Joint Committee on Aviation Pathology: IV. Crew behavior in accident causation

The behavioral intercrew dynamics were investigated in three fatal air carrier accidents. This is apparently the original research done on this vital safety area and certain important factors have been identified for use in the prevention of future accidents. It is seen that a pilot in a flying situation is, in reality, a processor of information encompassing a system of behavior patterns. A failure in the information processing modes may be contributory to accident causation. The processing system contains four interrelated phases: 1) sensing the incoming information (Perception); 2) analyzing and understanding the processed information (Comprehension); 3) making a decision based on the understanding (Decision); and 4) performing or not performing some physical act based on the decision (Action). The dynamic factors of selective inattention, ego function, and level of awareness are present in all crew behavior. If any one of these dynamic factors affects the performance of the flight task, the behavior may lead to inappropriate performance. This may result in a fatal accident. Conclusions concerning accident prevention are drawn from this study.