Fatal distraction

Spanish investigators have just released more information about the Spanair MD82 take-off accident at Madrid Barajas in August last year. If you remember, the crew attempted take off having omitted to set the flaps, and there was no take-off configuration warning to alert them to their mistake. The aircraft was destroyed and almost all on board were killed.

The new interim factual report makes it clear that three opportunities to prevent the tragedy were missed. Twice the crew were distracted during their pre take-off checks, and then there was a technical anomaly whereby tripping a circuit breaker to overcome a minor fault appears – unbeknown to the crew – to have disabled the take-off configuration warning.

In March we revealed a new NASA study that looked at more than 50 events in which crews had inadvertently taken off without setting flaps, and mostly they got away with it – just. NASA’s purpose was to find out why it happened, and they did. In a Comment at the time, Flight International said: “Another of those uncanny studies has been produced. The type that produces a conclusion that – once you have read it – is so obvious that it’s suddenly amazing the industry has not noticed why a clearly imperfect way of operating has been allowed to continue - since the Wright Brothers - to permit by default the fatal mistakes it does. Like unintended flapless take-offs.”

What they “discovered” was that distractions and interruptions between pushback and take-off are legion. This, they say, should be taken seriously for what it is: a very uncongenial state of affairs during a safety-critical sector of the operation. There is no equivalent of the “sterile cockpit” pre take-off. The only reason why, presumably, we have ignored this fact is that it is far too obvious, and there is very little you can do about the R/T chatter on the ground frequency, that late clearance or departure amendment, the “cabin secure” report, etcetera ad infinitum.

But maybe there is. Just a new level of pilot awareness of the fact that the whole pre-take-off period is a minefield of distractions and – literally – an accident waiting to happen – would be a good start.

This subject is one of many that will be examined at the 2009 Flight International Crew Management Conference in London, 30 November-1 December, at which the theme is Pilot Best Practice .

3 Responses to Fatal distraction

  1. David Nicholas 19 August, 2009 at 1:21 pm #

    I have just had one of those little (no hard evidence) thoughts that people mention over a beer in the pub – it used to be the practice at busy airports (LHR was certainly one) to have a pair of eyes in an orange and white caravan at the departure end of the runway. This (and the not dissimilar “last chance” check carried out visually at military airfields and aircraft carriers) doubtless had a different purpose (detection of FOD, open panels, leaks, flat tyres, birds, smoke being among those that spring to mind). Those who did these now defunct jobs (at civil airports anyway) must have developed a lot of practical knowledge of what looked right and what looked wrong and I would speculate that a number of flapless takeoffs (some perhaps at high weights) were averted over the years by the sharp eyes of these runway control assistants.

    Which brings me to another point – the much-trumpeted “non-VCR” near to LHR. A good tower controller uses his eyes as well as his equipment and while the rate of departure and landing may be less than the maximum runway capacity with this fallback facility, it does nothing to prevent an aircraft departing with the aforementioned leaks, smoke or even fire unless there are a pair of eyes at the threshold (perhaps with night vision equipment). I wonder if this was considered in the safety case?

  2. alloycowboy 25 August, 2009 at 7:36 pm #

    They should bring back the third crew member to handle communications and specifically trained in trouble-shooting systems on the aircraft.

  3. P.PUTZ 4 September, 2009 at 7:38 pm #

    Most of the recent accidents would not have happened had there been a good,old, Flight Engineer in the cockpit.I have always maintained that one engine saved during a F.E’s career will pay his salary.The flapless take-offs and mid-air collisions avoided come free.No major emergencies will be handled efficiently by just two pilots.I was lucky to have had ,from the D.C.4 up,a third crew-member and a third pair of eyes to get me unscathed through 40 years and 22 000 hours of flying.