Behavioral Traps in Flight Crew-Related 14 CFR Part 121 Airline Accidents

159 Pages·2016·1.78 MB·English

by  Jonathan Velázquez

PhD Dissertations and Master's Theses
2016
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Jonathan Velázquez
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Velázquez, Jonathan, "Behavioral Traps in Flight Crew-Related 14 CFR Part 121 Airline Accidents" (2016).
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BEHAVIORAL TRAPS IN FLIGHT CREW-RELATED 14 CFR PART 121
AIRLINE ACCIDENTS
by
Jonathan Velázquez
A Dissertation Submitted to the College of Aviation
in Partial Fulfillment of the Requirements for the Degree of
Doctor of Philosophy in Aviation
Embry-Riddle Aeronautical University
Daytona Beach, Florida
March 2016

© 2016 Jonathan Velázquez
All Rights Reserved

ABSTRACT
Researcher: Jonathan Velázquez
Title: BEHAVIORAL TRAPS IN FLIGHT CREW-RELATED 14 CFR PART
121 AIRLINE ACCIDENTS
Institution: Embry-Riddle Aeronautical University
Degree: Doctor of Philosophy in Aviation
Year: 2016
This dissertation examined pilot behavioral traps in the multi-crew Part 121 air carrier
environment. Behavioral traps are accident-inducing operational pitfalls aviators may
encounter as a result of poor decision making. The traps studied were: Loss of
Situational Awareness; Neglect of Flight Planning, Preflight Inspections and Checklists;
Peer Pressure; Get-There-Itis; and Unauthorized Descent Below an Instrument Flight
Rule (IFR) Altitude. The purpose of this dissertation was to study the nature of their
occurrence in the airline domain. Another key component was to explore the
relationships between the behavioral traps and factors such as pilot age, pilot flight
experience, weather, flight conditions, time of day, and the first officer certification level.
The dissertation was conducted using an archival combined-methods
methodology. Four subject matter experts analyzed 34 National Transportation Safety
Board (NTSB) accident reports. Behavioral traps were found in all accidents with Loss
of Situational Awareness and Neglect of Flight Planning, Preflight Inspections, and
Checklists dominant. The SMEs were able to identify many pilot actions that were
representative of the behavioral traps.
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During the qualitative analysis, various themes began to emerge which played
important roles in many accidents. These emerging themes were Crew Resource
Management issues, Fatigue, Airline Management, and Flying Outside the Envelope.
The quantitative analysis discovered a moderate correlation, r = -.34, p = .05, between the
Captain’s Flight Experience and the behavioral trap Unauthorized Descent Below an IFR
Altitude. No other correlations were found to be significant between the variables and
the behavioral traps. The findings of this study indicated that behavioral traps were
prevalent in airline accidents including habitual noncompliance by pilots. Further
research should focus on other flight domains and other informational sources such as air
taxi operators, incident accounts, and flight recorded data. Attitude management training
is recommended.
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DEDICATION
My journey to a doctoral degree began more than four years ago. This
dissertation is dedicated to Amos. I trust the time and effort spent completing this
manuscript was part of your plan. With your guidance, everything is possible.
To my parents, Israel Velázquez and Sonia I. Rivera, who inspired me to
persevere and pursue the highest goals in life. Without their moral and financial support,
the road and destination would have been different.
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ACKNOWLEDGEMENTS
Many thanks to the four subject matter experts: Kevin Roman, Omar Carle,
Oswart Mora, and Pablo Ortiz whom collaborated in this research project. Your
outstanding participation was key in the completion of this dissertation.
Many thanks to Dissertation Chair Dr. Tim Brady. Your attention to detail and
unwavering support to my study was crucial. From the moment I took your course in the
doctoral program, I knew I wanted you on my team. Thanks for accepting to work with
me, even when you became the university’s chancellor and your duties increased
exponentially. Also, thank you for helping me become a better writer.
Thanks to dissertation committee members Drs. Andy Dattel, Dennis Vincenzi,
and Paul Craig. Dr. Dattel, thank you for your statistical support and for answering my
messages even after midnight. You rock! Dr. Vincenzi, without your insightful
perspective, this dissertation would not be what it is. Thank you for pushing me forward.
Dr. Craig, thank you for participating in my research. Who would have thought that our
paths would cross again almost 17 years later?
Many thanks to my advisor Dr. Haydee Cuevas. You are the reason I have been
able to stay airborne during my Ph.D. journey. You are my advisor, but even better, my
mentor and friend. I would have to write another dissertation to fully express my
gratitude toward you.
Dr. Alan Stolzer, thank you for instilling the necessary research interest in all of
us, for believing in my research, and for encouraging that I publish. I hope you can see
that it has worked.
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To all my classmates, especially: Nicole Bier, Timothy Sestak, Al Peck, and
Susan Archer. Nicole, it was fun, and enlightening, working and publishing with you. I
hope we can do it again, my friend. Thank you Uncle Al and Timothy for accepting to
follow me through with my pilot study in our mixed-methods statistics course. Thank
you Susan for those fun residency study moments and collaboration in the various
courses.
Finally, many thanks to my colleagues Mario Signoret, Maria Franqui, and Carole
Gelpí. When I was your undergraduate student, you saw a potential in me that I had not
seen. Thank you for suggesting a career in research and education and for believing I
could go all the way.

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