Shattered LivesMaking Sense of September 11th and its Aftermath

This dissertation examined pilot behavioral traps in the multi-crew Part 121 air carrier environment. Behavioral traps are accident-inducing operational pitfalls aviators may encounter as a result of poor decision making. The traps studied were: Loss of Situational Awareness; Neglect of Flight Planning, Preflight Inspections and Checklists; Peer Pressure; Get-There-Itis; and Unauthorized Descent Below an Instrument Flight Rule (IFR) Altitude. The purpose of this dissertation was to study the nature of their occurrence in the airline domain. Another key component was to explore the relationships between the behavioral traps and factors such as pilot age, pilot flight experience, weather, flight conditions, time of day, and the first officer certification level. The dissertation was conducted using an archival combined-methods methodology. Four subject matter experts analyzed 34 National Transportation Safety Board (NTSB) accident reports. Behavioral traps were found in all accidents with Loss of Situational Awareness and Neglect of Flight Planning, Preflight Inspections, and Checklists dominant. The SMEs were able to identify many pilot actions that were representative of the behavioral traps. iv During the qualitative analysis, various themes began to emerge which played important roles in many accidents. These emerging themes were Crew Resource Management issues, Fatigue, Airline Management, and Flying Outside the Envelope. The quantitative analysis discovered a moderate correlation, r = -.34, p = .05, between the Captain's Flight Experience and the behavioral trap Unauthorized Descent Below an IFR Altitude. No other correlations were found to be significant between the variables and the behavioral traps. The findings of this study indicated that behavioral traps were prevalent in airline accidents including habitual noncompliance by pilots. Further research should focus on other flight domains and other informational sources such as air taxi operators, incident accounts, and flight recorded data. Attitude management training is recommended. v DEDICATION My journey to a doctoral degree began more than four years ago. This dissertation is dedicated to Amos. I trust the time and effort spent completing this manuscript was part of your plan. With your guidance, everything is possible. To my parents, Israel Velázquez and Sonia I. Rivera, who inspired me to persevere and pursue the highest goals in life. Without their moral and financial support, the road and destination would have been different.

Journal of Contemporary Ethnography, 2002

During the terrorist attacks on September 11th, 2001, the author was on a plane headed to Dulles Airport. She narrates and analyzes her experience in terms of how she reframed and made sense of these events. After she first resisted the frame of terrorism, her perceptions were influenced by her location during the attacks as well as by personal experiences of loss, both current (her mother's and mother-in-law's deteriorating health) and past (her brother's death on a commercial airplane). Through autoethnography, she shows that everyday stories of those not directly involved in the attacks, yet devastated by what happened, merit telling. She tells this story to find personal and collective meaning in this tragedy and to provide incentive for others to tell their stories so that we might discuss and better understand the impact of what happened. The author hopes this piece will stimulate a dialogue among qualitative researchers about their role in understanding September ...

2016

Itis; and Unauthorized Descent Below an Instrument Flight Rule (IFR) Altitude. The purpose of this dissertation was to study the nature of their occurrence in the airline domain. Another key component was to explore the relationships between the behavioral traps and factors such as pilot age, pilot flight experience, weather, flight conditions, time of day, and the first officer certification level. The dissertation was conducted using an archival combined-methods methodology. Four subject matter experts analyzed 34 National Transportation Safety Board (NTSB) accident reports. Behavioral traps were found in all accidents with Loss of Situational Awareness and Neglect of Flight Planning, Preflight Inspections, and Checklists dominant. The SMEs were able to identify many pilot actions that were representative of the behavioral traps. iv During the qualitative analysis, various themes began to emerge which played important roles in many accidents. These emerging themes were Crew Resource Management issues, Fatigue, Airline Management, and Flying Outside the Envelope. The quantitative analysis discovered a moderate correlation, r =-.34, p = .05, between the Captain's Flight Experience and the behavioral trap Unauthorized Descent Below an IFR Altitude. No other correlations were found to be significant between the variables and the behavioral traps. The findings of this study indicated that behavioral traps were prevalent in airline accidents including habitual noncompliance by pilots. Further research should focus on other flight domains and other informational sources such as air taxi operators, incident accounts, and flight recorded data. Attitude management training is recommended. v DEDICATION My journey to a doctoral degree began more than four years ago. This dissertation is dedicated to Amos. I trust the time and effort spent completing this manuscript was part of your plan. With your guidance, everything is possible. To my parents, Israel Velázquez and Sonia I. Rivera, who inspired me to persevere and pursue the highest goals in life. Without their moral and financial support, the road and destination would have been different.

This tragic accident was the result of a series of events leading to a physiologically normal misperception of pitch orientation by both pilots at the controls of the aircraft. Due in part to the compelling nature of this false information, and in part to the task saturation created by workload associated with tasks related to the “go-around,” the pilots did not perceive the true attitude of the aircraft. Indeed, based on our model of the pilots’ illusory perception of pitch-up, the pilot in command provided inputs that yielded further pitch down changes, resulting in near vertical impact with the ground.

International journal of emergency mental health, 2011

Dr Boscarino was in the World Trade Center complex on September 11, 2001 when the first plane struck the Twin Towers. His World Trade Center work was supported in part by grants from the National Institute of Mental Health (Grants # R01 MH66403 and R21-MH-086317) and the Pennsylvania Department of Health (Contract #4100042573).

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