The Human Factor: Deadly Conversations

“Recognize that conversation is a powerful distracter.” As I quoted those words from the NASA study of crew error accidents in January’s article, a flood of accident case studies flowed through my head. Some I had discussed earlier in that same article — the Teterboro controller who was engaged in a discussion on the phone and delayed communicating a new frequency to a pilot for two minutes, the two Northwest Airlines pilots who became so engrossed in their conversation about airline scheduling policy following Northwest’s acquisition by Delta that they lost all track of the time and their location and did not hear calls from ATC.

In my July 2010 article, I wrote about how the tired, inexperienced Colgan Air crew that crashed near Buffalo had an hour and a half conversation as they inched toward the runway for takeoff from Newark, New Jersey. It appears this extended period of relaxed conversation combined with their lack of sleep may have affected their professionalism later in the flight when they again lapsed into non-pertinent conversation on final approach and neglected the simple task of adding power after leveling off at a low power setting with the gear extended.

I personally experienced the distracting power of conversation while I was driving a new SUV with an integrated cell speakerphone. As I was driving north across Tempe and Scottsdale, Arizona, I had my first opportunity to try out this supposedly safer “hands-free” phone system. I was enjoying a long conversation with my son when I realized I had just driven past my exit. Like the Northwest pilots, the conversation caused me to lose awareness of my location.

One of the classic examples of how distracting conversation can be and how it can undermine the professional standards of an aircrew is the crash of American Airlines Flight 965 on approach to Cali, Colombia, in December 1995.

The Setup — In a Hurry and Not Focused

In sports, the setup is the preparation and execution of a scoring play. In a perverse twist for American Airlines Flight 965, two factors provided the setup for the string of unfortunate decisions and actions that ultimately led to the crash and the deaths of all but four people on board. The flight was almost two hours late departing from Miami. First, they lost over half an hour waiting for the arrival of connecting passengers and their baggage, and then gate congestion and airport traffic led to an additional hour and a half delay before they finally took off for Cali. This put them into “makeup time” mode. Of course, there is not much a crew can do to reduce their flight time, but they typically desire to do the best they can and announce that to the passengers.

Then, during the three-hour flight to Cali, the flight crew got into an extended conversation about flight attendant crew duty time rules, with detailed analysis of what time the crew could leave the hotel based on their estimated arrival into Cali two hours late at approximately 10 p.m. Eighteen minutes before the crash and only three minutes before starting their descent into Cali, the captain asked the first officer, who was flying the airplane, to let him know a few minutes before he started his descent in case there was a language problem. They then discussed how much they preferred the three-hour trip to Cali over eight-hour flights, which, in turn, led to talk about the danger of driving home at 5 in the morning after such a long flight and a pilot they knew who preferred the longer flights.

After recalling how their friend had been robbed at knifepoint in Rio de Janeiro, Brazil, the copilot said, “Well let’s see, we got 136 miles to the VOR, and 32,000 feet to lose, and slow down to boot, so we might as well get started.” The captain confirmed that he was still in makeup time mode when he responded, “If you keep the speed up in the descent, it would help us too, OK?”

That was it. Even though they were landing at night at an airport surrounded by mountain peaks towering as high as 11,000 feet over the airport, and even though air traffic control philosophy and standards in South America can be very different than in the United States and even though the copilot had never landed at Cali before, they started their descent and approach with an offhand, almost lackadaisical, “we might as well get started.” The crew did not accomplish the required descent and approach checklists and briefings, and there was no discussion about the various risks involved in landing at Cali, especially at night. The stage had been set.

Strike One — Initial Confusion

When the flight contacted Cali Approach Control, the controller said they were "cleared to Cali VOR, descend and maintain one five thousand." He then added, "report Tulua VOR." He obviously intended for them to continue on their flight plan over Tulua, which is north of the Cali airport, to Cali VOR, which is located south of the airport and is the initial approach fix for the ILS 01 approach into Cali. However, the captain read back that they were "cleared direct to Cali VOR, report Tulua … is that all correct, sir?" The controller responded "affirmative." Believing they were cleared direct to Cali VOR, the captain entered that into the FMS, which resulted in all the intermediate fixes being erased from the route.

Strike Two — Bait and Switch

So far, despite not completing any descent or approach checklists or briefings, the flight was headed in the right general direction at the correct altitude, with the only problem being that the intermediate fixes between their location and Cali were no longer displayed on the FMS. Then the controller offered the bait, “Sir, the wind is calm. Are you able to approach runway one niner?” The captain asked the copilot if he would like to “shoot the one nine straight in?”

While the ILS 01 typically flown at Cali is a straightforward 7.5 mile ILS approach, starting at the Cali VOR, the VOR DME Runway 19 starts at Tulua VOR and covers 32 miles with a turn and three step-down descents. Even worse, the crew was not only unfamiliar with this approach, they did not even have the approach plate out and did not realize that they were already passing Tulua VOR.

The copilot, who wasn’t sure of their position and had no idea what that approach entailed or even where it started, in true impulsive, invulnerable, macho pilot style, responded, “Uh, yeah, we’ll have to scramble to get down. We can do it.” When the controller cleared them for the approach, scramble is hardly the word for it. Massive confusion was evident as the captain asked if the copilot wanted to “go right to Cal, er to Tulua?” The copilot responded, “Uh, I thought he said the Rozo One arrival?” The captain agreed, “Yeah, he did. We have time to pull that out?” He then started paging through the approach binder, looking for the approach.

After two minutes of confusion, with comments like, “Uh, where are we?” “Where are we headed?” “I don’t know, what’s this ULQ? What the, what happened here?” the captain asks rhetorically, “We got [messed] up here, didn’t we?”

Strike Three — The Final Blow

The crew finally decided to go direct to Rozo NDB, which is actually the final step-down fix, only 2.6 miles from the end of the runway. However, when they entered the identifier “R,” the FMS pulled up a fix near Bogota, and the airplane started to turn to the right. Soon the ground proximity warning system started warning, “Terrain, terrain, whoop, whoop, pull up, pull up!” The final blow was that the speed brakes were still extended from their rapid descent, and as the copilot pulled back on the wheel and added power, the stick shaker activated. If the speed brakes had been retracted, they might have been able to clear the ridge by a few hundred feet.

The Final Irony

An eerily similar accident case study is presented during training at American Airlines in hopes that its pilots will recognize that a similar situation is developing and avoid a similar outcome.

This accident is a compelling example of the impact conversation can have on our level of alertness, both during and after the conversation. No one expects a flight crew to sit on a taxiway or at cruise altitude for extended periods of time in silence, but it is critical to recognize the negative impact conversation can have and have a plan to re-establish full flight alertness at the appropriate time. This would include a specific point of time when all nonoperational conversation will end and a specific action to take to bring the entire crew back into full alert status about where you are, what happens next, when it happens and what is required to be ready. Simply stating that they were returning to sterile cockpit rules about five minutes prior to their descent with a review of what was coming up followed by the descent and approach checklists would have re-established a professional demeanor with full situational awareness for the American Airlines Flight 965 crew, making the tragic outcome much less likely.


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