Luke, a gentile (non-Jewish person) and physician, and close friend of the apostle Paul, wrote the gospel of Luke and the sequel to it, the book of Acts, during A.D. 61-64. Acts picks up where the gospels left off, and documents the rapid growth and events of the early Christian church after the resurrected Jesus Christ, in bodily and glorified form, appeared to many disciples and followers.
What occurs in the book of Acts is exactly what one would expect from resurrection witnesses empowered with a conviction of the mind and the presence of the Holy Spirit (which Jesus promised them). The apostles act boldly, teaching, preaching, performing miracles, and endure much persecution, suffering, and dying for God‘s glory. The church grows rapidly as a result.
Here are just a few events in the book of Acts: the outpouring of the Holy Spirit comes at Pentecost; the gospel is preached to the Jews and the Gentiles; the church grows rapidly in spite of resistance and persecution of it; Saul (a zealous Jew who persecutes Christians) is met by a blinding Jesus on the road to Damascus, believes, and is renamed Paul; and Paul and others go on missionary journeys as far as Greece and Rome.
Acts is certainly a book of action, and a perfect sequel to the gospels. It’s an historical ‘gut-check’: it’s stories and history are evidence for an affirmative answer to the question ‘did Jesus really rise from the dead?‘ Instinctively, it makes sense. The followers of ‘The Way’ wouldn’t have been willing to endure the persecution and suffering they did if the resurrection wasn’t true.
Christians pronounce that Jesus is risen: we say it and believe it, but do we keep it hidden? Do we act like we really believe it so others can see our faith? The stories in Acts can be used as evidence of the new church’s knowledge of the truth, resulting in the bolstering of one’s faith in Jesus.
I’m reading through Acts this month, and am behind the reading schedule in my Bible. So often it seems things don’t happen on my schedule, they happen on God’s schedule. But that’s the way it should be. After a week of good vacation and getting the taxes done, I’m having an enjoyable three day trip in sunny weather. It’s the third morning in Jacksonville, North Carolina, and I’ll be flying OAJ-CLT-LEX-CLT-DCA today (Charlotte, Lexington, and Washington).
We had an overnight in Lexington the first night of this trip. I liked it there, it was lushly green, with absolutely beautiful tree lined, hilly horse farms and meadows, complete with painted wooden fences. The folks are friendly there with true southern hospitality, and I had a good jog over to the nearby ‘UK’ (University of Kentucky).
However, in spite of the niceness of Lexington, I can’t go there without thinking of the tragedy of Comair 5191, on August 27, 2006.
The Delta Connection flight to Atlanta attempted to takeoff on 3,500 foot long runway 26, instead of 7,003 foot long runway 22. Forty-nine out of fifty souls on board died after the jet struck a fence and trees while struggling to get airborne beyond the short runway.
They attempted takeoff on the wrong runway because the Captain steered the jet onto it by mistake. The taxiway route to the runway offered the crew an opportunity to take a left turn at two locations. The first left turn was onto the ill fated short runway, the second left turn, a little further down the taxiway, was onto the correct runway.
It can be argued that there were many contributing factors for this accident. The control tower controller didn’t watch their takeoff attempt, information about the airport wasn’t supplied appropriately to the crew, the layout of the taxiways and runways could potentially trick pilots into using the wrong runway, the Captain didn’t get good rest the night before, and the crew engaged in non-essential conversation while the plane was taxiing. However, in spite of all these factors, in the end it was the pilots responsibility to make sure they were taking off on a runway that had adequate length.
What prevented either pilot from noticing they were on the wrong runway? Apparently, they didn’t check that the magnetic direction the plane indicated while on the runway was the same direction of their intended runway for takeoff (260 degrees instead of 220 degrees). More fundamentally and less technically, apparently they didn't do a gut check: they didn’t ask internally or to the other pilot ‘does this feel right, is everything OK?’ Professionals in all fields of work perform ‘gut-checks’ routinely. ’ Experience is the best teacher’, and it teaches them to safeguard their work just by being aware and sensing when something is amiss and out of the ordinary. Gut checks are vitally important when operating at less than full mental capacity, as when fatigued, distracted, or both.
The paradox is that at the very time when it’s most critical to maintain a good situational awareness, when fatigued or distracted, is the very time when it’s most difficult to do so. I know this from experience.
The two most humbling mistakes (and they were very humbling) I’ve made in my airline career have occurred while I was taxiing the plane on the ground, and I believe they happened in part because I didn’t perform a gut-check. I wasn’t able to because I was tired and fatigued, rushed, and too distracted in non-essential (to the flight) conversation with my Co-Pilot on the ground. In the industry this is known as ‘violating sterile cockpit’, and it is big on the FAA’s hit list. Airline pilots are to observe a sterile cockpit - no conversation that doesn’t pertain to the safe operation of the flight - anytime the plane is moving on the ground or anytime below 10,000 feet in flight.
Applying this line of thought to this accident, I believe that short term fatigue and distraction from violating sterile cockpit helped to prevent this crew from taxiing to the correct runway, and to prevent them from aborting the takeoff before it was too late.
I examined the cockpit voice recording transcript briefly, and the crew (mainly the First Officer) did ‘violate sterile cockpit‘, but not to a gross extent, in my opinion. However, lack of focus is possible when distracted by emotion or thought about a non-essential conversation, even if its a short one. I have seen this occur to me numerous times, and I believe it is one of the main considerations for the sterile cockpit rule. What I mean is that’s how I think the mechanism works: while a mistake can occur during the moment sterile cockpit is violated, it can also occur afterwards. Non-essential conversation can induce a type of lingering distraction to pilots during a period of flight operations that is critical to the safety of flight.
I mentioned fatigue as another characteristic which reduces the ability to maintain situational awareness. Unfortunately, the Captain of the accident flight didn’t get good rest the night before, due to his wife and two infants spending the night in the hotel with him. He complained on the CVR about his lack of sleep to his Co-Pilot. I was fatigued when I had both of my problems aforementioned on the ground, the first after a short night of sleep after commuting in to my base for an early showtime, and the second after a long duty day full of schedule changes. When fatigued, one simply doesn’t have the ability to perform to the same level as when not. Slowing down the pace at which one completes tasks and adhering to SOP’s (standard operating procedures) are two ways to counteract the effects of fatigue.
This accident, like other airline accidents and incidents recently, exhibit symptoms of a lack of flight discipline, which stems from a lack of professionalism. Frankly, others I've talked to are like me, we never expected Comair, a regional airline whose pilots always had a reputation for being true professionals, to have an accident like this. If Comair could have this accident, any regional airline could. This problem of a lack of professionalism is endemic in our industry, and it seems to be difficult to get across to all pilots the insidiousness of it. The negative reaction seen at times involves an impulse to blame airline management for poor schedules and reduced pay, instead of examining their own personal standards of professionalism and flight discipline. Poor schedules and reduced pay are problems the pilot unions continue to battle to win improvements on, but these issues are no excuse to absolve pilots from their duty and responsibility to safely transport the flying public with the highest standards possible.
OK, short rant over. In review, fatigue and distraction both reduce pilots ability to ‘trap errors’ and perform a gut-check. Performing a gut-check is good thing to do in aviation or any industry:
- be in tune to your instincts, trust them, and follow them
- when fatigued and/or distracted, the ability to perform a gut-check is diminished
- when fatigued and distracted is the time when SOP’s are the most important to follow to the letter. Adhering to a checklist, callout, or procedure when fatigued and/or distracted makes it more likely than otherwise that a critical item won’t be missed.
I got a little academic, but this is the way I see it, and I make no apologies for it. The opportunity to learn and lessen the likelihood of more tragedy and loss of life makes it worthwhile. Thanks again for reading my blog.
PS: In case you're curious, I continue to battle against fatigue and distraction I encounter on the flight deck. After I've made mistakes of the type which in the past I would point to others and say quietly "I could never do something that silly", I operate more conservatively and with better flight discipline than I ever have as a pilot. I still learn new things about the airplane and how to better perform my job, and I hope I always will.
