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incapacitation, the pilot demonstrates manifestly inappropriate behaviour involving action or inaction, and
the inappropriate behaviour is associated with failures of comprehension, perception, or judgement.
These kinds of incidents seldom occur in isolation because, in most cases, they represent a pattern of
behaviour. Two excerpts from reports to NASA’s ASRS (National Aeronautics and Space Administration
Aviation Safety Reporting System) illustrate the repetitive nature - or pattern - of what may be examples
of this grey, but important, problem area.
a) “On two occasions we descended through our assigned altitude. I was the non-flying pilot and made all the
call-outs . . . On both occasions, in addition to the required call-outs, I informed the flying pilot that we
were descending through our assigned altitude. His corrections were slow and on one occasion we went
400 feet below, and on the other, 500 feet below the assigned altitude. In addition, his airspeed and heading
control were not precise . . .”
The reporter elaborated further in a telephone call:
“. . . Captain reacted almost catatonically to his altitude call-outs and the additional call-outs that they were
descending through the cleared altitudes. Definitely very delayed reactions. Other aspects of the trip were
reasonably normal except that Captain missed several radio transmissions. `It was as if he simply didn’t
hear them’ . . .”
b) From a telephone call to a pilot reporting a different incident:
“Reporter believes Captain has serious and persistent ‘subtle’ incapacitation problem. Reported incident
(which included successive altitude deviations) . . . happened on first trip of the month . . . Remainder of
month with Captain has had same pattern with many cases of very poor performance . . . Seems to be
increasingly slow thinker in the aeroplane. Has to be reminded of things several times, even including
getting his signature on required papers . . .”
The deliberate failure to follow established rules and procedures is a very old problem and the “maverick”
pilot is by no means a new phenomenon. One Chief Medical Officer commented on the difficulties with
dealing with aberrant behaviour in the medical context. The following paragraph is taken from his paper
given at an aeromedical examiner symposium in the 1980s:
Psychiatric disturbances giving rise to unusual behaviour are . . . like alcoholism . . . often covered up.
There is, however, genuine difficulty here, for aviation attracts eccentrics - indeed, aviation has only
reached its present state because of eccentrics. It is often very difficult to define the boundaries between
normality, eccentricity, and psychiatric disorder, and individuals, not uncommonly, cross over these
boundaries from day to day. The ICAO definition - ‘manifested by repeated overt acts’ - is a useful
indicator of the need for, at least, investigation.
The nature of air transport operations is such that the individuals in the best position to observe repeated
overt acts and, from a practical standpoint, the only ones situated to do so, are other crew members. This
creates a different sort of resource management problem. It is an obvious challenge for management. It is
ICAO Preliminary Unedited Version — October 2008 I-3-7
also a challenge for pilot-representative organizations.
Control of the incapacitation risk is dependent upon effective operational monitoring. A basic requirement
for that monitoring is that all flight crew members must know what should be happening with and to the
aeroplane at all times. This is one of the most important reasons for following standard operating
procedures (SOPs) and flying standard flight profiles. The real importance of SOPs lies as much in the
area of information transfer as it does with respect to the issue of the proper way to fly the aircraft.
Routine adherence to SOPs helps to maximize information transfer in much the same way that the use of
standard phraseology does in air traffic control communications.
Detection of subtle incapacitation may be indirect, i.e. as a result of a pilot not taking some anticipated
action. If, for example, the pilot conducting the approach to land silently loses consciousness and his body
position is maintained, the other pilot may not be aware of his colleague’s predicament until the expected
order of events becomes interrupted. Regular verbal communication, built into standard operating
procedures, and use of the “two communication rule” are helpful to detect subtle incapacitation,
especially when physical control inputs are unnecessary, e.g. automatic approach.
Fail-safe crew
The object of “fail-safe crewing” is to provide an adequate number of crew members to cope with flight
　
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本文鏈接地址：Manual of Civil Aviation Medicine 1(52)