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Fatal Distractions


Jul 9, 2010



 

The deadly loss-of-control accident of a Colgan Air Bombardier DHC-8-400 on Feb. 12, 2009, during a night instrument approach to Buffalo Niagara International Airport again makes it clear that cockpit distractions during critical phases of flight represent a substantial risk to aviation safety. Both pilots, two flight attendants, 45 passengers and one person on the ground were killed when the Continental Connections Flight 3407 slammed into a residential neighborhood five miles short of the airport.

While training, fatigue and general competency were likely causes of Flight 3407's crash, contributing to some degree was the pilots' conversation about non-pertinent matters, creating an environment that impeded timely error detection.

Credit: GETTY IMAGES

As such, the crew failed to notice the decreasing margin between IAS and the low-speed cues, the changing color of the numbers on the IAS display and the excessive nose-up pitch attitude, all of which would have given them adequate time to initiate corrective action. When the stick shaker activated, the captain's improper aft control column inputs led to an accelerated stall from which they could not recover.

Task Management

The Buffalo accident is the most recent in a number of high-profile crashes involving a breakdown in sterile cockpit procedures, and the FAA wants the aviation community to take corrective action.

Our best understanding of why routine conversations can interfere with monitoring or controlling the aircraft comes from studies on task management.

But cockpit conversation is not the only cause of distractions or preoccupation among flight crews. Radio communication, head-down work such as programming the FMS or reviewing approach plates, searching for VMC traffic or responding to abnormal situations have all led to distractions that have caused incidents and accidents. A disregard for SOPs is the common thread revealed among these broad categories.

While many claim easy mastery at multitasking, cognitive research indicates that people are able to perform just two tasks concurrently and only in limited circumstances, even if they are skillful in performing each task separately. It is generally accepted that humans have two cognitive systems with which they perform tasks — one involves conscious control, the other is an automatic system that operates largely outside of conscious control.

The conscious system is slow and requires effort; it basically performs one operation at a time, in sequence. Learning a new task typically requires conscious processing, which is why learning to drive a car or fly an airplane at first seems overwhelming: The multiple demands of the task exceed conscious capacity. Automated cognitive processes develop as we acquire skill; these processes are specific to each task, operate rapidly and fluidly, and require little effort or attention.

Many real-world tasks require a mixture of automatic and conscious processing. A skillful driver in a familiar car traveling along a familiar road can perform largely on automatic, leaving enough conscious capacity to carry on a conversation. However, if the automatic system is allowed to operate without any conscious supervision, it is vulnerable to certain types of error, especially a type of error called habit capture.

For example, if we intend to take a different route home from work, we are prone to miss our turnoff and continue our habitual route if we do not consciously supervise our driving. Also, if we encounter a section of road that is difficult to navigate, we find that we cannot continue the conversation without risking errors in the driving. This is because the automatic processes are not adequate to handle the unpredictable aspects of the driving task.

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