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Safety Snapshot: Generation Clutter

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As the father of two teenagers who by all indications have never met a consumer product they can put away in its proper place (a recent picture of my 16-year-old’s closet above), I have a bad feeling about the kinds of clutter that might muck up cockpits when members of this generation become pilots.  

This is a malady the UK’s Military Aviation Authority (MAA) is already getting familiar with. My colleague Tony Osborne describes a harrowing February 2014 incident caused in part by cockpit clutter and untidiness in a recent article. Here are the highlights:

  • Royal Air Force captain finds himself alone in the cockpit of an A330-200 Voyager tanker/troop carrier in the boring cruise portion of a flight; tinkers with digital SLR camera, taking 28 pictures of this and that. Captain puts camera down between his left armrest and side-stick controller when purser comes into the cockpit for a chat, then soon after the captain adjusts the seat forward, apparently forgetting about the camera
  • As the seat moves, the armrest pushes said camera into the base of the side-stick, kicking the auto-pilot off and sending the Airbus into a screaming dive toward the ground (recreation of the blunder pictured below - credit UK MAA)
  • The Airbus’ self-protection systems saved the day by keeping the aircraft put together while the camera somehow got dislodged
  • Click here to see the final report

While from the outside looking in, anyone could have easily looked at the forensics and called this a one-off, bumble-headed mistake, a closer look revealed a chain of events that started at least a year before. And like my sons’ rooms, that chain is littered with all kinds of stuff not put in its proper place.

Excerpts from the MAA report (some in my own words)

  • An Air Safety Occurrence Report issued 11 months before the incident showed concern in the C-130 fleet, where a “growing body of reports” were being received from C-130 engineers describing how “numerous aircrew items were being left on flight decks at the end of flights,” none of which were reported missing. Over a three-month period, the litter included: five personal oxygen masks, one aircrew knife, three sets of spectacles plus cases, two night vision goggle (NVG) eyepiece covers, seven NVG helmet counterweights, and six folders or notebooks
  • The RAF at the time determined that the problem was limited to the C-130 fleet (the Voyager investigation later proved that to be untrue….) and the “issue was highlighted” with pilots. No word on the age of this group, but I would imagine fairly young
  • Despite the focus, loose articles continued to be reported. During the month of October 2013, the leftovers included: two NVG batteries, one set of spectacles, one mobile phone, one finger-torch pouch, one NVG helmet counterweight, one set of flight reference cards, two maps and one jacket. None of the items found had been reported missing by crews.

The Voyager incident investigation panel “saw and heard evidence” that the problem was not limited to the C-130s. One of the problems for the A330 pilots was the amount of kit they were required to take on trips. Included: two sets of body armor each, combat survival waistcoats, crew weapons, aircraft documentation, two route bags, a set of worldwide navigation kit and charts and a bag of classified materials. Only some of the items had designated storage, the rest was ad hoc.

With that much required equipment, the panel came to realize pilots bringing along “a small number of personal effects would not have seemed unreasonable.”

A picture the captain took of the co-pilot's workspace several minutes before the incident, annotated by the MAA, illustrates the kind of clutter that was status quo for such a cockpit.

The panel found no evidence of “official guidance or training” on what was allowed or where it should be stored or placed during a flight, which led pilots to “develop their own norms and practices” as a result of experience and advice from others. Critically, the panel found that the “area around the side-stick appeared to be treated no differently than to any other surface on the flight deck,” aka, an accident or incident waiting to happen.

And more incidents did happen after the Voyager dive, even after the MAA issued safety advice highlighting the risk of side-stick interference. In June 2014, four months after the dive, two reports emerged –- a documents folder had slipped from the pilots’ tray table and made contact with the side stick, disconnecting the autopilot and causing a master warning; and a pilot whose leg inadvertently knocked against the side stick. In both cases the autopilot was immediately reengaged without the aircraft deviating from its flight path, according to the report.

While the RAF is now finally putting fixes in place, I have to wonder if the true fix will have to start way back in the teen years, on desks and in the closets of kids with too many gadgets and parents with too few organizational (or kid management) skills.

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