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Distractions Are Deadly: How You Can Avoid This Accident

While pilots are usually good at multitasking, too many accidents each year are caused by distractions in the cockpit. Most distraction related accidents boil down to two problems: not knowing your airplane well enough, and not maintaining a sterile cockpit.

Let's take a look at what happened...

NTSB

The Fatal Accident

On May 24th, 2013, a twin-engine Piper PA-34-200T Seneca broke up mid-air over Johnstown, NY. Both the pilot and single passenger were killed. According to the NTSB, "the volunteer medical transport flight was established on course toward an en route navigational fix. Upon reaching the fix, the flight was expected to continue toward the initial approach fix for an instrument approach at the Rome, NY Airport (KRME). About 5 miles southeast of the en route fix, the airplane began to deviate off course."

Basinbah

"When asked by an air traffic controller about the reason for the deviation, the pilot stated that the airplane had turned "the wrong way" and indicated that he had incorrectly loaded the instrument approach into the airplane's GPS. The controller provided a vector to the pilot to return the airplane to the previously established course, and the pilot acknowledged. About 1 minute later, radar contact with the airplane was lost" (NTSB).

How One Distraction Led To Deadly Disorientation

Spatial disorientation most commonly occurs when pilots lose exterior visual references. According to weather data, the pilot was likely in IMC.

Restricted visibility, turbulence, and the airplane's unexpected off-course turn were all factors leading to spatial disorientation. But worst of all, the pilot became distracted with the operation and configuration of the GPS. Before reaching the fix, the sudden unintended course change clearly resulted in the pilot struggling to fly the airplane in a level attitude while figuring out correct avionics settings. According to the NTSB, the resulting ground track, rapid turning descent, and breakup were consistent with a loss of control as a result of spatial disorientation.

matthewpiatt

Undetected Spatial Disorientation

With his head down inside the cockpit, correcting for improper autopilot and GPS settings, the pilot most likely didn't notice the airplane entering an unusual attitude. When bank and pitch changes at rates slower than 3 degrees per second, your inner ear (the vestibular system) has a hard time detecting the change, especially in cases where visual references are totally lost.

While inside the clouds and focused on the autopilot and navigation systems, the pilot probably didn't sense any change in bank, pitch, or speed. According to the NTSB, "radar data indicated that the airplane entered a rapidly-descending left turn in the final moments of the flight during which it reached an estimated 80-degree left bank, lost about 3,700 feet of altitude in 36 seconds, and accelerated to an airspeed of about 240 knots before breaking up." The airplane's Vne speed was 195 knots.

How You Can Avoid This Outcome

While there wasn't a cockpit voice recorder or surviving witness, there is one important lesson we can learn from this accident.

You must know how to operate all of your aircraft's systems. In this tragic case, it's likely that the pilot was startled by the unintended course change. As he struggled to re-load the approach and reset the autopilot, the aircraft entered an undetected unusual attitude. The saying "Aviate, Navigate, Communicate" holds true in this case study. Always ensure you're maintaining positive aircraft control before troubleshooting navigation systems or contacting ATC for assistance.

matthewpiatt

Why Sterile Cockpit Procedures Are Critical

A distraction or two can turn deadly quickly, whether you're flying VFR or IFR. That's why airlines have strict sterile cockpit rules for their pilots during critical phases of flight to reduce distractions. In a sterile cockpit, attention is focused solely on operational procedures and situational awareness. Even if you aren't flying for an airline, there several things you can do to maintain a sterile cockpit:

  • Stop non-essential conversations (with both passengers and crew)
  • Keep your eyes outside the cockpit and scanning for traffic
  • Silence your phone and put it away
  • Don't reset or operate any cameras you might've mounted to record your flight
  • Monitor the correct frequencies and listen for your callsign
  • Perform and verify all your checklist procedures

Critical phases of flight are usually checklist-saturated, traffic-saturated, and require a high amount of focus. Some of these critical times include traffic pattern operations, takeoff, climb, descent, and landing. Don't just limit your sterile cockpit to these times, however. If you're approaching bad weather, near other traffic, or in busy airspace for instance, you should follow the same precautions.

Sterile cockpits are all about eliminating unnecessary distractions. They'll help you fly safer and more efficiently during the times you need it most.

NTSB

How do you eliminate distractions in the cockpit? Tell us in the comments below.

Swayne Martin

Swayne is an editor at Boldmethod, commercially licensed pilot with multi-engine and instrument ratings, and a commercial aviation student at the University of North Dakota. He's the author of the articles, quizzes and lists you love to read every week. Swayne's experience ranges from international flights in a King Air F90 to ferrying a 1943 Grumman Widgeon across the country. You can reach Swayne at swayne@boldmethod.com, and follow his flying adventures at http://www.swaynemartin.com.

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