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 FAA's effort met the intent of Safety Recommendation A-96-133, it was classified "Closed--Acceptable Action."

1.18.5.1 Safety Board Study of Flight Crew Involvement in Major Accidents

In a 1994 safety study, the Safety Board examined the operating environments and errors made by flight crewmembers in 37 major accidents between 1978 and 1990. The safety issues examined in the report included the performance of flight crews when the captain was the PF, the performance of the PNF in monitoring and challenging errors made by the PF, and the adequacy of CRM training programs.

The study concluded that the captain was the PF in more than 80 percent of the 37 accidents reviewed. This result was significant because U.S. air carrier flights during the study's time frame were divided about equally between those flown by the captain and those flown by the first officer.

The Safety Board identified 302 flight crew errors in the 37 accidents; the median number of errors per accident was 7. Of the total number of errors, 232 were considered primary errors, and 70 were considered secondary errors. The primary error categories identified by the Safety Board included aircraft handling, communication, navigational, procedural (for example, not conducting or completing required checklists or not following prescribed checklist procedures), resource management, situational awareness (for example, controlling the airplane at an incorrect target altitude), systems operation, and tactical decision (for example, improper decision-making, failing to change a course of action in response to a signal to do so, or failing to heed warnings or alerts that suggest a change in the course of actions). Secondary errors resulted from the failure of a crewmember to monitor or challenge a primary error made by the other crewmember. Table 4 shows the distribution of the 302 errors identified in the 37 accidents by type of error.

The Safety Board's study determined that procedural, tactical decision, and resource management errors were largely errors of omission and that navigational and most of the aircraft handling, communication, and systems operation errors were errors of commission. Of the 232 primary errors identified, 123 (53 percent) were errors of omission, and 109 (47 percent) were errors of commission.

The safety study also determined that captains were responsible for 168 of the 302 identified errors. Of the 168 errors made by captains, 49 (29 percent) were tactical decision errors, the most common error type attributed to captains. The 49 tactical decision errors made by captains accounted for 96 percent of the 51 tactical decision errors made by all crewmembers, which is consistent with the captain's ultimate responsibility for decisions. The study also found that procedural (23 percent) and aircraft