I had been a member of the NTSB for only seven days when the call came during the pre-dawn hours on that Sunday morning: a regional jet had crashed at Lexington, KY and there were massive fatalities. With that, I was on my way to Lexington.
One look at the TV that day would immediately tell us what happened, as unbelievable as it may have seemed: two experienced airline pilots – inexplicitly – attempted to takeoff on a runway that they weren’t cleared to, was unlighted, and, most importantly, was too short to allow a successful takeoff.
So, right off the bat, we knew what happened. NTSB investigators would spend the next 11 months trying to determine why it happened. In the intervening months, there would be lots of talk and speculation within the media and piloting community about the effect of taxiway construction, certain runway and taxiway lights being inoperative, the crew’s airport diagram being incorrect, and the fact that the control tower had only one controller instead of the required two. All of these factors were true, but NTSB analysis found that despite these factors, “adequate cues existed on the airport surface and available resources were present in the cockpit to allow the flight crew to successfully navigate from the air carrier ramp to the [proper] runway” (NTSB, 2007, p. 103).
Two other air carrier crews had successfully navigated to the correct that runway under the same circumstances that morning. So, how did this experienced crew end up in this situation? If you had the opportunity, as I did, to listen to the cockpit voice recorder, perhaps you’d understand why the NTSB’s report stated what it did. “The flight crewmembers’ nonpertinent conversation during the taxi, which was not in compliance with Federal regulations and company policy, likely contributed to their loss of positional awareness…. The flight crew’s noncompliance with standard operating procedures, including the captain’s abbreviated taxi briefing and both pilots’ nonpertinent conversation, most likely created an atmosphere in the cockpit that enabled the crew’s errors” (NTSB, 2007, pp. 103-104). Quite simply, their cockpit conversations distracted them from successfully navigating to the correct runway. As one of my colleagues said during the NTSB’s board meeting, the crew’s head wasn’t in the game that day.
As you know, maintaining a sterile cockpit rule is a regulatory requirement for Parts 121 and 135 operators, but it is not required for Part 91 operations. It essentially prohibits
nonpertinent activities – those not required for safety of flight, including extraneous conversation – from being conducted during critical phases of flight, including taxi (FAA, 1981; FAA, 2014).
A good friend of mine will retire this year from a 34 ½ year career as pilot for a major airline. He once told me that the reason he followed the sterile cockpit wasn’t because it was a regulation – it was because he found it to be a great tool to help avoid distractions during critical phases of flight. I agree – during my flying career, I also found that maintaining a sterile cockpit was a tremendous attention control technique.
If you’re looking for additional ways to add to professionalism in your cockpit, practice and insist on maintaining a sterile cockpit – regardless of whether or not it’s required by regulations or company policy. It’s what professionals do. And, doing so is additional technique to ensure NTSB investigators don’t have reason to listen to your voice on a CVR.
References and additional reading
FAA. (2014) FAA regulations 14 Code of Federal Regulations 121.542 spells out the requirements for sterile cockpit rules for Part 121 operators at http://www.ecfr.gov/cgi-bin/text-idx?SID=9328626eaf04ffebf79b2cf69bc0b546&node=14:22.214.171.124.126.96.36.199&rgn=div8
FAA. (1981). FAA regulations 14 Code of Federal Regulations 135.100 spells out the requirements for sterile cockpit rules for Part 135 operators at http://www.ecfr.gov/cgi-bin/text-idx?SID=9328626eaf04ffebf79b2cf69bc0b546&node=14:188.8.131.52.184.108.40.206&rgn=div8
NTSB. (2007). Aircraft accident report: Attempted takeoff from wrong runway, Comair flight 5191, Bombardier CL-600-2B19, N431CA Lexington, Kentucky, August 27, 2006. (NTSB Report No. NTSB/AAR/07-05). Retrieved from http://www.ntsb.gov/doclib/reports/2007/AAR0705.pdf
Sumwalt, R. (1994). Accident and incident reports show importance of ‘sterile cockpit’ compliance. Flight Safety Digest, 13(7), 3-10. Retrieved from http://flightsafety.org/fsd/fsd_jul94.pdf
Honorable Robert L. Sumwalt III
Board Member, National Transportation Safety Board
490 L’Enfant Plaza SW
Washington, DC 20594