DENVER, AUG. 26 -- It's called the "human factor," and it causes an estimated 65 percent of all airline accidents, including, possibly, the crash of Northwest Flight 255 in Detroit Aug. 16.
And Allan McArtor, head of the Federal Aviation Administration, has called a meeting in Kansas City Thursday of all chief pilots of the airlines for a session on what to do about the problem that has been around since the beginning of aviation.
Here at the United Airlines flight training center, "pilot error" or "crew error" or the many other terms for tragic mistakes have become a major focus of United's pilot training program.
For instance, before Dick Ouren and Bernie Slaten can be promoted to captains of Boeing 727 jetliners, they will relive -- on simulators -- a series of plane crashes that might have been prevented if pilots had performed differently.
The training goes so far as to pump up the pilots to stand up against majority opinion if they have doubts, with a Hollywood movie, "Twelve Angry Men," about how one doubting juror in a murder case reverses a clear guilty sentiment among his fellow jurors.
The "Cockpit Management Resource" program was incorporated into United's training and refresher courses after the airline reviewed nine catastrophic accidents over 30 years and found only one was caused by mechanical failure.
"How crew members work together in the cockpit was lacking in our training," said William Traub, vice president of United's flight training.
Traub began developing the program in the late 1970s. In addition to reviewing the accidents, United's 7,000 pilots have also been required to attend a three-day seminar that has been compared to an encounter group on how human beings react in crisis situations.
Once a year, crew members are videotaped in the flight simulators as they respond to a noncritical emergency and then are shown the tape so they can see how they behaved.
"The real key is to design our training and checklist programs so that the next accident never occurs," Traub said.
"Nobody is infallible," he said. "What we try to do is have enough backup systems in place. Hardly any accident occurs that there aren't a whole chain of events that occurred. If you can break that chain you have a safe operation."
In the wake of the tragic crash of Northwest's Flight 255 in Detroit, attention has shifted to competence in the cockpit. According to preliminary results of a National Transportation Safety Board investigation, the Northwest crew did not extend the wing flaps and slats to give the proper lift at takeoff, although the board cautioned that it has not reached a final conclusion on the cause.
"We haven't taken a fundamental look at pilot training for some time," said John Lauber, a safety board member who is a psychologist and specialist in human factors research at the National Aeronautics and Space Administration's Ames Research Center in California before joining the board in 1985. "We've got a different situation."
He cautions that a call for review of training "doesn't imply anything" about the Detroit crash.
"I think something needs to be fixed," said Mel Hoaglander, a United pilot and a representative of the Airline Pilots Association. "But it stems from certain philosophical questions. What is it about the entire system that causes a pilot to break altitude or air speeds or not put the flaps down on takeoff? I can't put my finger on it."
In the hallways outside the simulators in the classrooms at United's flight training center here, pilots say they are skeptical that the Kansas City meeting will be productive. Pilots are sensitive about laying the bulk of the blame on cockpit crew performance, and some pilots bristle at discussions of pilot fatigue or pilot complacency.
One pilot completing United's wind-shear training said it is easy for the FAA to focus on airline pilot training because it will not cost the government any money. What is needed, he said, are more improvements to weather and radar equipment at airports, longer runways and better signs on taxiways, all of which cost.
On the other hand, the pilots have quietly mulled their theories on the cause of the Detroit crash. Could a checklist item have been avoided? Did a change of runway distract the crew?
"There are too many things in the bag," said Ouren, referring to the air traffic system as a whole. "The cushion is removed. Fatigue, weather -- maybe it only takes one thing now to push it over the edge."
Traub said the FAA has had a number of ways to work on the "human factor" for some time now, but he was critical of the government's sluggish rulemaking procedures.
For instance, the safety board recommended a year ago that the FAA develop cockpit management programs and singled out United's program as an example. United was involved in development of a wind-shear training program delivered to the FAA last spring -- but the final rule has yet to be put in place.
"We've known about the severity and hazards of wind shear since 1982 and yet it's still not a law," Traub said.
Aircraft manufacturers like Boeing, which has been studying the human factor since it began building planes with two-man crews instead of three, discount the theory that automation has lulled pilots into complacency. Boeing is now building planes which will be fully automated for landings and takeoffs.
"Automation is a factor," said Del Fadden, a Boeing crew requirement specialist. But he added that routine and repetitive tasks lead to complacency as well.
Ouren, who is moving from the two-man 737 to the three-man 727, said the automated cockpit's chief drawback is not pilot complacency, but the tendency of the equipment to keep the pilot's eyes focused on the instruments instead of looking outside.
"Automation doesn't keep you less busy, it gives you more information," he said. "It keeps your head in the cockpit. The colors on the switches are designed to draw your attention, and they do."