Another of those uncanny studies has been produced. The type that produces a conclusion that - once you have read it - is so obvious that it's suddenly amazing the industry has not noticed why it has continued, for more than 100 years, to make the fatal mistakes it does. Like unintended flapless take-offs.
The study, by NASA Ames, looks at actual incidents, including fatal accidents and near-disasters that crews got away with but later reported, and finds the common factor. It is about why crews frequently fail to complete - or even to carry out at all - routine checklists.
The answer, NASA concludes, is distractions. The report's theme is "the hidden complexity of cockpit operations". Why hidden? Because complexity and distractions are obvious, endemic, they are a way of life, they are inevitable. When that's the nature of the job, pilots don't question it and neither do the airlines or the military. There are measures that acknowledge complexity, like "the sterile cockpit" during descent, but air traffic controllers that call with a new clearance don't know they are interrupting a checklist - and there are countless other such interruptions.
This report's conclusion is that pilots have to recognise - should be trained to recognise - when distraction is dangerous, or when too much is going on for safety to be maintained, and even to slow down if that is what it takes. And airlines have to respect that.
Source: Flight International
