the Commercial Pilot-ACS are classified as the most prevalent in terms of human factors and should have more emphasis in pilot training programs?” The literature review themes focused on human factors in pilot training, the HFACS model, previous accident rates, causal factors centered around “pilot error,” and systems safety. The result that answers the research question is that the largest skill-based task contributing to the most events are Task IV. B. “Normal Approach and Landing” with a knowledge-based risk element of Human Factors situational awareness. The conclusion is that causal factors of accidents have remained unchanged and centered around pilot error despite increased pilot training requirements. The recommendations are to (1) enhance the ACS to include the identification of hazards and risk control as the current ACS generalizes hazards across systems; (2) Prevent labeling accidents as “pilot error”. Aviation safety becomes constricted when investigations focus solely on pilot error. Hindsight bias criticizes actions pilots should’ve performed when outcomes are already known. This allows the labeling of accidents as pilot error, even if no error occurred and hinders the discovery of new system hazards.