TonyC, I think that it is very easy to Monday morning quarterback events post incident. You seem to be putting the blame solely on the pilots. However, I think that there were many contributing factors that lead up to the crash and fault lies with many and not the few.
The term "contributing factors" is an interesting term indeed. The NTSB uses that term, doesn't it? Doctors use the term. Lawyers use the term. Sociologists use the term. What does it mean?
Do contributing factors make the outcome inevitable? Were those passengers doomed from the beginning because of contributing factors? How did Skywest 6819 manage to overcome the same contributing factors and find the correct runway just moments before? How did Eagle 882 escape the fate of the contributing factors and escape certain death?
Contributing factors are challenges that we meet each and every day. Would it be easier without them? Certainly. Can we survive despite them? Absolutely. Sure, it would have been nice if there had been no construction at the airport. Sure, it would have been nice if the airport diagram they had in their possession accurately reflected the present state of asphalt, concrete, mud, paint, and lighting. Sure, it would have been nice if the tower controller had devoted his undivided attention to providing progressive taxi instructions and eye contact to the Comair flight right up to the point where they should have begun their takeoff roll. Sure, lots of things could have been done better.
But, ultimately, the Pilot in Command is, as Doug so aptly stated, in COMMAND. HE, and HE ALONE, is responsible for the safe outcome of the flight. The Skywest Captain did it. The Eagle Captain did it. It obviously could have been done again.
Considering this is an aviation audience, I would hope that most readers would appreciate this concept. I wouldn't expect the grieving families of the dead passengers to understand these relationships, and I wouldn't be so insensitive to even discuss them with those family members. I don't expect lawyers to comprehend my job, so I wouldn't waste my breath trying to explain it to lawyers. But, as pilots, we MUST take the responsibility to heart. If we don't, or we can't, then we need to find another vocation, another hobby.
So, back to your question -- do I blame the pilots? Yes. Since we're pilots, we need to face that responsibility square in the eyes. Would I say that to a lawyer? No, he wouldn't "get it." Would I say that to a Comair 5191 widow? No, she doesn't need it, and it wouldn't help her.
As pilots, we need to get it, and it will help us.
Honest question TonyC, been wondering. Are you captain or FO on the DC-10? Which ever position you hold, is there casual conversation in the cockpit not related to work when you're taxiing? Or is it silence unless communicating with ground or tower?
Aww, you shouldn't have wondered, you shoulda just asked. Captain.
There seems to be some confusion about what a Sterile Cockpit is. Rarely does it mean silence. Conversation relates to the task at hand: taxiing the airplane. For starters, taxi begins with a "ritual" of sorts. After receiving taxi clearance and the First Officer acknowledging that clearance, I verbally state what I think to be our clearance. Everybody knows then what I understand to be the clearance, so they know what to expect of me. If there's the least bit of confusion, or disagreement, about the taxi clearance, we do whatever is necessary to clarify or verify before I even think about releasing the parking brake. Then, I look to the left to ensure the area around the airplane is clear, and say "Clear left." The First Officer looks to the right to clear the area I can't see, and says, "Clear Right." I turn on the taxi light, and release the parking brake. From that point until the brakes are set again, it's all business. When ATC gives us further taxi clearance, I read it back aloud so that the other crewmembers can hear what I say. They compare that with what they just heard on the radio, and correct me if I'm wrong. That way, they know what to expect from me, and they have a chance to help me correct a mistake before it happens. As we approach each intersection, I announce my intentions -- straight ahead, left turn, or right turn -- and announce that it's clear to the left. Nobody has to guess. Occassionally, I get it wrong -- no, it's the next left. Oh, you're right, thank you, OK, straight ahead here, and the NEXT left. If we approach an intersection where we're supposed to turn and I haven't announced my intention to turn, they can prompt me -- they don't have to wonder and wind up saying, "Well, I thought you were going to turn, so I didn't say anything." Perhaps we're more concerned about this than an airplane that can do a 180 degree turn on the taxiway. If he misses a turn, he can "fix" his mistake relatively easily. I can't back up (without a tug) and can't turn around on taxiways, so I have to get it right the first time. If we cross a runway, extra lights come on, I announce "Cleared to cross Rwy 27, Crossing Runway 27, clear left." All crewmembers are supposed to cease other duties and look outside while we cross the runway. I always look back at the Engineer just prior to crossing to make sure he hasn't gotten distracted doing some other important duty, and missed the fact that we're crossing the runway. If need be, I'll nudge him gently with a "Hey, John, help me cross the runway here, we'll have time for that after we cross." I try to plan checklists so that they're not interrupted by runway crossings so that we all devote our attention to those crossings.
Are we perfect? Certainly not. We're human. Have we ever seen an airplane over there and mentioned something about its livery, or wondered aloud why that AirTran 717 is sitting under the tent? Well, yes. It's there because he ripped the nose gear up while trying to taxi off the runway. Ooops. Oh, yeah, that's what we're doing, too. Taxiing. Part of my job is capturing errors, and making sure they don't become the proverbial weak link in the chain that led to failure. It's my job to get us back to the sterile cockpit concept, to make sure that we're focused on the job of taxiing. When we get to the end of the runway and have time to set the brakes while waiting for our turn, then we can talk about the AirTran 717. Otherwise, we save it for cruise.
Early in my Air Force career it was impressed on me that one's aviation career could survive many mistakes, but never a taxi accident. You might land gear up and get promoted, but if you bent metal while taxiing, you could kiss your career goodbye. I don't have data to prove that assertion, but I took it that seruiously. Even today I attach that much importance to driving the airplane around on the ground.
Early in my FedEx career I was jumpseating on a FedEx airplane, and while taxiing a long distance in the early morning, found myself engaged in a casual conversation with the 727 engineer. I don't think I started the conversation (I was too scared to interrupt, being a new guy), but I certainly didn't stop it. When the Captain announced, "Sterile Cockpit," I was a little startled, but the cockpit went immediately silent. Mind you, it was a simple taxi -- 2 miles south on a parallel, we were something like 15 or 20 in line playing follow the leader, how hard could that be? My first thought was, "Man, this guy sure is grumpy." After I got over the "What crawled up in his stuff?" attitude it occurred to me that he was right. We don't get to the point that we are so good that it doesn't apply to us anymore. The hazard doesn't go away when we get 5,000 hours under our belt. Whether we've been there 1 time, or a thousand times, the hazards still exist, and the responsibility still sits squarely on our shoulders. Would there have been ANY excuse if that Captain had accidentally taxiied into the back of the airplane in front of us?
Contributing factor: taxi light was partially burned out, and misaimed, so it didn't provide optimum illumination.
Contributing factor: airplane ahead made a sudden stop without turning off his taxi light to indicate he was stopping.
Contributing factor: Captain was tired, having operated from MEM to LAX the morning before, and having had his sleep interrupted by vacuuming outside his hotel room door, and having flown around a line of thunderstorms to get back to MEM, and having not gotten a sleep room during the hub turn because he was late, and ... well, he was just tired, but he wanted to move the freight
Three contributing factors, and there could have been more. Does that make the Captain only 70% responsible for the taxi accident? Nope. 100% responsible. If I can't deal with the challenges, I need to set the parking brake and go home.
Why even talk about this stuff? Why risk coming off like I'm Monday morning quarterbacking? Because I think there are valuable lessons to be learned. We can all afford to be reminded from time to time of things we already know, but can't afford to forget or ignore. My crew discussed this incident during dinner this past week, and we all agreed that we need to not foget how important it is to observe the sterile cockpit rule. If you think it's silly during taxi, then you'll think it's ridiculous during the last 1,000 feet of a climb or descent. We've been flying at FL310 for the last two hours, and talking about all kinds of things, and now we step climb to FL330. The last 1,000 feet of the climb might be at 800 fpm -- talk about a "long" 75 seconds. Conversation stops dead in the water, and doesn't continue until we see "ALT HOLD" in the Flight Mode Annunciators. Why? Because I don't want to miss a leveloff. What happens if for some reason the autopilot doesn't capture the altitude? Should I wait until I get another audible alert several hundred feet high? Should I wait until ATC queries us? What should I say on the ASRS ("NASA" form) report? Should I include the autopilot glitch as the "contributing factor"? What I would have to say is, "Captain failed to monitor progress of the flight to ensure autopilot captured the assigned altitude."
The First Officer I flew with this past week was senior to me, and has more experience in the DC-10 than I. The Engineer is an over-60 guy that last year was a very experienced DC-10 Line Check Airman. He has already forgotten more about flying than I could ever hope to learn. When we pass FL320 for FL330, who is responsible for pressing the PAUSE button on that conversation about restaurants in Indianapolis? All of us are supposed to observe the rule, but the Captain is ultimately responsible. "Well, it was the First Officer's leg, and the Engineer, who used to be a Line Check Airman, but was facing the panel and didn't notice the altitude, kept talking, and I didn't want to interrupt" won't work. Do I enjoy the long silence while the General Electrics claw through the atmosphere for the last 300 feet of the climb? Not really, but I find it's preferable to filling out the ASRS report, even in the convenient new on-line form.
Like SteveC said, it's up to us to glean lessons from others' mistakes. Save the fingerpointing and blamesharing for the lawyers -- let's just do our jobs correctly.
Sorry for the long-winded repsonse. I hope you found the answers you were looking for.
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