September 1, 2001
By Bruce Landsberg
Bruce Landsberg has served as executive director of the AOPA Air Safety Foundation since 1992.
The captain's last words were,"Hey—what's happening here?" as the Eastern Airlines Lockheed L-1011 slipped into the Everglades. There had been no catastrophic engine failure, no severe weather, and no crippling airframe failure. Only a nose-gear warning had distracted the three-pilot crew during the final four minutes of flight.
This problem of distraction is a major cause of accidents in everyday life, not just in aviation. Every day there are dozens, if not hundreds, of automobile accidents caused by drivers using cell phones, tuning the radio, fumbling with cassettes or CDs, eating, drinking—you name it. We all do it and we've all been successful, most of the time.
Clichés abound in describing the problem: "The main thing is to take care of the main thing"; "Aviate, navigate, communicate"; "Fly the airplane." The message is simple—and sometimes very hard to follow. In many accident debriefs the pilot confesses that he or she was distracted to disaster, or at least to mishap.
This problem afflicts all pilots, newbies to graybeards, in every phase of flight. Let's start with preflights. Did you ever overlook the cowl plugs, miss the pitot tube cover, fail to replace an oil or fuel cap, or forget to pull the chocks? Some have neglected to untie the wing, resulting in turns around the tiedown.
Cowl plugs, while not reaching low-Earth orbit, can be tossed an impressive vertical distance after engine start. This tends to attract the attention of bystanders. If a plug stays in place, that is worse because the engine will overheat without proper airflow.
Leaving the pitot tube cover on is more subtle. The little flag just flaps quietly under the wing. A commercial pilot student rejected the takeoff in a Cessna 150 and went off the end of the runway into some bushes. There was no major damage and when asked what happened, the pilot claimed that he had no airspeed and was afraid the aircraft would stall on liftoff. His instructor had failed to demonstrate that the aircraft will fly just fine with no indicated airspeed—it's the real thing you need to stay aloft. By the way, turning on the pitot heat to burn off the cover is not recommended as the residue usually works its way back into the tube and will require far more technical support upon landing. It also doesn't resolve the initial problem.
The absence of oil and fuel caps is also subtle because they usually don't make much noise—but will result in the loss of mechanically critical fluids. This does not require much imagination to see the possibilities.
Forgetting to pull the chocks is easy, if a little embarrassing, to fix. You'll notice it right off when attempting to taxi. Shut down the engine, get out, throw the blasted things over the airport fence, and recommence.
What has all this to do with distraction? In almost every case, the pilot was not paying attention to the main thing—readying the aircraft for flight. There is a preflight procedure suggested by several old-timers. When doing the walkaround, become an introvert and do not to talk to anyone. With guests, friends, or other pilots, just politely excuse yourself; take the time to do your normal, thorough job; and then reengage in conversation with them. Be especially careful when another pilot is there to "help." It's easy to miss things by assuming that the other pilot checked it. Professional pilots do the preflight before the passengers arrive—it saves time and there are no distractions.
The next big opportunity to get into trouble is taxiing out for takeoff. Runway incursions happen when pilots get their heads down and start dithering in the cockpit rather than committing to reach the end of the runway without any deviations. It's tempting to run the checklist, set flight and nav instruments, and brief the passengers or get a clearance. Two pilots can accomplish more than one but if both heads are down and someone isn't minding the store, there may be trouble. Good procedure suggests that one drive and the other organize. Both heads should be outside when crossing or taking the runway.
On the ground while the engine is running, dollars are being consumed, so the natural tendency is to hurry. A single pilot loading a flight plan into the GPS while taxiing frequently results in neither job being done well.
Consider installing a ground power or ground communications avionics switch. Rather than starting the engine and lighting up the whole stack or turning on the master and draining the battery by running gyros and radios, just turn on the essentials. This switch allows you to use only one com radio and the GPS with practically no battery drain. Get a clearance and load the flight plan in the quiet before moving. What a concept! I'm surprised the manufacturers and avionics shops don't make this little gem a standard item.
After takeoff, the two big things are to not hit the ground or another aircraft. Another item that causes grief is an open door. Most unpressurized aircraft will fly just fine with a door open, so don't trade your pilot's uniform for a doorman's. Aviate first to return to the runway and then worry about the door.
Several years ago, the AOPA Air Safety Foundation was involved in an FAA human factors simulator experiment to study how pilots programmed and flew GPS approaches. Distraction was evident as the flight path during programming frequently fluctuated out of limits. Pilots pushed buttons and navigated the pages of the box rather than accurately navigating the airspace. Once the units were programmed, flight control improved considerably.
An ASF staff member recently flying the Northeast corridor was given the inevitable "minor" rerouting that included new airways and intersections. He timed how long it took to reprogram the late-model GPS without using the autopilot, while accurately maintaining heading, altitude, and an active outside scan. Seventeen minutes later, the job was done, and this was with a pilot who was very familiar with the equipment. GPS is wonderful but it can be a significant distraction. The human interface still needs work on most of the units.
Almost nobody today flies without a headset and boom mic—it is practically standard equipment for two good reasons, both related to distraction. Communications are much easier—there's less need to retransmit, and there's no dropping or fumbling the microphone. As with car cell phones, hands-free functionality helps.
Distraction occasionally results in a gear-up landing. Invariably, the pilot claims that something else occupied his mind, even if it was the gear warning horn blaring. The airframe manufacturers use several devices to preclude the belly slide, such as switches on the throttle quadrant and flap sensors. If the power is reduced below a certain level or landing flaps are selected without the gear being lowered, a horn sounds.
One of the most elaborate antidistraction devices ever was installed on Piper Arrows years ago. It had an airspeed sensor that would automatically lower the gear if the airspeed dropped below about 90 knots. There was an override system to revert total control to the pilot to assist in special situations such as power loss, stall practice, icing, or short-field operations. You could land an Arrow gear up but it took real effort. Sadly, a few pilots became so distracted that they failed to follow some simple procedures regarding the override, and the system that was put in place to save them caused accidents. A few enterprising attorneys and the FAA put an end to some innovative engineering, in my opinion.
"Bitchin' Betty" is the not-so-complimentary term that fighter pilots use for a voice reminder system that helps them focus on the main thing. The only time they ever hear from Betty is when exceeding some parameter or when the aircraft is not properly configured. Apparently, male pilots respond more readily to a female voice telling them they are about to do something stupid. This system—almost standard in bizjets—is working its way into light-aircraft cockpits.
Every pilot, driver, boater, and machine tool operator has had a moment's inattention and gotten away with it — not once, but hundreds of times. Most of the time distractions won't get you—and then one day they will. Don't sweat the small stuff — but contrary to the popular saying, not all of what we do in aviation is small stuff.
See also the index of "Safety Pilot" articles, organized by subject.
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Stanley R. Mohler, physician, pilot, educator, author, and former member of AOPA’s Medical Advisory Board, has died.
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