REVIEW ARTICLE Spatial Disorientation: Decades of Pilot Fatalities Randy Gibb , Bill Ercoline , and Lauren Scharff G IBB R, E RCOLINE B, S CHARFF L. Spatial disorientation: decades of tion community. Although we primarily address military pilot fatalities. Aviat Space Environ Med 2011; 82:717 - 24. aspects of SD, the problem also exists in both the com- Spatial disorientation (SD) has been a contributing factor in aviation mishaps for decades and efforts to mitigate SD have not been propor- mercial and general aviation sectors. The accurate per- tionate to the danger it poses to pilots. We argue that SD contributes to ception of one’s orientation in space is vital for safe nearly 33% of all mishaps with a fatality rate of almost 100%. However, aviation operations and, despite assumed improvements SD has not garnered the respect and awareness it requires from leader- ship and pilots because of historically inaccurate reporting within acci- in training programs and technology, SD-related mishaps dent investigations and under-reporting of SD data in research. Over 30 continue to occur and the most common types of SD ex- research studies and 10 mishap case studies are presented to portray periences have not drastically changed over the decades. SD’s role in aviation accidents since 1913. Research and training are SD is defi ned by Benson ( 6 ) as, “ the pilot fails to sense recommended to improve pilot respect and awareness for SD-inducing scenarios that would include pilot recognition and successful recovery correctly the position, motion, or attitude of his aircraft Delivered by Ingenta to: Baylor Universityor of himself College within of theMedicine fi xed coordinate system provided using SD-specifi c simulators. Consequently,IP: funding 128.249.1.198 is needed to furtherOn: Mon, 20 Jun 2016 17:46:49 SD research, to fund SD training, as well as amendCopyright: the current Aerospace mishap Medicalby the surface Association of the Earth and the gravitational vertical ” investigation process to better articulate SD contributions in aviation (p. 277). The 2005 United States Air Force Manual of accidents. Keywords: aviation mishaps , aviation accidents , aviation spatial orienta- Instrument Flying Procedures, 11-217 Volume I ( 45 ), tion , aviation safety , aviation training simulators . defi ned SD as “ the erroneous percept of any of the pa- rameters displayed by the aircraft control and perfor- mance instruments … regardless of a pilot’s experience or HE DAY THE MUSIC died … , ” as written and profi ciency, sensory illusion can lead to differences be- “ T sung by Don McClean, references the February tween instrument indications and what the pilot “ feels ” 1959 tragic airplane crash in which singers Buddy Holly, the aircraft is doing ” (p. 355). It is important to note the Ritchie Valens, and JP Richardson (aka, The Big Bopper) multisensory contributions to SD. Both vision and equi- were killed. The cause of the crash is believed to have librium/vestibular perceptions contribute (inter actively) been spatial disorientation (SD) by the pilot during the to spatial orientation perception, with vision accounting dark night takeoff while attempting to interpret a newly for nearly 80% in the aerospace environment ( 35 ). designed attitude indicator display. Unfortunately, even In contrast, for many years within the aviation com- such a high profi le crash did not prompt a serious effort munity, SD was often thought of only within the context to reduce SD-related mishaps for several decades. In the of vestibular illusions. It was not until Gillingham’s 1992 fall of 1984, Col. (Dr.) Grant McNaughton, USAF Flight landmark paper ( 19 ) published in the Journal of Vestibu- Safety Center, decided to produce a safety video for lar Research that “ tied the loose ends ” of the complete SD use in military fl ying squadrons. The video was titled problem together. However, there are still many exam- “ Spatial Disorientation — Still a Killer! ” Col. McNaughton, ples where it is obvious that the role of SD is not being a fl ight surgeon and private pilot, understood the prob- recognized, as noted in two 2009 SD mishaps presented lem of spatial disorientation in aviation and wanted to below. Another example of the failure to understand the do something that would help USAF pilots be better multisensory concept of SD is seen in the U.S. Naval prepared for SD. Aviation Safety offi ce ( 46 ) release of aeromedical causes Now, almost three decades later, the aviation commu- nity has still not substantially reduced the likelihood of in mishaps from 1990 to 2008. The #1 causal factor SD-related mishaps; Col. McNaughton has long since was SD and then listed at #4 were “ visual illusions. ” retired, but the issue of SD remains a threat to all fl ying Visual illusions should be considered a form of SD. The communities. Williams and Johnson in 2010 ( 52 ), also interplay between vision, proprioceptive, and vestibular from the USAF Flight Safety Center, sum up their recent SD fi ndings with a very poignant statement (and echo From the USAF Academy, CO. This manuscript was received for review in January 2011 . It was from the past), “ the only way to save your life from a accepted for publication in March 2011 . leading killer of fi ghter pilots is to prevent it ” (p. 21). In Address correspondence and reprint requests to: Col. Randall Gibb, six decades what have we learned? What are we doing Behavioral Sciences & Leadership, USAF Academy, 2354 Fairchild Dr., about this “ known killer ” ? Ste. 6L-166, USAF Academy, CO; [email protected] . Reprint & Copyright © by the Aerospace Medical Association, This paper summarizes current research and mishaps Alexandria, VA. involving SD, an issue that cuts across the entire avia- DOI: 10.3357/ASEM.3048.2011 Aviation, Space, and Environmental Medicine x Vol. 82, No. 7 x July 2011 717 SPATIAL DISORIENTATION — GIBB ET AL. systems is vital for accurate perception of a pilot’s ori- fl ight accomplishing a high-altitude strafe while wear- entation; thus all play a key role in understanding the ing NVGs. That night the illumination was defi ned as causes of and countermeasures for SD. “ low ” and the pilots overestimated their height above Perhaps the long history and commonness of SD have the featureless terrain. The primary causal factor deter- led the aviation community to become numb and desen- mined by the AIB was the incorrect calculation of the sitized to its threat, to the point of it being considered target elevation. Five contributing factors were also pre- “ the cost of doing business. ” For example, in 2000, sented by the AIB: misperception of operational condi- Lessard ( 26 ) simply stated that SD “ remains a problem tions, erroneous expectation of a typical night strafi ng for current pilots as it was for early aviators ” (p. 27). attack, inexperience executing night strafi ng, channel- We argue that SD contributes to at least 25 – 33% of all ized attention, and an improper crosscheck. Despite the aircraft mishaps and it results in the highest number of investigation presenting many aspects of SD in terms of fatalities. Other research reports generally do not credit an extremely dark night, featureless terrain, and NVG (blame) SD to that high of a causal/contributing percent- visual limitations, SD again was not formally listed in age. However, given the underreporting and inaccuracy the report. Are these really examples of ‘ pilot error ’ or of SD in mishap reports, and its correlation with con- might mission requirements simply be exceeding human trolled fl ight into terrain, loss of control, inadvertent physiological/perceptual capabilities? fl ight into weather, and loss of situational awareness In contrast to the two above mishaps and their lack of ( 47 ), SD’s actual impact may even be higher than one- formal SD acknowledgment is a recognized SD mishap third. that occurred in 2008 involving an F-16, from which the We are not the only ones who are pushing for height- pilot successfully ejected and survived ( 1 ). The experi- ened awareness of SD. In a 2002 keynote address, enced pilot was fl ying a nighttime NVG training mis- Benson ( 7 ) clearly stated that SD has continued to plague Delivered by Ingenta to: Baylor Universitysion off theCollege coast of of Medicine Florida. The AIB determined the pilots for 50 years and, despite improvedIP: 128.249.1.198 understanding On: Mon, cause 20 Jun of the2016 accident 17:46:49 was SD due to environmental con- of its etiology and enhanced pilot displays,Copyright: SD continues Aerospace Medicalditions ofAssociation a limited horizon over featureless terrain com- to kill pilots. He provided a historical perspective of SD bined with excessive maneuvering. The pilot surviving and detailed aviator SD mishaps going back to 1913. De- this SD mishap certainly helped investigators determine spite the fact that today’s pilots have instruments/visual the contributing causes to the accident compared with displays to help maintain orientation, it is apparent that the two previously discussed mishaps. However, de- aviation’s extreme demands on pilots exceed human spite the fatalities in the other mishaps, suffi cient infor- sensory-perceptual-cognitive capabilities, even with new mation regarding aspects of SD was presented in the technology. In fact, at times the new technology plays a investigative report. The question becomes why SD did contributing factor in SD (see below). not make its way into the executive summary and offi - Despite warnings such as Benson’s and others ’ , SD- cial list of contributing causes. related mishaps are still occurring and, unfortunately, Our objective in writing this paper is to highlight the SD is often not formally recognized as a contributing continuing danger of SD and offer solutions. More im- factor in mishaps. For example, in 2009 ( 2 ), a $21M F-16 portantly, we want to enlighten readers that lives and aircraft and pilot on a night training sortie wearing night resources lost could have possibly been saved had a vision goggles (NVGs) impacted the ground while meaningful investment been made in treating SD as the accomplishing a high-altitude strafe.