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A Crash's Improbable Impact
'82 Air Florida Tragedy Led To Broad Safety Reforms

By Del Quentin Wilber
Washington Post Staff Writer
Friday, January 12, 2007

On a snowy day 25 years ago tomorrow, co-pilot Roger Alan Pettit was at the controls of an Air Florida jetliner taking off from Washington National Airport. As the plane rolled down the runway, Pettit looked at his instruments. Something was wrong.

"God, look at that thing," he told the plane's captain, Larry Wheaton, apparently referring to an anomaly in engine instrument readings or throttle position. "That doesn't seem right, does it?"

Pettit repeated himself, but Wheaton ignored him, according to a transcript of the cockpit voice recording. The crew continued down the slushy runway. After lifting briefly into the air, the plane slammed into the 14th Street bridge, killing 78 passengers, motorists and crew members, including Pettit and Wheaton, on Jan. 13, 1982.

While most air disasters quickly become historical footnotes, aviation safety experts say few crashes have left a legacy as sweeping as Air Florida Flight 90. Though some of the lessons may seem simple, such as communication and management skills, it helped break down an authoritarian cockpit culture dominated by captains. Over time, the principles learned from the disaster gradually migrated to other modes of transportation and into businesses, even hospitals.

"This accident was pivotal because it helped draw attention to the fact that pilots need to communicate better," said Robert L. Sumwalt III, vice chairman of the National Transportation Safety Board and a former airline pilot who took off from National hours before the Air Florida crash. "This accident was ingrained in the minds of the entire world, and we watched the recovery efforts as they happened. I don't know of any other accident that has had this amount of impact on aviation but also in other industries."

The maritime and rail industries adopted lessons from the crash used to combat communication problems on ocean liners and in trains. Hospital executives became worried after an influential report in 1999 concluded that tens of thousands of Americans died each year because of medical errors. They began searching for ways to more easily avoid such errors. Some have turned to airline pilots.

"We are also in a high-risk environment," said Steve Smith, chief medical officer at the Nebraska Medical Center in Omaha. "The model of a surgeon being captain of the ship was very similar to the model in the cockpit many years ago."

In the months after the crash, the safety board and other regulators focused intensely on de-icing operations of Air Florida 90 in 20-degree temperatures during a snowstorm. Ice build-up can cripple an airplane's ability to fly.

The NTSB found errors in the way the way the plane was de-iced -- the crew even tried to reduce the build-up on their Boeing 737 by using the exhaust of a jet in front of them. That decision may have only worsened potential icing on the wings. Investigators believe that ice also covered critical engine probes, giving the pilots a false reading of the thrust needed for takeoff. Ice or snow on the plane and the lack of thrust likely caused the to crash, the board concluded.

As experts and airline executives digested the safety board's report, they began to more closely scrutinize other problems in the cockpit that day. It emerged that Pettit and Wheaton were emblematic of aviation's lingering cowboy culture, a residue of an era when fighter jocks from World War II and Korea flew for the airlines. In that gung-ho environment, captains were always right. They did not need advice, and co-pilots and other crew members often were afraid to assert themselves.

"It was a more romantic time frame when aviation, wasn't just a transportation system, but that needed to change," said Larry Rockliff, vice president of training for Airbus North America.

The industry was starting to tackle some of those communication and management problems in the United States, especially after the 1978 crash of a United Airlines jet in Portland, Ore. Other major air crashes had also raised alarms about the lack of communication in cockpits.

But some experts believe it took the spectacular crash of Air Florida in the Potomac to drill the lessons home and spur widespread use of what was then a revolutionary training regime, later to be known as Crew Resource Management.

Soon, airlines were teaching the Air Florida crash as a textbook example of what can go wrong when pilots do not communicate and listen properly. Students at Embry-Riddle Aeronautical University, many of whom are destined to work for airlines, study the crash. Even budding aircraft engineers at the University of Iowa review the accident so they can think of better ways to design systems to avert communications breakdowns.

At Embry-Riddle, in Daytona Beach, Fla., professors use the accident to highlight a litany of human errors made that day. They even evaluate how the crew went through the pre-flight checklist.

"Anti-ice," Pettit said, referring to a device that prevents icing of critical gauges in the engine.

"Off," Wheaton replied, almost as if he were sitting on a tarmac in Florida and not watching the snow through the windshield.

"The co-pilot was reading the checklist, and he reads the anti-ice item. But then he kept going," said Thomas Kirton, an Embry-Riddle professor, adding that the fateful moment serves to bring home to students the need to carefully consider all actions in the cockpit, no matter who is in charge.

Kirton also has students dissect the last words of the pilots: Pettit is trying to explain that something is wrong. Many experts believe that Pettit should have been more assertive and that Wheaton should have rejected the takeoff so they could determine what was wrong.

Kirton uses the comments to reinforce in his students that they need to forcefully tell captains that something is amiss in a way that cannot be ignored.

"You say: 'Captain Smith, I have a concern. . . . Do you agree with me?' " Kirton said. "If you are in the co-pilot's role, you have to be assertive without being offensive."

A similar ethos has moved into the hospital operating room. At the Nebraska Medical Center, surgical teams have begun to use checklists before each operation to ensure that they have the right patient, are conducting the right procedure and have given patients the appropriate medication. The last checklist item raised by the surgeon is meant to embolden team members to raise concerns, and it is the same one many airline pilots reiterate to their crews: "If anybody sees any red flags, something they are uncomfortable with, bring it to my attention."

Safety experts said evolution in the cockpit's culture, which now also includes listening more attentively to advice from flight attendants, has made aviation far safer. Still, experts say, the industry needs to keep pushing pilots to communicate effectively. The most recent major U.S. crash occurred in August after a regional jet's pilots tried to take off from the wrong runway. Next week the NTSB is scheduled to make public the reports on the crash. The board's investigation is expected to focus intensely on what went wrong in the cockpit that would have led the pilots to attempt taking off from a runway that was too short and not properly lighted.

In other instances, pilots acting and communicating quickly have averted disaster.

In June 2005, a US Airways Boeing 737 was hurtling down a runway at Logan International Airport in Boston when the co-pilot looked out the windshield and saw a wide-body jetliner heading on a collision course. Both jets had been cleared to take off at the same time on intersecting runways.

The co-pilot of the US Airways jet, James Dannahower, pushed down the yoke to prevent the pilot from taking off and told him to keep the plane on the ground. The Aer Lingus jet took off and flew safely overhead.

"He saw it out of his peripheral vision, and I trusted him," the pilot, Hank Jones, said.

Jones, who said the cockpit was too "autocratic" when he started flying in the 1970s, begins each trip with a briefing that involves the first officer and flight attendants. He tells them to alert him to anything that concerns them. As he was descending into Mobile, Ala., recently, the co-pilot did some quick math and told him that the tailwinds were too strong for his aircraft to land safely. The crew then diverted to another airport. "Little things can prevent big things," he said.

Staff researcher Richard Drezen contributed to this report.

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