Fatal distraction

Recently we have learned from studies by the NTSB and NASA that distractions in cockpits can be fatal, and certainly represent a considerable risk that has not been properly acknowledged.

The NTSB’s senior human performance investigator Dr William Bramble finds that all the recent fatal airline accidents caused by pilot disorientation were preceded by crew distraction or fixation on an issue other than flying. This is most common when the distraction occurs just before or during a turn at night or in instrument meteorological conditions.

NASA is just beginning a programme to see if there is a better way of training pilots to recover from the upsets that can result from distraction-caused loss of control. But that is a strategy to cope with the results of a problem, not an attempt to eliminate the problem in the first place. In fact the previous blog addresses an aspect of this issue.

Now a NASA Ames study finds that cockpit operations are far more complex than pilots, airlines and the military acknowledge in their training and procedures. It’s not just the “linear procedures” laid out in crew manuals and checklists that make up crew workload. That’s an ideal world scarcely related to the real one. Distractions cause flapless take-offs as well as loss of control, NASA’s study demonstrates, and they are more frequent than we thought, because crews sometimes get away with them.

Routine flights, from arriving at the aircraft to shutting down the engines, are packed with potential distractions as a part of doing business. The golden rule of flightcrew priorities is “aviate, navigate, communicate”, but pilots are rarely left alone to do things in that order. Distractions, maybe interrupting checklists, take the form of air traffic control communications, calls from the cabin crew in the essential course of their duties, weather anomalies. The list is endless.

Talking of cabin crew, before the cockpit security door and associated procedures were adopted, flight attendants who had to deliver anything, from a message to a coffee or a meal, could enter discreetly, wait until the pilots were obviously between tasks, then deliver. The interphone does not give cabin crew the opportunity to judge when the time is right, and when the flightcrew are aware of an attempt to communicate it is a distraction if they are busy. That leads to a reluctance of the cabin crew to communicate, and sometimes that can be a risk in its own right.

The “sterile cockpit” concept adopted during descent to approach is about the only acknowledgement of the need to limit distractions. The rest of the time pilots have to cope with whatever  comes their way. NASA says they have to recognise distractions for what they are: potential dangers. And to recognise when the distractions are taking over from the  aviating.

 

3 Responses to Fatal distraction

  1. David Nicholas 27 March, 2009 at 4:00 pm #

    A third pilot would handle most of this without either the PF/PNF having to be disturbed.
    I realise that we are not going to turn back the clock, but pilots of the remaining “classic” big jets still have the benefit of the Flight Engineer or P3. From a human factors viewpoint distraction is a significant contributor to accidents and serious incidents. Breakdown in SOPs caused by unexpected events (in other words, distraction) can lead to any number of unintended consequences. Once this has happened, there may be safety nets or there may not, but either way an accident is that much closer in terms of possibility.
    Any thoughts from our pilot readers (2 crew or 3 crew)?

  2. David Learmount 27 March, 2009 at 4:18 pm #

    David N, the Turkish Airlines 737 that crashed on approach to Amsterdam Schiphol recently had a third pilot in the jump seat, but the aeroplane still stalled. I know a pilot in the jump seat is not psychologically fully integrated into the crew, so maybe that’s a red herring.

    But there have been numerous instances when the entire crew, including a flight engineer, have become so fixated on a particular distraction (usually troubleshooting, sometimes quite an unimportant issue) that the aircraft has ploughed in or gone out of control while the crew were all distracted.

    A crew of three that is not well commanded is no better than a crew of two.

  3. David Nicholas 30 March, 2009 at 10:12 am #

    Yes indeed (the Eastern Tristar in the Everglades is a further example that comes to mind). However, in the case of the Turkish 737 the third pilot was present only because (as I understand it) the P2 was a recently qualified co-pilot under line training from the captain. This was not, therefore, a three-person crew in the accepted sense of the term (where each have their designated duties and associated checklists/tasks concerning the operation of the aircraft and its systems). Furthermore, the locked cockpit door leaves unchanged the potential distraction of the interphone call from the cabin. Unless specifically briefed to do so, would the pilot on the jump-seat have automatically taken the call, or did the Captain have to tell him to do so?. Having no information of the CVR contents we don’t know.
    Go back to the Staines Trident accident where a 3-pilot crew managed to stall the aircraft on departure for another example of the exception that (might) prove the rule.
    What we have, of course, in the field of aviation safety is a situation where no two accidents are ever the same, although there are often common aspects which have to be revealed and analysed. Distraction takes many forms, but the potential consequences are severe.
    Some pilot comments would certainly help here, as while most will not have suffered an accident, I am sure that most will have experienced distractions ……..