Blame Me: I’m Used To It

Engine fire after take-off, no hydraulics, no electricity, and the nose gear won’t  extend for an emergency landing. Did you read about this? Burifire warninged on the bottom of pg. 4 in the 8 April, 2009 Wall Street Journal was a story about an American Airlines MD-82 compound emergency in 2007 that ended well. By ‘ending well’ I mean there were no fatalities and the plane was returned to service. One would think the Captain and First Officer did a pretty nice job of getting the aircraft back on the ground.

Not so much. Here’s what the head of the National Transportation Safety Board had to say about their work that day.

Here is an accident where things got very complicated very quickly and where flight crew performance was very important,” said NTSB Acting Chairman Mark V. Rosenker. “Unfortunately, the lack of adherence to procedures ultimately led to many of this crew’s in-flight challenges.”.  ……and that was the ‘pleasant’ part of their analysis.

Thank you Mr. Rosenker for those ‘kind’ words. With all due respect for the Honorable Acting NTSB Chairman, these pilots’ colleagues are mumbling (loudly) for him to stuff his findings where the sun doesn’t shine. Whether or not the NTSB liked the actual performance of the pilots, at the end of the day 143 people got to see the next morning. To me it’s hollow coming from a political appointee that in spite of his 37 years in the Air Force has nothing in his resume that would suggest he ever spent a single hour in command of a cockpit on a functioning aircraft let alone one with an engine on fire at low altitude.

Ah, the quintessential bureaucrat.

Having read reports like this for 30 years I found reporting of this latest NTSB effort to be typically heavy handed and unfriendly in light of the result. If you were to ask those onboard that fateful day, my guess is they would say the end truly justified the means. Ironically, there is a thing called Captain’s Authority which gives license for the captain to make certain decisions or redirect certain priorities that may go against procedure and policy but are in the best interest during the heat of battle. People that write final reports are seldom governed by the same ‘heat’.  

“Typically pilots are blamed for whatever goes wrong,” says Susan Baker, a Johns Hopkins University professor at the Center for Injury Research and Policy, who is also a general aviation (not commercial) pilot,…

And what exactly does Baker consider pilot error? “It’s something that did happen but should not have happened, based on the information that should have been available to the pilot.” (Pilot Error In Air Carrier Mishaps: Longitudinal Trends Among 558 Reports, 1983 – 2002. Aviation Space Environ Med 2008; 79:1 – 5)

The investigators that look into incidents and mishaps have the luxury of time, quiet, and second chances. Those luxuries weren’t available to the two pilots that just lifted off and had their normal routine shattered by bells, sirens, and warning lights.  But they are judged as if they did.

This is not to dismiss those aviation accidents when pilot error is rightly designated a causal factor. Statistics indicate that this hovers between 50-60% of all aircraft accidents. And when this is the case, the report is usually pretty ugly. A recent case was the US Marine F/A-18 accident at MCAS Miramar, CA. The aviator lost an engine inflight and bypassed an emergency divert field enroute to his homebase. Unfortunately, while on final approach just 7 minutes after passing atop his emergency divert field, the other engine quit. The jet went down in a residential area  resulting in fatalities on the ground. Murphy’s Laws are merciless as was the accident report. Fair enough, as this pilot had the luxury of time and altitude to exercise better judgement.

Even with the luxuries of time and altitude it’s not uncommon while practicing emergency procedures in a simulator, that pilots don’t silence an annoyingly loud fire warning bell because they become so focused on keeping the airplane right side up or just acknowledging what has just happened to their perfectly good airplane. They literally don’t respond to the noise of the bell because they don’t hear it. Priorities and Concentration.

Getting back to the American Airlines incident; to read the NTSB’s findings delivered for public consumption that simplified a complex series of related, time critical emergencies (each requiring a different procedure from a different checklist) while operating in the low altitude environment, down to finding fault with crew interaction and  task delegation gives teeth to Professor Baker’s assertion that pilots are always to blame.  We’re used to it; don’t like it though.


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