Pilot error must be stopped!

First up, total click bait mini title because that is categorically not why investigations occur, or the purpose of them.

Let’s jump back a few steps to why I am writing this (very brief and summarised bit of info on accident investigations). In February 2025, a very serious accident occurred at CYYZ/Toronto Pearson airport in Canada, involving an Endeavour CRJ9. The aircraft landed and flipped over injuring a fair few (but thankfully not resulting in any fatalities).

If you want to read the current facts as we know them then personally I find sites like AvHerald good because they don’t speculate, they just post what is currently known. Things like the weather conditions,

Right, so something happened which resulted in an aircraft lying on its back at the end of a runway. We know WHAT happened but we don’t know WHY it happened.

Clearly pilot error, right?!

No, and here is why: we try not to use that phrase anymore because the purpose of investigating an accident is not about apportioning blame. It is about trying to learn why and how something happened so that we can learn from it.

Saying “pilot error” doesn’t actually tell us anything at all. What we want to understand is what led to something going wrong. This is based off something that came out in 1993 – the ‘reason model’ or ‘cumulative act effect’ or as many know it the ‘Swiss cheese model’, developed by James T. Reason (who very tragically passed away earlier this year).

Basically, we want to know what led to the error being able to occur, how it slipped past our barriers, what caused it to creep in. We all generally know when an error has been made, but we don’t learn from that.

Identifying “an airplane flipped over” isn’t insightful in anyway. Saying “pilots shouldn’t flip the aircraft on landing” isn’t remotely useful. Even saying “the pilot messed up the landing” is lacking in any learning because we don’t know why – that why is more than likely part of a bigger chain, or maybe it was, in itself, down to something else. Fatigue, insufficient training, company culture, distraction, conditions… whatever the cause, understanding (and mitigating) that is how we prevent future events. Not by shouting “don’t do stuff wrong!”

OK, how do we get these insights?

The standards for accident investigations are laid out in ICAO Annex 13, ‘Aircraft Accident and Incident Investigation’. This can be purchased from the ICAO store, but there is an older version here on Skybrary.

These is all about how to do an accident investigation. I’m not going to go into detail except to say (or rather, show) this:

In case you’re in any doubt, it’s the SOLE objective!

How they go about gathering the info, drawing conclusions etc from it is a process I have no knowledge of, but the important thing is this – they work from facts. They draw conclusions from facts. They don’t speculate.

Speculation is guesswork, making assumptions, drawing conclusions without basis, and it achieves nothing. Generally, folk who do this a) probably don’t have the full picture, b) probably aren’t trained to draw conclusions from facts anyway and c) won’t really gain anything from it in terms of learning.

But discussing things is good?

Yes, it is. Using an event to discuss things with the intention of learning from them is always good. But there is a balance.

With the recent crash, we know something must have happened to result in it flipping over. Something went wrong with the landing. We don’t know what, we don’t want to speculate and we certainly don’t want to pointlessly apportion blame.

But we can have discussions on things that this might raise for us, so long as we do so with the intention to learn.

For me, discussions on things like:

• how to handle a last minute intervention on landing
• what to monitor with regards an approach and landing
• how to handle aircraft in contaminated winter ops conditions

could all be useful discussions which this accident might cause us to consider. We aren’t saying that is what caused this one, but we might learn something by having these and this could be an opportunity to do so.

Learning is key

When the report comes out, we can read the facts, take in the recommendations and conclusions drawn by experts, and we can think about how to apply these to our operations and to our own performance.

These are often ‘human factors’ (a phrase much preferred to ‘pilot error’). This looks at why things happened and gives us insights which we can learn from, they don’t apportion blame, they try to say why and how something occurred.

We can use these to build an awareness of potentially contributory factors – in other words things which we might experience in our own operation, or in ourselves. We can think how they could impact us, and then we consider ways to mitigate against them.

Let’s give it a go.

What can we say about this accident now?

Not much, and I would really encourage anyone who is making assumptions and speculating negatively to be called out on it. It achieves nothing, it disrespects those involved, it can even lead to negative learning, and it often paints a picture for the general public which is inaccurate and which can damage our industry and our reputations.

We know an aircraft landed into Toronto in challenging winter ops conditions and that it ended up on its back. We know something happened during that landing which resulted in this. If we’ve see the video we might even make an educated guess that it was down to some failure during the landing). But that is all we can say.

We can’t whether that ‘failure’ was due to human factors, training problems, handling issues… and we can’t why because we don’t know!

Go learn

Rather than spending time speculating/ judging etc, why not go read an actual investigation report and learn from that while you wait for this one to be released.

Here are some recommendations of recent ones (with juicy little learning points):

• AAIB Bulletin 2/2025: A recent AAIB bulletin containing reports of various incidents including a low fuel situation which we could all learn from
• AAIB 29768: A serious incident on go-around involving a Boeing 737
• AIFN/0016/2021: Final report of Boeing 777 shallow climb after takeoff serious incident