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Fatal Distractions

Even innocent errors can have consequences.

The story of the two Northwest pilots over-flying their destination by 150 miles towards the end of 2009 resonated within the aviation community and with the non-aviating public- alike.

Beyond the late night talk show jokes and the regulatory ramifications of the pilots’ flight-deck activities- the event raised other issues about the flight safety risks of distractions on the cockpit.

Distractions take many forms – from the nearly absurdly unbelievable as two airline pilots working on their personal notebook computers- simultaneously – to non-flying topics- personal spats- sports chat and- sometimes- even discussing a problem with the flight to the point of losing the aircraft. We’ll look at some examples here- and the steps companies and regulators take to help avoid these problems from occurring.

THE ICING DEBATE
Continental Connection Flight 3407 faced many issues the evening it crashed near Buffalo- New York (BUF) on February 12- 2009. Among the issues: a crew already weary from travel to their work site; weather; and an apparent lack of familiarity with a hallmark of the conditions that day- airframe ice.

The cockpit discussion about how to deal with the conditions- and the co-pilot’s recorded talk about her lack of exposure to icing flight (this was- apparently- her first) contributed to an environment in which both crew seemed distracted by issues effecting the airplane’s performance and condition- and made noticing some of the indicators of developing problems more difficult.

As the aircraft approached BUF- the airframe began to accumulate ice precipitously- adding weight and denigrating performance at the same time. Deploying flaps with anti-icing equipment activated changed the flight-control system profile- and the aircraft tried to compensate.

Confusion about whether the airplane should be going faster- and a perceived unfamiliarity with the Dash 8’s stick-shaker system compounded with a lack of icing experience coupled with distractions of making decisions meant that the aircraft ultimately was allowed to fly too slowly for its situation. It stalled- rolled and crashed into a house.

The Cockpit Voice Recorder transcript revealed the flight crew discussing- rather than acting all the way down – a sign- many pilots say- of the situation itself becoming a fatal distraction.

THE RUNWAY CONUNDRUM
The Comair Regional Jet flying for Delta Air Lines Flight 191 out of Lexington- Kentucky about 18 months ahead of the above Dash 8 crash offered its own lessons about the possible consequences of fatal distractions.

Again- the cockpit crew was discussing some of the necessary items and some not so necessary - to the point that they missed a runway turn while taxiing around a construction area.

Distracted and confused- they yielded a decision to launch from an unlighted runway believing they were on the lighted runway nearby - the one on which they had arrived on other occasions after dark. The distractions over the situation and the effort to get away on-time- contributed to the two crew members missing several indicators that showed a different compass heading than that of the assigned runway.

Had they noticed- they should have immediately checked for an error against other instruments and- after finding them all consistent- should have come to the realization that they were lined-up on the wrong runway. The distractions and confusion that led to missing those indicators proved the fatal flaw on that day in August 2006.

Too short by more than half- the CRJ ran off the end of the runway just about the time the flight crew came upon the realization that they had a problem. The co-pilot was the only survivor of the 50 souls on board.

THE CONFLICTED BUSINESS PILOT
The next example comes from a private conversation with a corporate pilot flying a popular medium business jet. New to the flight deck- but recently trained and appropriately type-rated – all on the simulator environment – the new First Officer (F.O.) was the crewmember in charge of programming the Flight Management System for the trip they waited to launch.

The near-fatal distraction here stemmed from a warm-and-friendly captain- who waited until he thought the F.O. was through with a task- a page or section of the pre-flight check list – and engaged in small talk.

“He wanted me to be comfortable- relaxed- and not sweating my first trip in a new job with a new captain in a new airplane… he couldn’t have been more accepting-” the F.O. related. Unfortunately- the FMS required a great deal of keypad use with airport- nav-aid- intersection and arrival information to load- and in the process the F.O. entered an incorrect entry. An intersection with a similar spelling had been a routine part of flying on his last job- and that one-letter mistake came during one of those brief moments of distraction.

“The guy wanted to know whether I had family- wanted us to be friends and not just cockpit co-occupants…and I miss-keyed one line-” the F.O. continued. As part of the crew coordination the captain scrolled through the entries after the F.O. finished- noticed nothing askew- and armed the system. A normal takeoff – the F.O. got to fly his first in that plane and job – an easy time with ATC- and the jet sped along at FL410 for about an hour when it reached the point where the erroneous intersection came into play.

With traffic passing about five miles toward their 10-O’Clock position- the crew monitored the FMS and the navigation instruments and the aircraft turned- just as programmed – to the incorrect waypoint.

“It wasn’t instantly noticed by either of us- but only after we got an alert that we could no longer make our destination with the fuel we had – instead of landing- as we knew we should- with more than two hours still on board.”

With the airplane flying a long dogleg diversion instead of a shallow correction to set up for an arrival- the crew needed a couple of minutes to sort out the problem; meanwhile a Center controller started asking them about their course change- at first congenially- then with an obvious degree of concern.

The incident lasted only about five minutes (about 50 miles at their cruise speed)- and had it happened in today’s security-conscious environment might well have prompted unneeded interest from people with armed aircraft. As it was- the Captain made the command decision to disengage the autopilot while the F.O. plugged in a new heading and then the captain armed the FMS to fly the heading bug while they finished fixing the problem – and explaining to the controller that there had been a “random role issue” they had to resolve.

“This ended benignly enough- but it made me more focused – and gave me the nerve to tell the Captain that we needed to observe the sterile cockpit plan the instant we started going down the flight plan or check list-” the F.O. concluded.

A STERILE COCKPIT – IT’S BUSINESS ONLY
The sterile cockpit concept isn’t new- but in an atmosphere in which pilots become friends- and spend long hours sitting in close proximity at the front of a machine hurtling along at eight or nine miles a minute- it’s not difficult to understand how familiarity can breed laxity.

The set-up may vary from operation-to-operation- but the key is setting a start point to cut off any source of distraction when performing critical tasks. Pre-flight flight planning; cockpit check lists; passenger briefings; ATC communications - all must be accommodated- but in a manner that excludes discussion about family- the weekend football scores- planned vacations and the like – at least- some safety authorities concede – until the flight reaches the cruise phase. Getting out- getting up- getting down- and getting in: all demand protection from distractions for the safety of the flight.

And in some operations with some aircraft- this discipline may even require interrupting the boss who likes to visit the flight deck to chat about “things”- or the charter passenger with an unrestrained curiosity about all things aviation. This mantra also has to apply to some of the invasive technologies of our lives – MP3 music players and iPods; the satellite radio feed playing on the audio system – even though it- by regulation- must mute the music when a radio transmission breaks the squelch on the receiver.

A captain acquaintance of mine likes to tell the story of a young flight officer alone on the flight deck while the senior F.O. answered a call to nature. The captain tapped the F.O. to signal his departure from the flight deck and the younger pilot promptly donned the oxygen mask as required by the regulations.

When the captain returned a few minutes later and donned his headset again- he heard an agitated controller ask that airplane to hit the transponder’s “Ident” button “if able to hear.” The captain keyed the mic and responded with an apology for a radio problem and that all was well now – then he received instructions for a flight plan revision they’d sought to speed them along.

So why didn’t the young F.O. deal with this in the senior F.O.’s absence? He was monitoring all of the flight-deck systems while music poured into his brain through the ear-buds underneath his headset – at a volume just high enough to mask a controller’s voice.

“Fortunately-” the captain recounted- “we upset nothing – but I still wonder if there had been an audible alarm… We can’t afford any fatal distractions.”

The moral of our story this month? Stay sharp- fly sharp- live long!

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