Impossible! 457 Plane Crashes Due to Pilot Error?
During World War II, the Boeing B-17 Flying Fortress was a lethal workhorse for the US Air Force and quickly became a symbol of American airpower. The four-engine long-range bomber could fly at high altitudes, was fast, maneuverable, and highly resilient. Numerous accounts attest to the plane’s ability to take heavy damage and successfully return to base to be repaired and fly again. Military analysts estimate that over 40% of the bombs dropped onto Nazi Germany fell from B-17s.
Boeing conceived the idea for the plane in the 1930s, where it evolved through various design changes. But wartime necessity accelerated aircraft production, producing criticism from many quarters that the later model’s engineering and design were rushed. This criticism was exacerbated when the Air Force reported numerous aircraft crashes, usually occurring on what should be routine landings, resulting in many fatalities. Often, ground crews would see the plane gliding to the runway but at the last moment dropping to the tarmac with no landing gear deployed. Investigators attributed the crashes to pilot errors.
During wartime, new enlistees were tested for aptitude and then assigned a role within a military unit based on their proficiency. Recruits that demonstrated a propensity for flying were trained as pilots. Air Force brass concluded that the pilots that crashed their planes were not fit to be pilots; the aptitude tests had failed. However, many pilots who survived their crashes could not recollect what they may have done wrong.
To solve the problem, the Air Force enlisted two psychologists. Paul Fitts and Alphonse Chapanis interviewed pilots, crawled through aircraft, and analyzed 457 crashes that had occurred in a 22-month window. Neither man could believe that the umbrella term “pilot error” could adequately explain the sheer quantity of accidents that occurred roughly in the same way. To discover the root cause of the problem, the two men studied a swath of potential cockpit errors, including reaching for the wrong switch, inability to locate a control, adjusting controls opposite to intention, or unknowingly turning something on when it was meant to stay off.
Fitts’ and Chapanis’ theory that the real problem was not pilot error was proven correct. In the B-17 cockpit, almost side-by-side, were two identical switches. One controlled the landing gear and the other the wing flaps. Pilots regularly confused these two similar switches and often reached for the flap control when they meant to lower the landing gear. With the flaps deployed, the plane would plunge. The culprit was not a pilot error but a design error.
Fitts’ and Chapanis’ solution was brilliant in its simplicity; they asked Boeing to re-design the cockpits. Engineers now organized instruments and controls in logical clusters that were intuitive to the user. Turning a dial to the right should mean more; turning left should mean less. Flipping a switch up should mean up or on; tossing it down should mean off or down. They also introduced the idea of shape-coding, whereby a pilot could know what switch, knob, or lever he was reaching for by the way it felt. Numerous controls were now rounded, squared, and wheeled; when you touched a control, you would know what it was by its shape.
Beyond simplification, shape-coding, and standardization of the cockpit mechanisms and displays, the team also introduced additional safety and true-to-intent measures, including sequenced activity progressions, inter-locks and lock-outs. These innovations in cockpit design resulted in numerous lives saved. Today, human-centric design features like the above make operating everything from your computer, kitchen appliances, or driving your car more intuitive and user fault-free.
Insight and Application
Fitts and Chapanis knew that while pilot error was a possibility, it could not explain the sheer quantity of plane crashes that happened in the same way. The team’s investigation centred on the design of the cockpit, which allowed, or in this case hampered, the safe and effective operation of the aircraft. In subsequent years, this human-centred design allowed the intersection of human psychology, ergonomics, cultural anthropology, and process flow. Operational design has an outsized impact on user behaviour; design yours with care and deliberation.
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