Aviation safety is a product of the many and not the few

WHEN an aviation accident occurs, attention quickly narrows to the actions of the flight crew, and in particular to the idea of “pilot error”. It is a familiar framing, but an incomplete one.

While pilot actions are visible at the sharp end of operations, they sit within a far broader system of human, technical and organisational support. In modern aviation, safety is not delivered by individuals acting alone, but by the combined actions of many.

Pilots rarely act in isolation. Almost every decision they make is shaped by inputs from technology, procedures, training, maintenance, air traffic services, operational planning and organisational culture. To attribute outcomes solely to the crew is, therefore, both unfair and misleading.

The industry has already moved some way from the language of “pilot error” towards the broader concept of “human factors”, recognising the involvement of a wider range of people and organisations. Even this, however, is not the complete picture.

Accidents and incidents typically arise not from a single failure, but from a chain of events in which multiple defences are weakened or bypassed. Understanding how that chain forms, and how it can be broken, is central to improving safety outcomes.

A benchmark of zero

In 2023, according to Cirium data, there were zero deaths in scheduled passenger operations involving aircraft with more than 14 seats anywhere in the world. This category covers the vast majority of commercial flights undertaken for business and leisure.

At any given moment, it is widely estimated that more than 1m people are airborne. Set against this scale, the safety record of aviation stands in sharp contrast to that of other modes of transport. In the UK, for example, road deaths in 2023 amounted to 25 per million inhabitants.

The 2023 data demonstrates what is possible. The challenge for the industry is not to regard it as an anomaly, but as a benchmark. This is already the key focus of many individuals, regulators, operators, manufacturers and service providers.

Attritional losses

From an insurance perspective, the relevance of accident chains extends far beyond catastrophic losses. Partial losses and attritional claims, typically considered to be those up to $10m for an airliner, are also frequently characterised by multiple contributing factors.

These events may not involve loss of life or injury, but they still reflect an accident chain that could have been broken to avoid the loss. Indeed, as aircraft values and repair costs rise, the financial significance of such claims continues to grow.

Breaking the chain is therefore a constant objective across all sectors of aviation. National Aviation Authority (NAA) investigators, such as the AAIB, NTSB and BEA, are primarily tasked with preventing future accidents and incidents. Aviation claims adjusters, by contrast, are engaged in understanding what occurred to assess and resolve the financial consequences of an event.

As a result, adjusters often see a wider range of incidents than NAAs, simply because financially driven investigations occur with events that fall below regulatory reporting thresholds. Where there is damage but no immediate human impact, the insurance process still demands a detailed understanding of causes and contributing factors. Insights from this body of work can therefore provide valuable perspectives on recurring vulnerabilities within the system.

Key factors

There are at least eight distinct dimensions involved in flying an aircraft. Ownership, design, regulation, maintenance, operations, navigation, environmental conditions and flight crew actions all play a part. Safety is established long before an aircraft leaves the ground.

The preparation of the airfield, the condition of the aircraft, the quality of maintenance, the robustness of operational planning and the clarity of regulatory oversight all represent links in the chain. In some cases, the concept of the aircraft itself, or the intended operation, may constitute the earliest link of all.

Crucially, aircraft and crews are often capable of coping with individual causal factors when systems are functioning as intended. It is when several elements degrade simultaneously that risk escalates. Alongside rare and tragic events, there are many avoidable repetitions, as well as incidents that are surprising or even benign in outcome despite unfavourable circumstances.

Training is a recurring theme. While it is indispensable, its effectiveness varies. Not all individuals respond equally well to computer-based training, and repetition of standardised modules can encourage pass marks without guaranteeing retention or application of knowledge. As aircraft systems grow more complex, the gap between procedural training and a genuine understanding of the aircraft and how to handle it on the ground and in the air can widen.

Economic pressures also play a role. The drive to bring new products into service quickly can result in operational exposure during early use. While in-service experience is often the most effective form of testing, it raises legitimate questions about where the financial consequences of developmental shortcomings should fall. At the same time, there is a trend towards limiting repairs in favour of replacement, sometimes justified on safety grounds, but also aligned with commercial incentives.

Technology, however, has been a powerful force for risk reduction. Controlled flight into terrain accidents, once a big cause of fatalities, have declined sharply over the past two decades as navigation and situational awareness systems have improved. Composite materials have provided impact protection that earlier metal structures could not. Electronic flight documentation has transformed access to information on the flight deck, while procedural standardisation has reduced variability in response.

Complexity of causation

Insights from emerging areas, such as drone operations, further underscore the complexity of causation. Across McLarens Aviation’s global network, drone direct operator error accounts for around 19% of drone events, but in a further 14% of cases the cause cannot be clearly established. So, was that just a remote pilot not seeing the tree or wall, or was there some other cause in the chain? Technical failures, signal loss, poor mapping and environmental interactions all feature and are not mutually exclusive.

Habitual behaviour and complacency are sometimes raised as concerns, though fatal passenger accidents rarely hinge on these alone. More commonly, outcomes such as runway excursions reflect an interplay of weather, training, information quality, decision-making and operational context. While the immediate cause of loss may be apparent, understanding why that cause emerged requires deeper investigation.

The sustained reduction in aviation fatalities is the result of continuous effort by countless individuals and organisations. The zero-fatality category of 2023 demonstrates that the goal is achievable. As the industry evolves, the number and cost of smaller events continues to rise, reinforcing the need to focus not only on preventing disasters, but on breaking as many links as possible in the accident chain.

Aviation remains one of the safest forms of transport, not by chance, but by design. It is the actions of the many that protect the lives of the many.

John Bayley is global technical director at McLarens Aviation