— Captain A. G. Lamplugh
A chain of events, often called an error chain, refers to the concept that a number of contributing factors, rather than one single event, typically lead to an accident. Breaking just one link in the chain could yield vastly different results, which is exactly why pilots recognize the importance of following the rules, regulations and procedures that govern how they operate their aircraft. However, it's often overlooked that the chain of events begins long before a pilot steps into the cockpit.
|Continental Express Dash 8 Q400|
The February 2009 crash of Newark to Buffalo bound Continental 3407 (operated by Colgan Air) is a good example The accident has resurfaced in the news lately as the final results of the crash investigation recently went public and new FAA regulations designed to combat the root causes of the accident are soon to be enacted. The NTSB investigation of this accident identified a series of facts, events and actions by the crew and the airline that lead to the accident. All links in the chain. The flight crew failed to monitor airspeed. Both pilots failed to adhere to sterile cockpit procedures. The Captain had no hands-on simulator training to teach stall recovery techniques and the first officer complained of being sick and spent the entire night before this fateful flight commuting to work and napping on the floor in crew ops. Remove any of these from the equation, break the chain of events, and the end result might be quite different. But the link in the chain I'm focusing on today started the night before the accident.
The NTSB focused much of its attention on fatigue as a contributing factor to the crash. Records indicate that on the day of the accident, the captain logged into the company’s crew scheduling computer system at 3 am and 7:30 am, and that the first officer commuted to Newark on an overnight “red-eye” flight and sent and received text messages on the day of the accident. Should they have been resting during this time?
The pilots reported for duty at 1:30 pm on the day of the accident and the schedule called for Flight 3407 to take off at 7:45 p.m. and arrive in Buffalo at 10:21 p.m. While the flight was pushed from the gate at 7:45 p.m., the crew did not receive taxi instructions until 8:30 p.m. and the tower did not clear 3407 for takeoff at 9:18 p.m. At the time of the crash, both pilots were operating on very little sleep and had been on duty for 8 hours and 47 minutes. Not a particularly long duty day by any means, but both pilot's actions prior to sign-in, specifically the FO's commute, turned what should have been a normal day into a deadly one.---John Bradford
There but for the grace of God, go I...
There but for the grace of God, go I...
Since I got my first commercial pilot job in 1992 until now, I’ve commuted six times for a total of 5 years, 9 months between my home in Texas to pilot bases in Corpus Christi, Atlanta, Miami and St. Louis. Everyone who commutes does so for different reasons, but regardless of the circumstances, commuting is hard on everyone involved. But while it comes at a cost, commuting also affords a significant up side as it allows pilots to live just about anywhere, regardless of where they work. If you love Colorado, but you’re based in New York…great! Have your house in the mountains if you want, because all you have to do is drive to the nearest airport and fly to work for free. Pilots and Flight Attendants alike have what are known as reciprocal agreements with other airlines, so if your employer doesn’t fly from your city of choice to where you need to go, just hop on another airline…the ride is still free of charge. Also, if the flight is full, there’s an extra seat or two in the cockpit specifically provided for the FAA to observe pilots at work, but if the seat is not in use by the FAA, it’s available as an extra seat for a pilot on a full flight. Similar seats exist in the cabin for Flight Attendants.
My longest stretch as a commuter took place over a 4 year period when I was based in St. Louis, Missouri and lived in Dallas, Texas. After a particularly ugly merger just prior to an especially difficult time in history for the airline industry, I was forced out of my base in Texas and assigned a position in STL. The airline was shrinking and furloughing pilots at an alarming rate and I was unsure whether my job would exist next month much less next year. Pilots were engaged in what we commonly referred to as a “death march” in which we were repeatedly displaced from one base to another before being furloughed. In my case, I first expected to be displaced to STL. After a few months in STL, I expected to be displaced to New York, our junior base. A few months later I fully expected to be furloughed from the company all together. With deep roots in Texas, a nice home, a good school for the kids and a support structure if things got worse, I elected to commute.
For a typical three day trip, I usually flew a sequence that signed in around noon on the first day, which meant I could commute to work on the same day my trip was scheduled to start. This kept me from having to travel on a day off, but it also meant that I was already well traveled and tired when I signed in for the first leg of my trip. The first flight from Dallas to St. Louis left around 6am and I could put my name on the standby list using an online check-in system 4 hours before departure at 2am. I did my best to get in bed early and get a good night’s sleep, but with young children in the house and a wife who likes late night TV, you can imagine how that went. In spite of my efforts, I rarely made to bed before 10.
When traveling as a non-revenue passenger, the seats in the cabin are first come first served. In other words, the first person on the standby list gets the first seat and if there isn't an open seat at departure time, you don't go. There was always a lot of competition for seats, so it was important to get my name high on the list. I would be at my computer with everything loaded just waiting to hit enter at exactly 2am. I had my watch set EXACTLY to company time so I wouldn’t be more than a few seconds off. I would hit enter at exactly 2am and hope for the best. Usually, there would be at least 4 or 5 names on the standby list during the first 30 seconds we were allowed to sign up. Timing was everything.
After putting my name on the list, I would go back to sleep until I had to get up to start my commute. So let me think out loud while I do the math…flight leaves at 6…be at the airport by 5…leave the house at 4…I’m a diva and I like to have 45 minutes to get ready, so…set the alarm for 3:15 and go back to sleep. That’s right, I slept from 10pm to 2am then from about 2:15 until 3:15 if I was lucky…that’s not much rest to prepare for what could be a very long day, but it’s what I did almost every time I commuted to work.
Once at the airport, the stress of commuting was just beginning. When I arrived at the gate, I would assess the competition. The flights to STL were almost always full, so seats in the main cabin were scarce and difficult to get. As I mentioned before, the seats in the cabin are first come first served, but the aforementioned cockpit jump seats are awarded in order of seniority. So, I would find the other pilots (there were usually at least 3 of us at this point) and compare numbers to see who was going to get the cockpit seat and who would be crossing their fingers in hopes that some paying passenger forgot to set his alarm.
As a direct result of the commute, the first day of a trip was almost always the most difficult. I remember telling myself if I could just get through this first day and get a good night’s sleep at the layover hotel, the rest of the trip would be easy. I remember one trip in particular that I flew with some regularity. I would start my day with the commute described above and a sign-in time in STL sometime around noon. My first flight was from STL back to Dallas at around 1pm. After a short break, the second leg was a flight from Dallas to Chicago with another short sit before the third and final leg to Seattle. Day one was a 13 hour duty day that ended in Seattle at about 1am body time…and that’s only if everything went as planned. Add bad weather, maintenance and equipment delays to the mix and things could get much worse.
In hind sight, I’m not proud of days like that. I think I owe the flying public and my fellow crew members more of myself. I rationalized my actions by convincing myself it was all in the name of normalcy for my wife and kids. It was a significant hardship, but the truth is, it was a choice. Furthermore, the trip I described above wasn’t my worst, just an average commute. Many were far worse and a few were a little better.
Continental 3407 crashed at 10:47 p.m. Feb. 12 while on approach to the Buffalo, New York. The plane, flying in an ice storm, pitched up violently as it neared a stall, then rolled over and crashed. There were many links in the chain that led to this accident, but according to the NTSB, one contributing factor was the First Officer’s commute. FO Shaw had flown a "red-eye" flight to Newark before Flight 3407 and allegedly spent no time in bed the night before the accident. She can be heard on the cockpit recordings complaining about fatigue, congestion from a cold and saying she should have called in sick. One link in an intact chain of events.