Human Factors Incident Reporting — Page 319, Lesson 518

I want to walk you through a chapter on Human Factors Incident Reporting. This is a very practical part of your training — it uses real-world reports to show how human factors, not just technical failures, cause incidents. The reports come from a system called CHIRP, which stands for the Confidential Human Factors Incident Reporting Programme. Pilots submit reports anonymously, so others can learn from their mistakes without fear of blame. Let's start with the opening quote. It's from CHIRP Report 15, labelled "Personality." The pilot says: "After long deliberations I can only reach the conclusion that, as a non-smoker, I had been adversely affected by the smoking to the extent that my ability and judgement had been seriously impaired." This immediately tells you that even something as simple as second-hand smoke in the cockpit can degrade your cognitive performance — your ability to think clearly and make good decisions. That's a human factor. Now let's look at the actual incident behind Report 15. Two senior captains are flying a medium-sized passenger aircraft back to the UK. One captain is flying the leg — he's an ex-fighter pilot, and the reporter says he "never forgot it." That means he carried that aggressive, competitive attitude into the airline cockpit. He's also a training captain, and he's "always trying to catch out co-capt" — the co-captain, the other pilot. He always had superior equipment: a better watch, a better calculator. So there's a personality dynamic here: one pilot is dominant, competitive, and the other is less forceful. On arrival, the reporter passes the weather to the other captain with the comment "You won't like it." The weather was poor with strong crosswinds. At the marker — that's a radio navigation fix on the approach — they were badly placed and too high. The reporter suggests, "Full power for overshoot." That means go around, abort the landing. The other captain says "Negative," closes the throttles, increases flap, and continues with the landing. They hit first on the port main wheel and wing tip, then the reporter hears the crunch as the port engine strikes the ground. The other captain calls for full power, but the reporter holds the throttles tightly closed, knowing the aircraft is structurally damaged. Further damage occurs before they stop. The reporter's own assessment: "My mistake was not being more forceful when it was quite obvious that a safe landing was impossible." And the other captain's attitude afterward? He said that if the reporter had obeyed his instructions and given him full power, he would have been able to take off again. That shows a complete lack of insight into the situation. This report illustrates how personality — dominance, lack of assertiveness, poor crew coordination — can lead to an accident. Next is CHIRP Report 16, labelled "Visual Illusions." They're descending to their destination airfield at night. The weather is reported good, so they request a visual left-hand circuit to Runway 29. While trying to keep the runway in sight, they encounter unreported stratus cloud over the sea. The aircraft descends beneath the cloud, and the runway looks "for to the left" — that's likely a typo for "far to the left." The GPWS triggers — that's the Ground Proximity Warning System, which warns you if you're too close to terrain. But positive action is not taken because the surface of the sea can be seen and looks OK. This causes them to misread their altimeters and mistake 200 feet QFE for 1200 feet QFE. QFE is the altimeter setting that reads zero at the airfield elevation — so 200 feet QFE means they're only 200 feet above the ground, not 1200. They're still some way from the airfield and heading for rising ground. Fortunately, they realize their mistake and rapidly climb to a safe height. This report shows how visual illusions — the sea looking safe, the runway appearing far away — can cause you to misread your instruments, even your altimeter. Next is CHIRP Report 17, labelled "Illusions." This one involves a helicopter. In the cruise, VMC on top — that means Visual Meteorological Conditions above a cloud layer — in bright sunshine. Blade flash through the front rotor system onto the flight deck causes a feeling of unease and tension. After about 45 minutes, the pilot leaves the flight deck, gets a baseball cap from his navigation bag, returns to the flight deck, and the symptoms immediately begin to subside and disappear totally within 10 minutes. The pilot notes this has happened before when he didn't have a cap available, and the problem continued until he either descended below cloud or completed the flight. This is a simple but powerful example of how a physical factor — bright flashing light — can cause psychological stress and degrade performance. The fix was a baseball cap. Now, the chapter concludes by telling you that these reports have been selected from CHIRP reports over the last ten years. Your instructor will have a fuller review of all the reports issued over that period. And here's the key message: many of these incidents happened to very senior, experienced pilots. It is not only inexperienced pilots who make human errors. Anyone, when they are tired, under stress, unwell, or simply not paying attention, can make mistakes. The final line is a warning: "DON'T LET IT BE YOU!"