The phone rang shortly before 7am on a Sunday morning. I had been sworn in as NTSB vice chairman just seven days earlier and I certainly didn’t think such a call would come so soon in my tenure. “Vice Chairman Sumwalt, please stand by while we connect the NTSB Chairman,” said the solemn voice from the NTSB’s 24/7 response operations center.
In that brief conversation, the NTSB chairman told me the grim news: About an hour earlier, an airline crash occurred in Lexington, Kentucky. The aircraft was still burning. Multiple fatalities were suspected. I should meet the NTSB Go Team at the airport and fly to Kentucky with them in a government jet.
Before our plane had even departed Washington, the pictures on CNN made clear what happened. For yet to be explained reasons, the pilots had attempted to depart on a runway that was too short. From the TV clips, it was clear that the CRJ had run off the runway end and traveled through the airport perimeter fence. From there, it struck trees and burst into flames while sliding to a stop. Of the 50 occupants onboard, only one survived.
The NTSB’s 11-month investigation revealed nonstandard checklist usage and sterile cockpit violations, along with lax cockpit attitude. On two occasions, the captain told the first officer--one whom he hadn’t flown with before--“I’m easy buddy.” Several times the captain instructed the first officer to initiate a checklist “at your leisure,” rather than calling for the checklist himself, as specified in the airline’s procedures. His pre-taxi briefing of the planned taxi route was inadequate and not in conformance with company requirements.
During taxi-out, both pilots continued chatting about irrelevant topics--a violation of the FAA’s sterile cockpit rule. NTSB concluded that this rule violation “likely contributed to their loss of positional awareness.” NTSB also found the abbreviated taxi briefing and noncompliance with standard operating procedures “most likely created an atmosphere in the cockpit that enabled the crew’s errors.” Quite simply, the crew was not performing as professionals. Professionals don’t intentionally violate safety regulations.
There were others where the NTSB noted lack of professionalism. There was the CRJ crew that endured a high-altitude stall and flamed out both engines on a nighttime ferry flight. The young crew evidently decided that since it was just the two of them, they would “have a little fun,” as they told ATC prior to things going sour. Post-accident analysis reveals that the crew performed several unauthorized actions before the upset, including intentionally causing the stall warning system to activate on three occasions, imposing dangerous sideloads on the aircraft’s tail structure by intentionally mishandling the rudder, swapping seats in flight (against airline policy), along with a series of other serious errors. Unfortunately, the crew was unable to restart either engine. They paid for this behavior with their lives.
The probable cause, as determined by NTSB, was, in part: “the pilots’ unprofessional behavior, deviation from standard operating procedures, and poor airmanship, which resulted in an in-flight emergency from which they were unable to recover…”
The week following that crash, a Jetstream J-3201 crashed on approach into Kirksville, Missouri. This CFIT crash claimed 13 lives. “The pilots’ nonessential conversation below 10,000 ft. msl was contrary to established sterile cockpit regulations and reflected a demeanor and cockpit environment that fostered deviation from established standard procedures, crew resource management disciplines, division of duties and professionalism, reducing the margin of safety well below acceptable limits during the accident approach and likely contributing to the pilots’ degraded performance,” concluded NTSB.
I later met a relative of one of the pilots. She expressed that sadly, he likely would not be remembered as the great person and skilled pilot that she said he was. Instead, his legacy would be tarnished by conduct on that flight. That’s certainly not the way any professional wants to be remembered.
Then there was the Gulfstream G-IV crew that attempted to takeoff without releasing the flight control gust lock. Procedures that should have caught this before advancing the throttles, such as performing a flight control check before takeoff and completing the checklist, were not done. All seven onboard died that spring evening. As if that wasn’t alarming enough, NTSB determined that the crew hadn’t done a complete flight control check in 98% of the previous 175 flights. It gets worse: A follow-on study by NBAA found that of the 143,756 flights evaluated using FOQA data, 17.6% of those flights did not have the manufacturer-required, checklist-directed flight-control checks before takeoff. “This report should further raise awareness within the business aviation community that complacency and lack of procedural discipline have no place in our profession,” stated NBAA’s Ed Bolen.
I know firsthand how disheartening it is to listen to a CVR where joking, laughing, off-hand comments and sterile cockpit violations are heard right before the crash. Even more difficult, however, is explaining to the pilots’ family how their loved one’s casual attitude led to the crash.
Some of the above-mentioned accidents happened 17 years ago, and many of us remember them well. However, there’s a new generation of pilots now entering training and the workplace. Many of these new pilots were less than 10 years old when some of these accidents occurred and, therefore, may not be familiar with the hard lessons they contain. As mentors, we have an obligation to model good behavior by following procedures, insisting on proper checklist usage, and exercising professional flightdeck discipline. Don’t hesitate to point them to these accident reports. The story they tell is powerful: Professionals do the right things, even when no one is watching.
Remember this--all that matters to the people sitting in the back of your airplane is that you get them safely to their destination. That’s what they’ve paid for--they rightfully deserve and expect that each and every flight will be conducted with utmost precision and professionalism. Insist on it. Accept nothing less. That’s what professionalism is all about.
Robert Sumwalt was a member of the NTSB from 2006-21, including being chairman from 2017-21. Before he managed a corporate flight department for a Fortune 500 company, and previously was a pilot for US Airways and Piedmont Airlines.
