The media recently reported the 25th anniversary of the Air Florida accident in a snow storm at Washington, D.C. in 1982. These reports touted the “sweeping legacy” of this accident and the safety improvements that it spawned.
This accident remains fresh in my mind, partly because I watched the live reports on the then-new CNN as survivors and wreckage were pulled from the icy Potomac River, partly because I used this accident as a case study in Crew Resource Management (CRM) classes in the years since.
As with all accidents, there was a chain of events that led to the end of 73 lives. As with most accidents, the crew had several chances to break the chain of events and avoid the accident. Their last opportunity was as they began the takeoff on KDCA’s runway 36.
15:59:24 TWR “Palm 90 cleared for takeoff.”
…
15:59:35 [SOUND OF ENGINE SPOOLUP]
…
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.”
38 seconds later they impacted the 14th Street Bridge.
During the takeoff roll, the first officer (CAM-2) repeatedly commented on the fact that the engine indications didn’t look right, but the captain (CAM-1) assured him that they were. Neither pilot took any action to resolve the discrepancy.
The NTSB investigation ultimately determined that the engine instruments were displaying faulty readings because the crew decided not to turn on the anti-ice system that keeps the engine sensors clear of ice and snow.
Within days of this anniversary, NTSB released the cockpit voice recorder transcript of last August’s Comair accident in Kentucky. The first officer’s comment “dat is weird with no lights” as they accelerated down a closed runway is eerily reminiscent of the first officer’s concerns on Air Florida.
Like Air Florida 90, Comair 5191 will likely become a CRM classic. There were numerous opportunities for the crew to interrupt the chain of events that was leading toward the deaths of 49 people.
There are several lessons for us in these two tragedies separated by one-fourth of the history of powered flight. The first is that regardless of the technology we bring to bear, the weak link in the system is still the Version 1.0 human being who runs things. Second, just because we have mandated CRM training for airline crews, we didn’t “fix” the human factors failures that lurk within the modern aviation system.
And finally for us pilots, if something seems “weird”, there is probably a reason that needs investigation. If you are on the ground, stop and talk about it. If you are in the air, get away from the ground and into a low workload environment so you can figure it out.
As the old saying goes, “If it doesn’t seem right, it probably isn’t.” Or maybe there should be a new version – “If things seem weird, they are.”
Fly Safe!
Neil
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March 12, 2009 at 10:00 pm
“I don’t know” probably ranks right up there with “oh sh–” as famous last words on a CVR.
March 19, 2009 at 2:47 pm
… and “What is it doing now?”