Effects of flight crew role assignment on aviation accidents and incidents: Evidence of a systemic safety issue

Abstract

To investigate whether a reported association between flight crew role assignment and accident/incident frequency has persisted subsequent to reforms introduced to address it, we analyze global civil aviation data on 841 accidents and safety critical incidents for the period 2000–2020 resulting in 5318 fatalities. We find that significantly more such events occur, and significantly more fatalities result, when the Captain (Pilot-in-Command) rather than the Co-pilot (Second-in-Command) is acting on the controls as “Pilot Flying” rather than acting as “Pilot Monitoring” – prima facie evidence that the regular combination of command and control (Pilot-in-Command as Pilot Flying) presents a significant systemic safety risk. The yearly proportion of events with the Pilot-in-Command as Pilot Flying significantly increased over 2000–2020. Moreover most (72.2%) events occurred in the absence of any emergency, in technically airworthy aircraft and most (87.9%) were also judgmentally assessed as preventable by the flight crew. Our findings are consistent with accounts of the crew assignment effect that invoke role-dependent status hierarchy effects interfering with effective monitoring and with cognitive overload debilitating the Pilot-in-Command when assigned as the Pilot Flying. We interpret these findings as evidence that measures specifically introduced to implement effective flight crew teamwork, such as Crew Resource Management training, fail to prevent ineffective flight crew teamwork. We consider the implications of our findings for the aviation industry and present options for mitigation and issues for further research.