AS IN ALL THINGS, OPENNESS:

A Crash's Improbable Impact: '82 Air Florida Tragedy Led To Broad Safety Reforms (Del Quentin Wilber, January 12, 2007, Washington Post)

On a snowy day 25 years ago tomorrow, co-pilot Roger Alan Pettit was at the controls of an Air Florida jetliner taking off from Washington National Airport. As the plane rolled down the runway, Pettit looked at his instruments. Something was wrong.

"God, look at that thing," he told the plane's captain, Larry Wheaton, apparently referring to an anomaly in engine instrument readings or throttle position. "That doesn't seem right, does it?"

Pettit repeated himself, but Wheaton ignored him, according to a transcript of the cockpit voice recording. The crew continued down the slushy runway. After lifting briefly into the air, the plane slammed into the 14th Street bridge, killing 78 passengers, motorists and crew members, including Pettit and Wheaton, on Jan. 13, 1982.

While most air disasters quickly become historical footnotes, aviation safety experts say few crashes have left a legacy as sweeping as Air Florida Flight 90. Though some of the lessons may seem simple, such as communication and management skills, it helped break down an authoritarian cockpit culture dominated by captains. Over time, the principles learned from the disaster gradually migrated to other modes of transportation and into businesses, even hospitals.

"This accident was pivotal because it helped draw attention to the fact that pilots need to communicate better," said Robert L. Sumwalt III, vice chairman of the National Transportation Safety Board and a former airline pilot who took off from National hours before the Air Florida crash. "This accident was ingrained in the minds of the entire world, and we watched the recovery efforts as they happened. I don't know of any other accident that has had this amount of impact on aviation but also in other industries."

The maritime and rail industries adopted lessons from the crash used to combat communication problems on ocean liners and in trains. Hospital executives became worried after an influential report in 1999 concluded that tens of thousands of Americans died each year because of medical errors. They began searching for ways to more easily avoid such errors. Some have turned to airline pilots.

"We are also in a high-risk environment," said Steve Smith, chief medical officer at the Nebraska Medical Center in Omaha. "The model of a surgeon being captain of the ship was very similar to the model in the cockpit many years ago." [...]

As experts and airline executives digested the safety board's report, they began to more closely scrutinize other problems in the cockpit that day. It emerged that Pettit and Wheaton were emblematic of aviation's lingering cowboy culture, a residue of an era when fighter jocks from World War II and Korea flew for the airlines. In that gung-ho environment, captains were always right. They did not need advice, and co-pilots and other crew members often were afraid to assert themselves.

"It was a more romantic time frame when aviation, wasn't just a transportation system, but that needed to change," said Larry Rockliff, vice president of training for Airbus North America.

The industry was starting to tackle some of those communication and management problems in the United States, especially after the 1978 crash of a United Airlines jet in Portland, Ore. Other major air crashes had also raised alarms about the lack of communication in cockpits.

But some experts believe it took the spectacular crash of Air Florida in the Potomac to drill the lessons home and spur widespread use of what was then a revolutionary training regime, later to be known as Crew Resource Management.

Soon, airlines were teaching the Air Florida crash as a textbook example of what can go wrong when pilots do not communicate and listen properly.

So, Intelligence is pretty much the last wholly closed endeavor? With predictable results...

Posted by Orrin Judd at January 12, 2007 1:21 PM