Cell phones and other portable electronic devices (PEDs) have introduced a “21st century twist” to the distractions that can permeate pilot decision-making processes, and more should be done to prevent their use during critical phases of flight and ground operations, Chairman Deborah Hersman of the U.S. National Transportation Safety Board (NTSB) says.
Hersman spoke during an NTSB hearing on the Aug. 26, 2011, crash of a Eurocopter AS350 B2 that ran out of fuel and crashed 1 nm (2 km) from the Midwest National Air Center in Mosby, Missouri, U.S., during a multi-leg flight. The crash killed the pilot of the Air Methods helicopter, flight nurse, flight paramedic and patient.
The NTSB said probable causes of the crash were the “pilot’s failure to confirm that the helicopter had adequate fuel on board to complete the mission before making the first departure, his improper decision to continue the mission and make a second departure after he became aware of a critically low fuel level, and his failure to successfully enter an autorotation when the engine lost power due to fuel exhaustion.”1
The U.S. National Transportation Safety Board (NTSB) was not unanimous in its belief that the use of a portable electronic device (PED) by the pilot of the accident helicopter contributed to the crash.
In dissenting remarks, board member Earl Weener said that, by emphasizing the role of the pilot’s use of a PED, the final report on the accident “provides a distraction from other critical safety issues identified and supported by the investigation.”
Weener added that the PED was “only one of many distractions for this pilot that day. As ill-advisable and disconcerting as his actions may be with regard to his PED use, the report fails to make the case for attributing the causes or contributing causes of this accident to distraction based explicitly on use of the device. The pilot’s flawed aeronautical decision making is the fundamental issue, which goes well beyond his decisions regarding cell phone use. It is the root cause of this accident.”
Weener said the accident pilot demonstrated poor judgment several times — including by failing to complete the preflight inspection and the before-takeoff confirmation checklist, and by exhausting the fuel supply rather than conducting an emergency landing.
“Once the pilot made his decision to proceed with this mission,” he added, “nothing was going to deter him from his course, regardless of whether he used a cell phone.”
Among the contributing factors was “the pilot’s distracted attention due to personal texting during safety-critical ground and flight operations,” the NTSB said (see “Dissenting Opinion”).2
The agency said its investigation of the accident prompted its issuance of nine safety recommendations, including four dealing with use of PEDs (ASW, 6/13, “Autorotation Aid”).
The recommendations call on the U.S. Federal Aviation Administration (FAA) to prohibit flight crewmembers in U.S. Federal Aviation Regulations Part 135, commuter and on-demand, and Part 91 Subpart K, fractional ownership, operations from using PEDs “for nonoperational use while at their duty station on the flight deck while the aircraft is being operated.”
Other recommendations say the FAA should require Parts 121 (air carrier), 135 and 91 Subpart K operators to inform pilots during initial and recurrent training of the “detrimental effects” associated with nonoperational use of PEDs, and ensure that their procedures prohibit nonoperational use of PEDs by operational personnel during flight and safety-critical periods on the ground.
In addition, the NTSB recommended that Air Methods, which strengthened its prohibitions on cell phone use after the accident, further expand its ban on the use of PEDs during flight to include “safety-critical ground activities” such as flight planning and preflight inspection.
NTSB investigators said the pilot’s colleagues told them it was uncharacteristic that he failed to recognize that the helicopter lacked the fuel to complete the planned mission.
The accident report said that the former military helicopter pilot might have been distracted by personal issues — his wife’s pregnancy, his father’s recent heart surgery, his commute to a base at St. Joseph, Missouri, after moving to a new city and his cell phone conversations and text messages with a colleague with whom he was to have dinner after his shift ended.
“The pilot needed to focus his attention away from personal issues when performing safety-related tasks, but at such times, both before departure and during the mission, he engaged in personal texting activities,” the report said, adding that investigators examined the pilot’s cell phone records “to see whether distraction caused by the pilot’s personal electronic communications could have played a role in his incomplete preflight inspection” (Figure 1).
The records showed that the pilot sent and received text messages and phone calls throughout the day, including a number of texts shortly after 1400 local time, when a maintenance technician said he and the pilot began a walk-around inspection of the helicopter as the helicopter was being prepared to return to service. The pilot first responded to the texts after 1430 — a delay that indicated that the texts “did not necessarily preclude the performance of a complete preflight inspection, but they could have distracted the pilot,” the report said.
The pilot either did not perform a preflight inspection or performed an incomplete inspection, the report said, citing his unawareness of the helicopter’s low fuel and his failure to sign off certain entries in maintenance records and the daily flight log.
The records showed that text messages also were sent from the pilot’s cell phone while the helicopter was in flight, including several sent during the accident leg of the mission (Figure 2). Company procedures prohibited pilots from using, or even turning on, cell phones during flight operations, the report said.
The original plan called for a two-part flight from the St. Joseph base at Rosecrans Memorial Airport to Harrison County Community Hospital in Bethany to pick up a patient and then continue to Liberty Hospital in Liberty, Missouri.
While in Bethany, the pilot told his company’s communication specialist that he had realized about halfway through the first leg of the flight that the helicopter did not have as much fuel as he had thought. Rather than continue to Liberty, which was 62 nm (115 km) southwest, he decided to stop in Mosby, along the same route but 4 nm (7 km) closer.
The pilot sent all of his in-flight texts after he recognized the low-fuel state — the last one about 20 minutes before the accident, the report said, noting that the pilot did not respond to two subsequent incoming text messages.
“There is no evidence that the pilot’s airborne texting activities directly affected his response to the engine failure,” the report said. “However, the personal texting activities would have periodically diverted the pilot’s attention from flight operations and aeronautical decision making. At a minimum, the pilot’s attention would be diverted for the amount of time it took to read and compose messages. Further, from a control usage standpoint, to send a text, the pilot would require at least one hand to be temporarily removed from active control of the helicopter.”
The report called the pilot’s personal texting “a source of distractions and interruptions,” citing research3 that has shown that distractions and interruptions “decrease cognitive capacity, reduce the processing of potentially relevant information and can cause information in working memory to be confused or forgotten. These effects degrade performance of complex tasks and increase the likelihood of decision errors. Time pressure, which the pilot faced when deciding to continue the mission, can exacerbate this effect by restricting opportunities to weigh potentially relevant cues and consider alternative courses of action.”
The FAA — acting in response to a 2012 law that called for a crackdown on the use of PEDs on the flight deck — issued a notice of proposed rule making (NPRM) earlier this year to prohibit Part 121 flight crewmembers from using PEDs for personal purposes “while at their duty station on the flight deck while an aircraft is being operated.” A final rule is expected after the FAA has reviewed public comments on the proposal.
The FAA said the rule was intended to “ensure that certain nonessential activities do not contribute to the challenge of task management on the flight deck and do not contribute to a loss of situational awareness.”
The NPRM cautioned that a loss of situational awareness can lead to “critical consequences, such as missing information from one source when concentrating on another source, altitude or course deviations, dominance of visual cues to the extent that pilots may not hear certain aural warnings, misinterpreting ATC [air traffic control] instructions or experiencing task overload.”
As an example, the NPRM cited an Oct. 21, 2009, incident in which a Northwest Airlines Airbus A320 bound from San Diego to Minneapolis flew 150 nm (278 km) past its destination because the pilots were using their personal laptop computers to retrieve information as they discussed the airline’s crew scheduling process.4
In the final report on that incident, the NTSB said the pilots had “allowed this conversation to monopolize their attention and thus lower their capacity to monitor their radio communications, notice the lack of contact [with ATC] and recognize, via airplane instruments, the flight’s progress.” The pilots failed, over a period of about 75 minutes, to respond to numerous radio calls from air traffic controllers in the Denver Air Route Traffic Control Center (ARTCC) and the Minneapolis ARTCC, the report said.
While the laptops were open, they blocked the pilots’ views of some flight and navigation displays, the report said, adding, “The computers not only restricted the pilots’ direct visual scan of all cockpit instruments but also further focused their attention on non-operational issues, contributing to a reduction in their monitoring activities, loss of situational awareness and lack of awareness of the passage of time.”
The pilots missed alerts from the aircraft communication addressing and reporting system (ACARS) and messages about their aircraft’s position, and as they neared Minneapolis, they had not entered landing data in the flight management computer, the report said.
“The pilots stated that their first indication of anything unusual with the flight was when they received a call from a flight attendant inquiring about their arrival,” the report said. The captain said that he then saw that there was no flight plan information on his multifunction control and display unit and that the navigation display showed the airplane was nearing Duluth, Minnesota, and Eau Claire, Wisconsin — both of which were beyond Minneapolis.
The report said that they then contacted ATC to report that they “got distracted, and we’ve overflown Minneapolis. We’re overhead Eau Claire and would like to make a one-eighty.” In response to questions from Minneapolis ARTCC, they said they had experienced “cockpit distractions.” Later, they told incident investigators about their laptop-enhanced conversations.
At the time of the incident, the airline had a policy prohibiting use of PEDs on the flight deck.
Texting During Taxi
The NPRM also cited the circumstances preceding the Feb. 12, 2009, crash of a Colgan Air Bombardier Q400 near Buffalo, New York, U.S., noting that, during the taxi phase of the flight, the first officer sent a text message on her personal cell phone — another example, the FAA said, of “the potential for such devices to create a hazardous distraction during critical phases of flight.”5
Although the airplane was not moving when the first officer sent her text message, the NTSB noted that FAA Advisory Circular (AC) 91.21-1B, “Use of Portable Electronic Devices Aboard Aircraft,” issued in 2006, says that cell phones “will not be authorized for use while the aircraft is being taxied for departure after leaving the gate.” Colgan’s policy conformed to the guidance contained in the AC.
FAA Safety Alert for Operators (SAFO) 09003, “Cellular Phone Usage on the Flight Deck,” issued five days before the Colgan crash, also cautioned flight crewmembers about the hazards of leaving cell phones turned on during critical phases of flight.
“The SAFO was the result of an inspector’s observation of a ring tone/warbling sound coming from a first officer’s cellular phone during a takeoff roll just before reaching the airplane’s takeoff decision speed,” the NTSB summarized in its report on the Colgan accident. “The SAFO stated that the ring tone was a distraction to the flight crew and could have resulted in an unnecessary rejected takeoff.”6
- NTSB. Crash Following Loss of Engine Power Due to Fuel Exhaustion; Air Methods Corporation; Eurocopter AS350 B2, N352LN; Near Mosby, Missouri; August 26, 2011, Aircraft Accident Report NTSB/AAR-13/02. April 9, 2013.
- The NTSB also cited as contributing factors the pilot’s “degraded performance due to fatigue,” the lack of a company policy requiring an operational control center specialist to be notified if a helicopter was low on fuel and the “lack of practice representative of an actual engine failure at cruise airspeed in the pilot’s autorotation training in the accident make and model helicopter.”
- The NTSB cited “The Effects of Interruptions, Task Complexity and Information Presentation on Computer-Supported Decision-Making Performance,” written by Cheri Speier, Iris Vessey and Joseph S. Valacich and published in 2003 in Decision Sciences Volume 34 (4): 771–797.
- NTSB. Accident report no. DCA10IA001. Oct. 21, 2009.
- NTSB. Loss of Control on Approach; Colgan Air Inc., Operating as Continental Connection Flight 3407; Bombardier DHC-8-400, N200WQ; Clarence Center, New York; February 12, 2009, Aircraft Accident Report NTSB/AAR-10/01. Feb. 2, 2010. The crash killed all 49 people in the airplane and one on the ground. In the final report, the NTSB said the probable cause of the accident was “the captain’s inappropriate response to the activation of the stick shaker, which led to an aerodynamic stall from which the airplane did not recover.”