Friday, October 30, 2009

Dead: Two in the Cockpit, Four in the Cabin and One Far Away

This accident investigation tells a sad tale. It's not just the story of an airplane that had some kind of problem after takeoff. The crew consisted of a results- (as opposed to safety-) oriented maverick chief pilot and what the NTSB terms an "ill-prepared" first officer. They explain that term only in stating that the company gave inadequate checkrides, but one can imagine he or she was new, got less actual training than the company records stated, hadn't been required to demonstrate an ability to fly the airplane unassisted, and did not operate in an environment where he was given the opportunity to absorb an understanding of two crew teamwork.

They take off, and something happens that makes control of the airplane difficult. It might be runaway trim, the autopilot misbehaving: the investigators don't know. As soon as this happens, the pilot who notices, probably the flying pilot needs to articulate the problem to the other pilot, even if they aren't quite sure what is wrong. "I can't hold the nose up!" "The trim is freaking out!" "I'm holding full left rudder to keep it straight." The flying pilot needs to continue flying the airplane, concentrating on keeping the airplane right side up, clear of obstacles and with an appropriate heading and airspeed. If it's an emergency for which there is an aircraft checklist, there will be a call for that, e.g "runaway elevator trim emergency checklist," and the correct aircraft configuration, procedures (and exactly what the pilots say to one another) may be specified right in the checklist with the first few steps committed to memory. If it's something outside the checklist, well that's why pilots learn how their airplanes work, so they can make reasonable decisions.

Usually any relevant checklists are followed exactly, but if there are extenuating circumstances and where the crew hasn't yet determined what is going on, the captain makes the final decisions. But the division of labour is fixed: one crew member flies the plane, and the other one does other stuff. For this reason the captain often gives control to the FO in an emergency, because anyone can fly a plane, I mean really, you could. I tell you "you have control. maintain 140 knots, three thousand feet, on this heading, and you're going to have to exert about 10 kilograms of back pressure to keep the nose up." If the FO has toothpick arms, then the captain may make a different decision, but someone has to be flying the airplane. They shouldn't both be trying to find a circuit breaker any more than they should both be working on their laptops.

There are many events like the one the NTSB describes that led to this fatal accident that are non-events, because a crew manages the situation professionally and returns to the airport to get it fixed. The "we don't know what happened, but they should have handled it better" vibe is a little harsh here. After all, if they don't know what happened who says that the crew didn't manage it in a flawless textbook manner, but it was more than human beings could handle? The dead, ex-drug runner captain has already shown a disregard for the law and others' safety, so he's an easy mark on whom to pin the blame.

Also do you see what they are doing regretting the absence of cockpit video monitoring? Every time they say "too bad there was no video recording," they are angling for video monitoring of our workplace. YouTube of the future will be a more grizzly place.

And finally, the fact that their cargo includes a human transplant organ, introduced extra pathos for me. Had there been five in the cabin instaed of four it would have made no difference to me, but I imagine someone's cellphone ringing that afternoon, with the joyous news that a matching donor organ had been found. That person grabbed an overnight bag and went straight to the hospital, or perhaps they were already in hospital, knowing a transplant was their last chance at life. They were prepped for the operation, and then received the news that the organ wasn't going to arrive after all. And the loved ones of the donor were hoping to hear news that their deceased family member's organ had helped someone else to live. Instead they learn that six people died transporting it, and the organ became fish food.

The NTSB investigation report from which I have inferred all this melodramatic speculation is here.

Yesterday Cirrocumulus pointed out that the aviation industry "needs objective research into effective ways of keeping boredom at bay and humans alert while they're just monitoring safety-critical machinery. At present the humans are between the rock of forbidden pastimes and the whirlpool of stupefaction." I liked this by itself, and then Aluwings took up the standard to outline some of the strategies employed. I laughed at his post because I have done and seen similar ones. Never met the UFO guy, though.


A Squared said...

"YouTube of the future will be a more grizzly"

More videos of bears?

Sarah said...

Yes, bears. And the bears will all have their own facebook pages.

Aviatrix said...

On ice skates!

nec Timide said...


Sarah said...

I guess I was (we were all?) a little burned out with bad-pilot/accident analysis lately.

But seriously folks...

It seems the NTSB almost always "blames the pilot". With hindsight, there is almost always something a crew could have done differently.

Once in a while, there's just no argument that the crew was responsible for lawn-darting a perfectly good airplane. That one still makes me mad. Along with a different accident that killed a friend and two others - but with karmic cruel justice the pilot responsible for the accident survived.

Aviatrix said...

The King Air one is sad. The long version of the report makes it look like a combination of incompetence and fraud, putting two people in an airplane and conditions where they weren't ready. You have to blame the system for that one too.

Anonymous said...

NTSB Animation of Marlin Air Cessna Citation Accident Investigation Near Milwaukee Wisconsin