Instrument Failure, Stress, and Spatial Disorientation Leading to a Fatal Crash With a Large Aircraft.

Abstract

An aircraft's orientation relative to the ground cannot be perceived via the sense of balance or the somatosensory system. When devoid of external visual references, the pilot must rely on instruments. A sudden unexpected instrument indication is a challenge to the pilot, who might have to question the instrument instead of responding with the controls. In this case report we analyze, from a human-factors perspective, how a limited instrument failure led to a fatal accident. During straight-ahead level flight in darkness, at 33,000 ft, the commander of a civil cargo airplane was suddenly confronted by an erroneous pitch-up indication on his primary flight display. He responded by pushing the control column forward, making a bunt maneuver with reduced/negative Gz during approximately 15 s. The pilots did not communicate rationally or cross-check instruments. Recordings of elevator and aileron positions suggest that the commander made intense efforts to correct for several extreme and erroneous roll and pitch indications. Gz displayed an increasing trend with rapid fluctuations and peaks of approximately 3 G. After 50 s the aircraft entered a turn with decreasing radius and finally hit the ground in an inverted attitude. A precipitate maneuvring response can, even if occurring in a large aircraft at high altitude, result in a seemingly inexorable course of events, ending with a crash. In the present case both pilots were probably incapacitated by acute psychological stress and spatial disorientation. Intense variations in Gz may have impaired the copilot's reading of the functioning primary flight display.Tribukait A, Eiken O. Instrument failure, stress, and spatial disorientation leading to a fatal crash with a large aircraft. Aerosp Med Hum Perform. 2017; 88(11):1043-1048.