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 Table 4. Distribution of errors identified in the 37 accidents reviewed in the Safety Board's 1994 safety study.

handling (20 percent) were the next most common error types made by captains. The aircraft handling errors made by captains accounted for 33 (72 percent) of the 46 aircraft handling errors made by all crewmembers, which is consistent with the captain conducting the PF duties on more than 80 percent of the accident flights reviewed in the study.

Further, the study stated that a common pattern in 17 of the 37 accidents was a tactical decision error by the captain (more than one-half of which constituted a failure to initiate a required action) followed by the first officer's failure to challenge the captain's decision. The study also concluded that, of the 49 tactical decision errors made by captains, 44 (90 percent) were made while the captain was serving as the PF and that 26 (59 percent) of these errors were errors of omission. Thus, the most common tactical decision error was the failure of a captain serving as the PF to take action when the situation demanded change. In addition, of the 26 tactical decision errors made by captains that were errors of omission, 16 (62 percent) involved the captain's failure to execute a goaround during the approach. These 16 errors were made during 10 different accident sequences. Of the 16 failures to execute a go-around, 8 involved an unstabilized approach.

The study found that the 70 monitoring/challenging errors committed by flight crewmembers occurred in 31 (84 percent) of the 37 accidents reviewed in the study and that most of these errors played very important roles in the accidents. The study concluded