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Crash Brings New Question of Complacency in Cockpit

August 26, 1987

WASHINGTON (AP) _ With pilot error developing as the most likely culprit, the recent Northwest Airlines crash is raising questions about cockpit discipline and how flight crews battle complacency amid highly repetitive routines.

Aviation psychologists have been concerned about flight crew coordination in commercial airliners for years, including increasing evidence of a danger of complacency in cockpits that are highly automated and where critical chores become a matter of habit.

Federal aviation accident investigators say more than 80 percent of the airline accidents involve human error. About 40 percent of the time the mistake is made in the cockpit, according to statistics from the National Transportation Safety Board.

A rash of embarrassing miscues, including two that nearly caused air tragedies, brought attention to Delta Air Lines earlier this summer.

Investigators believe the likely reason for the Aug. 16 crash of Northwest Flight 255 on takeoff from Detroit, which killed 156 people, was the failure of the flight crew to properly set the wing flaps, a basic chore of flying critical to get the plane safely airborne.

Why are such mistakes made?

The Federal Aviation Administration is bringing together chief pilots of the nation’s airlines for a meeting Thursday in Kansas City, Mo., to discuss the problems, which have been the topic of aviation literature for years.

″We must return to the basics - the basics that put all of us in the left (captain’s) seat, in a word, our professionalism,″ FAA Administrator Allan McArtor recently told an Air Line Pilots Association safety seminar.

Since coming to the FAA last month, McArtor has promised a ″top-to- bottom″ review of pilot training to reduce the likelihood of careless mistakes.

″The reasons (for a pilot mistake) are probably as extensive as the reason any person makes a mistake - a distraction, fatigue, task overload or stress. It can be complacency. It can be inexperience,″ said Clay Foushee, a NASA psychologist who specializes in human factors in aviation.

If the theory that the Northwest pilots neglected to set their plane’s wing flaps holds true, it will not be the first time a pilot has forgotten to perform one of the most basic pre-flight tasks in aviation, according to reports filed with the National Aeronautics and Space Administration.

Since 1981, there have been at least seven incidents reported through NASA’s Aviation Safety Reporting System in which flaps were improperly set for takeoff. In six cases, warning alarms sounded and the takeoffs were aborted.

In another incident, the pilot noticed the wrong setting too late, but adjusted his takeoff speed and lifted off successfully.

″The biggest cause of this incident was complacency and routine,″ the co- pilot wrote NASA. He said the crew had flown the aircraft for six months with the same flap setting, but required a different one this time because of strong cross winds.

″The routine which had developed turned into a very tough habit to break,″ the co-pilot continued in the report, which like the others was filed anonymously with no public reference to the airline involved.

Human errors in the cockpit also seem to have little relationship to experience, according to specialists.

Two of the Delta incident this year involved senior captains. In one a captain mistakenly shut down both engines of his plane, bringing it to within 600 feet of ditching into the Pacific Ocean, because he pulled the wrong switches. Another veteran flight crew put the wrong coordinates into a navigational computer and came within 100 feet of colliding with another jetliner over the North Atlantic.

The captain of Northwest Flight 255 was a 32-year veteran and his co-pilot was well seasoned. But long before the Detroit accident, experienced pilots have been involving incredible cockpit mistakes.

The head of flight training at KLM Royal Dutch Airlines was at the controls on March 27, 1977 when he started a takeoff without clearance from the airport tower at Tenerife, Canary Islands. His plane collided on a fog-covered ruwnay with a Pan American World Airways jet, killing 582 people in the world’s worst aviation accident.

″Human error has been there since the Wright brothers flew and all we can do is design against it,″ said Henry Duffy, president of the 34,000-member Air Line Pilots Association. He suggested that long hours, flying a half-dozen legs a day and repetition contributes to the problem.

″Machines aren’t perfect and neither are people. If you’ve done a good job you’ve designed a system where the two look out for each other,″ said Foushee, the NASA psychologist.

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