Professionals do the right things, even when no one is watching.
IMPACT
The phone rang shortly before 7 a.m. on a Sunday morning just seven days after I had been sworn in as NTSB vice chairman. I certainly hadn’t expected that 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 1 hr. earlier, an airline crash had occurred in Lexington, Kentucky. The aircraft was still burning. Multiple fatalities were suspected. I was to 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 had 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 apparent that the Bombardier 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—with 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 out 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. The NTSB concluded that this rule violation “likely contributed to their loss of positional awareness.” The 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 have been other cases in which the NTSB has noted a lack of professionalism. In one, a CRJ crew was faced with 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 air traffic control before things went 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) and 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 the 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 accident, a Jetstream J-3201 crashed on approach into Kirksville, Missouri. This controlled flight into terrain 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 the 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 the conduct on that flight. That’s certainly not the way any professional wants to be remembered. Then there was a 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 weren’t alarming enough, the 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 the NBAA found that of the 143,756 flights evaluated using flight operations quality assurance (FOQA) data, the manufacturer-required, checklist-directed flight-control checks had not been conducted before takeoff on 17.6%. “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 the NBAA’s Ed Bolen. I know firsthand how disheartening it is to listen to a CVR recording in which 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 ones’ 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 not even 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 flight deck 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 2006-2021, including being chairman from 2017-21. Before that he managed a corporate flight department for a Fortune 500 company, and previously was a pilot for US Airways and Piedmont Airlines.
