To Err is Human Case Reports of Two Military Aircraft Accidents: Possible mechanisms of human failure.

It has been postulated that pilot error or in-flight incapacitation may be the main contributory factors to 70-80% of aircraft accidents. Two fatal aircraft accidents are presented in which either of the above possibilities may have played a role. The first case report describes an erroneous decision by a fighter pilot to use a seat position adjustment of the ejection seat leading to fatal injuries when he had to eject from his aircraft. Injuries to the body of the pilot, and observations on the state of his flying clothing and the ejection seat were used to postulate the mechanism of fatal injury and establish the cause of the accident. The second case report describes the sequence of events which culminated in the incapacitation of a fighter pilot while executing a routine manouevre. This resulted in a fatal air crash. Possible contributions of environmental factors which may have resulted in failure of his physiological mechanisms are discussed.