Though always tragic, aviation accidents always have a certain silver lining: there are always lessons learned and those lessons go some way to preventing the same tragedy happening again. However, where making this happen is relatively simple when a mechanical or procedural problem is identified, it’s not so easy when it comes to the leading cause of aviation incidents: pilot error. Some improvements have been made in the processes that govern the cockpit environment, with the Multi-Crew Co-operation course being a great example. It teaches how to best work together as a crew, and it empowers the most junior first officer to challenge the most senior captain if they see something going awry. Consider the case of Air Florida Flight 90, which crashed into the freezing Potomac river in 1982. The conditions were highly prone to icing, and despite being de-iced, the aircraft had spent some time on the ground before actually being in a position to take off. The first officer called for the anti-ice systems to go on, but the captain overruled him. This is from the cockpit voice recorder:
15:59:28 TWR No delay on departure if you will, traffic’s two and a half out for the runway.
15:59:32 CAM-1 Okay, your throttles.
15:59:35 [SOUND OF ENGINE SPOOLUP]
15:59:49 CAM-1 Holler if you need the wipers.
15:59:51 CAM-1 It’s spooled. Real cold, real cold.
15:59:58 CAM-2 God, look at that thing. That don’t seem right, does it? Uh, that’s not right.
16:00:09 CAM-1 Yes it is, there’s eighty.
16:00:10 CAM-2 Naw, I don’t think that’s right. Ah, maybe it is.
16:00:21 CAM-1 Hundred and twenty.
16:00:23 CAM-2 I don’t know
16:00:31 CAM-1 Vee-one. Easy, vee-two.
16:00:39 [SOUND OF STICKSHAKER STARTS AND CONTINUES UNTIL IMPACT]
16:00:41 TWR Palm 90 contact departure control.
16:00:45 CAM-1 Forward, forward, easy. We only want five hundred.
16:00:48 CAM-1 Come on forward….forward, just barely climb.
16:00:59 CAM-1 Stalling, we’re falling!
16:01:00 CAM-2 Larry, we’re going down, Larry….
16:01:01 CAM-1 I know it.
16:01:01 [SOUND OF IMPACT]
The first officer knew of the problem, but wasn’t confident enough to speak out and contradict his captain. However… there is an even more worrying situation, and that’s when the first officer and captain are both missing the bigger picture. Focused on the goal of just getting to their destination, the usual rational decision making process is subverted. I’ll talk about two case histories and how we can learn from them.
New Mexico State Police Helicopter
On the 9th of June 2009, a hiker had got lost the Pecos Wilderness Area, about 20 miles Northeast of Santa Fe. The hiker was a Japanese citizen who had limited grasp of English, but was able to contact the emergency authorities on 911 and provide enough information for a Search and Rescue (SAR) mission to be mounted. The SAR helicopter that was dispatched was an Agusta Westland 109, registration N606SP. The pilot was at the end of a long shift but felt compelled to go out on the SAR mission given the location of the lost hiker. Emergency Services dispatch had been able to find an approximate location and it was in an area with no nearby roads, meaning rescuers on foot would have to hike to her location. There were concerns that the hiker might not survive the night with temperatures being what they were. Already, the pilot was adding pressures onto himself. Conditions that evening were Visual Meteorological Conditions (VMC) when the pilot left Santa Fe Municipal Airport, and after a short flight of only about fifteen minutes he was within the search area, and when the 911 dispatcher told the helicopter pilot that he was directly over the hiker (they were also in comms with the hiker by phone), the pilot found a place on the mountains to set the helicopter down and begin a search on foot. The pilot had with him an observer, who remained in the helicopter while the pilot went out to search for the lost hiker. The search was successful and the pilot returned to the helicopter with the lost hiker after about an hour outside the helicopter in poor weather with unsuitable clothing. At this point, all appeared to be going well. The hiker had been found, and the safety and warmth of Santa Fe Municipal Airport is but fifteen minutes away. It was right there. However, there’s a problem. It’s nearly two hours since the pilot took off and weather conditions now are much worse, and they have deteriorated to being within the realms of Instrument Meteorological Conditions (IMC). The pilot is surely feeling cold, tired, and just wants to get home and complete the mission. It’s a decision that will ultimately result in the death of both him and the hiker, and serious injuries to the spotter.
At 2127, despite the IMC conditions, strong winds, sleet and poor light in mountainous terrain, the pilot started up the helicopter’s engines for the return to Santa Fe. Eight minutes later, having struck the mountainside and lost the use of their tail-rotor, the helicopter crashed, killing both the pilot and the hiker. The spotter suffered serious injuries. The NTSB report describes the incident as follows:
The spotter recalled hearing the pilot curse and then felt the helicopter pitch up abruptly, after which it began to make a grinding noise and the ride “got wild.” He said he assumed that the helicopter’s tail had hit something, and he stated that it seemed as if the pilot was struggling to control the helicopter. The spotter recalled that, after the abrupt pull-up, the helicopter moved in a “jerky” fashion, like there was “obviously something wrong”; however, he could not tell exactly how the helicopter manoeuvred because he could not see anything outside. Dispatch recordings show that, at 2134:10, the pilot radioed the dispatcher, asking if she could hear him. After the dispatcher responded in the affirmative, the pilot stated, “I struck a mountainside. [I’m] going down.” The dispatcher asked, “Are you [okay]?” and the pilot replied, “negative.” The pilot continued to key his microphone, and, on the dispatch recording, he could be heard breathing rapidly for about the next 39 seconds. The dispatcher inquired, “Santa Fe 606?” The pilot then said, “hang on [unintelligible],” and the radio transmission cut off immediately thereafter. The last radar return for the helicopter was recorded at 2135:25.1
The pilot in this case, despite the awful conditions on the mountain, despite his fatigue, and despite the cold he was likely feeling, decided to take off and get back to Santa Fe, almost certainly influenced by the desire to complete the mission… because the home base was such a short flight away. It could all be done and dusted in but fifteen minutes. Weigh that against the (with hindsight) wiser decision to not risk flight in those conditions and wait out the evening in the helicopter. The hiker’s condition was not grave, and the helicopter would have provided sufficient shelter (albeit not the most comfortable) to survive the night and wait for better conditions. Here, the temptation to just get things finished was what killed the pilot and the person he was sent to rescue.
American Airlines Flight 1420
American Airlines Flight 1420 crashed in Little Rock, Arkansas, after skidding off the end of the runway. The captain and 10 other people were killed. The accident should not have happened. Having departed Dallas Fort Worth a little over an hour before, already under time pressure owing to the legal limit on how long flight crews can fly in a single day, the aircraft arrived in the vicinity of Little Rock as a number of large storm systems were converging on the airport. The crew had the option to divert to another airport where weather was more favourable, but the flight crew opted to continue to Little Rock, keen to just get the aircraft on the ground. Besides, they were close enough to see the runway lights. The airport was right there. It was here that a chain of events would begin that would result in the aircraft leaving the end of the runway, and the death of the captain and ten of his passengers.
There was one telling piece of information that investigators would later discover on the cockpit voice recorder:
1145:15 – I hate droning around visual at night in weather without, having some clue where I am.
– Captain Buschmann, Pilot in Command.
The Captain was having distinct trouble figuring out where the aircraft was with relation to the airport, where the storms were, how bad they were and what the crosswind meant for his landing. He was becoming overloaded, but didn’t see that because of his desire to get the aircraft down. It’s sometimes referred to as “get-there-itis”.
The flight crew eventually did get the aircraft lined up for the runway, and even got down onto it, but with the driving rain and the intense winds, an overworked and tired crew had forgotten to arm the spoilers. Those are the large surfaces you see pop up from the wings when the wheels touch. Their job is to disrupt the airflow over the wings so that the wings stop producing lift, forcing the weight of the aircraft down and increasing the effectiveness of the brakes. What happened instead here was the aircraft had a large portion of its weight still supported by the wings, meaning the wheels had much less traction than they needed to stop the aircraft in time. The aircraft left the end of the runway, hit some runway lighting poles, and broke up then caught fire. Below are the last words caught on the Cockpit Voice Recorder:
2348:19 CAM-1 well we’re established on the final.
2348:21 CAM-2 we’re established we’re inbound, right.
2348:25 RDO-2 okay, American fourteen twenty, we’re established inbound.
2348:27 APR American fourteen twenty roger, runway four right, cleared to land, and the wind, three four zero at three one. north wind, north uh, boundary wind is three zero zero at two six, northeast boundary wind three two zero at two five, and the four right RVR is one thousand six hundred.
2348:37 CAM [sound similar to stabilizer- in- motion horn]
2348:42 RDO-2 American uh, fourteen twenty, thanks.
2348:44 CAM-2 that’s a good point.
2348:46 CAM [unidentified intermittent tone]
2348:48 CAM-2 keep the speed.
2348:51 CAM-2 thousand feet.
2348:55 CAM-1 I don’t see anything. lookin’ for four sixty.
2348:59 CAM [sound similar to stabilizer- in- motion horn]
2349:01 CAM-2 it’s there.
2349:03 CAM-2 want forty flaps?
2349:05 CAM-1 oh yeah, thought I called it.
2349:06 CAM-2 forty now. thousand feet. twenty, forty forty land.
2349:11 CAM [unidentified tone similar to sound at time 2928]
2349:13 CAM-1 this is, this is a can of worms.
2349:11 APR wind is three three zero at two eight.
2349:18 CAM [sound similar to stabilizer- in- motion horn]
2349:23 CAM [sound similar to stabilizer- in- motion horn]
2349:25 CAM-1 (I’m gonna stay above it a little)
2349:25 CAM-2 there’s the runway off to your right, got it?
2349:27 CAM-1 no.
2349:28 CAM-2 I got the right runway in sight.
2349:31 CAM-2 you’re right on course. stay where you’re at.
2349:32 CAM-1 I got it, I got it.
2349:33 APR wind three three zero at two five.
2349:38.6 CAM -? wipersss.
2349:42.3 CAM [sound similar to windshield wiper motion]
2349:47.3 CAM-2 five hundred feet.
2349:51.0 CAM -? *.
2349:54.6 CAM-1 plus twenty.
2349:54 APR wind three two zero, at two three.
2349:57.5 CAM -? aw #, we’re off course.
2349:58.5 CAM -? **.
2350:01.4 CAM-2 we’re way off.
2350:02.5 CAM-1 I can’t see it.
2350:05.4 CAM-2 got it?
2350:06.1 CAM-1 yeah I got it.
2350:08.9 CAM-2 hundred feet.
2350:10.4 CAM -? above.
2350:12.1 CAM-2 hundred.
2350:14.66 CAM-2 fifty.
2350:13.75 CAM-5 sink rate.
2350:15.5 CAM-2 forty.
2350:15.16 CAM-5 sink rate.
2350:16.8 CAM-2 thirty.
2350:18.6 CAM-2 twenty.
2350:19.3 CAM-2 ten.
2350:21.2 CAM [sound of two thuds similar to aircraft touching down on runway concurrent with unidentified squeak sound]
2350:23.2 CAM-2 we’re down.
2350:25.4 CAM-2 we’re sliding.
2350:27.1 CAM-1 #… #.
2350:32.9 CAM -? on the brakes.
2350:34.2 CAM -? oh sh …
2350:34.6 CAM [sound similar to increase in engine RPM]
2350:36.2 CAM -? other one, other one, other one.
2350:42.0 CAM -? aw #.
2350:42.7 CAM -? ##.
2350:44.9 CAM [sound of impact]
In both cases, the pressure to just get the job done prevented the pilots from taking that condor moment and thinking “Am I starting down a dangerous road here?”. Had they done so, there is a good chance that all of those people would still be alive today. So be sure and always check your decision making. Are you about to needlessly put your life or the lives of others at risk, perhaps blind to that risk because you’re almost home, or the job is almost done. Risk is always risk, it doesn’t diminish because your job is nearly done.