Plane & Pilot
Tuesday, April 1, 2014

Breaking The Accident Chain


The danger of multitasking and inattentional blindness: hang up, focus and pay attention


Mistakes are a part of life, but when it comes to aviation, sometimes even a simple mistake can lead to disaster. This one happened in early January 2007, on a cool, clear Los Angeles morning. The second pilot of N77215, a Citation jet getting ready to depart out of Van Nuys Airport, arrived at the plane while it was being fueled to load some baggage. The pilot and line person spoke while the pilot loaded bags into the front left baggage compartment. When he finished fueling, the line person informed the pilot that they'd have to tow the aircraft to a different area for startup. The pilot was seen closing the front baggage door, but he didn't latch it shut. After the plane was moved, the first pilot arrived, and the line person left to marshal another aircraft from the ramp. When he arrived back at the Citation, he noticed that the crew took an extraordinary amount of time getting ready in the cockpit. The aircraft eventually taxied out and was cleared for departure. Just as the plane rotated during the takeoff roll, the forward baggage door suddenly popped open. Witnesses reported that the plane slowed and turned downwind in an apparent effort to return to the airport. Unfortunately, it never made it. Perhaps distracted by the flailing door, or concerned that it might rip off, the pilot slowed the aircraft enough to completely lose control of the aircraft. It stalled and spun into a residential neighborhood, killing the crew.

This event didn't happen to an inexperienced crew. The 72-year-old pilot, who was a former airline captain, reported his total flight experience at over 38,000 hours, and the second pilot had 1,693 hours of flight time. The Citation 525 is equipped with a warning system that shows when the forward baggage door isn't properly secured, and previous incidents where doors have come open have demonstrated that the Citation can be successfully flown with the door open. This was a tragic end to a series of events that started with a seemingly simple mistake.

It doesn't matter what you fly. Pilots at all levels land gear-up, take off with baggage doors open, taxi away after startup with a ground power cart still connected, start engines with covers in place, depart with a tow bar attached, take off from taxiways, forget to replace a fuel cap and a host of other mistakes too numerous to list. Most of these events start with a simple mistake, and there are often multiple warnings that something is wrong, yet even experienced pilots miss all the clues. Sometimes, the results are inconsequential, but most of the time, the results are very expensive and sometimes fatal. These kinds of mistakes caused by acts of omission—simply forgetting or missing something—are particularly insidious. Under the right set of circumstances, the human brain operates in a way so that these kinds of mistakes are very easy to make and sometimes nearly impossible to catch. Let's take a look at how we process information and what conditions are the most likely to set us up for potentially catastrophic acts of omission.
Recent studies show the human brain is simply not good at processing multiple tasks at one time.
The Danger Of Multitasking
As pilots, most of us pride ourselves on our ability to handle multiple tasks at once. We're trained to aviate, navigate and communicate all at the same time during normal operations. Our daily routine of reading email and listening to the news on the radio while answering the phone reinforces a belief that we can effectively handle multiple tasks at one time. Recent studies show otherwise—the human brain is simply not good at processing multiple tasks at one time. It turns out that our modern lifestyle of trying to do multiple things at once is actually having an adverse effect on our ability to completely focus on even one task at a time.

To understand why, we need to look at how multitasking works. A true multitasking processor has multiple processing units, each fully dedicated to a given task. The processors run independently, without regard to the others, to complete each task uninterrupted. Studies show that with regard to cognitive events, the human mind simply doesn't work this way. Instead, the brain must multiplex—switching rapidly between multiple tasks to do more than one thing at a time. This is a common strategy in the computer world where a single high-speed processor is used to perform multiple tasks at once. The processor flips between tasks at high speed, flawlessly keeping track of where it is in each task to make sure nothing gets dropped.



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