THE PLANE CRASH DIARIES
How the Brain Crashes Airplanes: The Short Flight of NWA 255
How could the pilots make such a stupid mistake? Blame their brains.
The story of Northwest Airlines Flight 255 starts, like so many catastrophes, with a minor annoyance. It turns out that’s all it takes to turn your aircraft into metal confetti scattered across half a mile of Michigan highway.
Welcome to 16 August 1987, nine days before I was born. It’s nearly 8:30 p.m., and it’s not a good time to be an airplane. If you tune into Detroit’s CBS affiliate right now (VHF Channel 4, if you’re a time traveler), you’ll catch Murder, She Wrote right at my favorite part: the investigative hijinks.
This evening’s summer rain comes late to Detroit Metro, the primary airport for Michigan’s largest city and one of the busiest in the country. As if by way of apology, the clouds open up with a vengeance. Rain continues to fall with hammering force, the bulging bellies of coal-black clouds upended onto the runways below. An incoming pilot reports a dangerous microburst at one end of the airfield. The airport’s wind shear alerts fire repeatedly in agreement. Down on the tarmac, droplets splatter down on wings and windscreens, their yammering enough to make you raise your voice, even in the cockpit.
The the twin-engine MD-82 is loaded and ready to depart. All that stands between the pilots and liftoff is a runway assignment and clearance from a air traffic controller. But they’ve been waiting. And waiting. And waiting. NWA 255 is already thirty minutes behind schedule, and it only looks like things are getting worse.
Inside the cabin of Northwest 255, Captain John Maus and First Officer David Dobbs peer out their windscreen at the curtain of rain. In my imagination, they are visibly dissatisfied. There’s nothing to be done, but the delay this weather brings weighs heavily on the minds of our pilots. Every delay does, but weather delays are especially quarrelsome. The pilots must be anxious to get in the air in the same way TV dads are eager to start a road trip.
This is a perilous attitude for flying an aircraft, and the conversation the two pilots indulge in only makes things worse. The the cockpit voice recorder, or CVR, transcript describes it dryly as “nonpertinent social conversation” with a flight attendant, but the scuttlebutt is that they were discussing the “mating habits” of the flight crew, the female flight attendant especially implicated.
On some level, we can’t blame them. Nonpertinent social conversation a known coping response in humans to encountering shared stressful conditions, especially those that can’t be controlled: we naturally seek to talk amongst ourselves. There’s something about it that soothes us, blows off our accumulating steam.
But it’s also very against the rules. The pilot’s conversation is in direct contravention of the FAA’s “sterile cockpit” rule: shut up below 10,000 feet, that includes the ground. Anything below 10,000 feet is a dangerous stage of flight requiring a high cabin workload, and pilots can’t afford to be distracted by conversations during those times. We know this because we’ve seen what distracted pilots do.
What Distracted Pilots Do
The pilots spend the rest of the time they sit on the apron waiting for taxi clearance focused on how the predicted bad weather in their flight path later that evening will affect their plans. Will they get airborne on soon? What airport will they be able to land at? What are their diversion options? Where is that in the flight computer? What’s my first name again? (Not kidding about that last one!)
Planning their route remains the pilots’ sole focus for more than fifteen minutes. Attention is a finite (if renewable) resource, and by the time the pilots were done figuring out their travel plans, they had little attention left in the tank for their primary task of actually preparing their aircraft for takeoff.
Further stressors gnaw at the pilots attention as they await their runway assignment. “On hold” waits like this, that require paying attention, are especially fatal to human focus even without the attentional deficit the pilots were already suffering. So while they wait, the pilots indulge in that most ancient stress management technique, making wise-cracks at the expense of a ground controller when they ask a different pilot for the heading of the earlier-reported microburst, which sort of implied the microburst was a dangerous fugitive someone was going to pursue. “Last I saw, it was headed eastbound,” quips First Officer Dobbs in response, “at Mach three!”
But perhaps the most haunting thing the CVR captures is one breezy assessment tossed out by a flight attendant: “Takeoffs are boring.” Usually, they are.
But by 8:33 p.m., the aircraft is finally pushed back from the gate. The pilots have one engine already spinning, ready for their drive, or taxi, to their expected runway, number 21L. Right now, the pilots are working to perform the necessary checklists to prepare the airplane for flight.
That’s when they get interrupted.
Interruptions are both a fact of life in the cockpit and incredibly dangerous. Based on studies of checklist management, there’s one fatal error that interruption causes again and again—pilots tend to resume their tasks incorrectly, skipping necessary steps.
The is exactly what happens to the pilots of NWA 255. When the call comes in their runway assignment at 8:34 p.m., it interrupts their checklist process with an anomaly: it’s not the runway they were expecting. Instead of using Runway 21L, the pilots must now take off from Runway 3C, a significantly shorter runway.
This sounds like a minor problem, but it actually throws a huge wrench in the works. With this new runway assignment, workload and time pressure both suddenly increase dramatically. The pilots will have a shorter taxi to their runway, meaning more work has to be done in less time. And there’s nothing quite like that to clear your mind—for better or for worse.
Checklists forgotten, the pilots now work to complete a substantially larger workload than expected. They will never get the time to return to their previous tasks, which include the essential TAXI checklist. Among other steps required to prepare the plane for takeoff, the first item on the TAXI checklist is setting the flaps.
But now, the pilots are slammed. They must hurriedly start up their other engine (only one had been running in anticipation of the longer taxi, a standard fuel economizing procedure) while First Officer Dobbs rushes to recalculate their takeoff speeds based on the new, shorter runway and reprogram the flight computer with the new values.
It gets worse. Distracted by their rising workload, the pilots get lost in the rainy murk while trying to locate their taxiway. Already well behind schedule, the pilots need to beat this storm in their travel plans have any hope of success. While they do eventually find their way, embarrassment must pile on stress, even further lowering the pilots’ cognitive resources. They’re ready to get going at all costs.
This kind of thinking is so dangerous, we admonish new pilots against it. Called “hurry-up syndrome,” it occurs any time a pilot is too focused on their goal to pay attention to the steps leading up to it. The deadliest aviation disaster to ever occur, the Tenerife collision, was caused by exactly this kind of deadly thinking.
But to be fair, I’ve always thought taxiway signs are really small, and it is “blacker than [hell] out there,” according to Captain Maus. But focused on navigating the benighted airport and updating their flight plans, neither pilot is doing what they’re meant to be doing at this point in the flight: preparing the plane for takeoff. This is when they’re supposed to be performing the TAXI checklist, which includes that all important flaps setting. But there is no indication on the CVR that the pilots ever realized they had neglected it, or even had time to realize they could have.
But at long last, they arrive, if 45 minutes late. By 8:41 p.m., Northwest 255 waits at the end of Runway 3C, engines idling for takeoff. At 8:44 p.m., their takeoff clearance comes through. Anxious to be airborne, Captain Maus immediately throttles up and starts his takeoff roll.
Distracted by weather, delays, conversation, and a late-breaking runway assignment, the pilots have missed something incredibly important.
They haven’t set the flaps.
Preparing for Takeoff
Flaps sound goofy, but they’re a crucial part of the aircraft’s ability to get and stay airborne. You’ll find them on the trailing edge of the wing, small adjustable wing portions that help shape the air flashing over the wings, providing the right mixture of lift and drag for the required flight characteristics. If you’ve ever flown in the emergency exit row and heard a noise like a slow-motion Transformer as the aircraft rose through into the air, you’ve heard the flaps moving from 15 degrees to zero, from takeoff to cruise.
Set to droop down from the trailing edge of the wing at a precise angle, the flaps scoop up lift from passing air when extended. For a demonstration, imagine your cupped hand out the window of a car driving at highway speeds. The flaps “bend” the wings in the same way, temporarily increasing its aerodynamically usefully area and producing more lift.
With the flaps retracted — a low-lift/high-efficiency configuration pilots call “wings clean” — it’s physically impossible for a large, heavy plane like 255 to get airborne.
Our pilots have no idea. They’re still rolling down the runway. The takeoff warning system, TOWS, should be alerting them to the misconfiguration of the wings for takeoff. It was created to prevent situations just like this, sounding an alarm when the plane isn’t set up properly for liftoff. But investigators would later make a chilling discovery: MD-82 pilots routinely disabled this warning system by disabling a circuit breaker behind their seat. During single-engine taxis, like the one our pilots attempted, the system often triggered false alarms. So pilots unplugged it. Oops.
Our pilots also pass up another opportunity to save their lives when First Officer Dobbs notices the autothrottle, which is supposed to hold the two engine throttles in place at takeoff thrust, won’t properly engage. It’s because their airplane’s flight computer isn’t in the right mode — setting the flight computer mode is another step on the TAXI checklist. Despite both pilots noticing the autothrottle’s failure and correctly identifying the problem as they roll down the runway, neither seems to wonder why the computer hadn’t been set properly. Had they put these two facts together, no one would have died.
But they do not put these facts together. At 20:44:57.1, First Officer Dobbs announces “V1,” and the last chance to reject their doomed takeoff has passed. The pilots do not remark on this moment, but we know they’re in trouble because the transcript starts giving the time in tenths of a second.
Six-tenths of a second later, the first officer calls for rotation, telling the pilot to start lifting the airliner’s nose off the runway. It’s the last thing either will ever say.
They try to fly with wings immaculate. They’ll barely get off the ground.
The Crash
As soon as the airplane leaves the ground, the pilot’s stick shaker fires. This is a tactile warning of an impending stall, where the airplane doesn’t have enough lift to stay in the air. The stick shaker rattles the pilot’s control column so hard, it can be heard on the CVR.
Then, at 20:45:05.1 p.m., the stick shaker’s warning comes true. Eight seconds after rotation and barely high enough to clear a football upright, the MD-82’s clean wings predictably stall. Thanks to their misconfiguration, the MD-82’s wings can’t generate enough lift to keep the heavy airplane in the sky at this speed.
The airplane knows it, too — it’s desperately trying to warn someone. In the cockpit, the disembodied voice of the annunciator chants its tuneless song: “STALL! … STALL! … STALL!” If the pilot immediately initiates stall procedures by lowering the nose and extending the flaps, he can still save the plane.
Unfortunately, the pilot is stunned. This defies his experience completely, and he has lots to go on. In his mind, he’s flying a normal takeoff — all of this is wrong. It doesn’t fit into what psychologists call the pilot’s schema, or his present conception of what’s happening in his world. Schema mismatches like this lead to some of our worst decisions.
Unsure of what to do, the pilot makes an intuitive choice. He tries to make the plane climb, tipping the nose up, in exactly the wrong direction. The sky, safety: it’s right there! How could he help but reach?
But not even 50 feet off the ground, Northwest 255 will get no higher. She swaggers drunkenly in the air at the same height as a telephone pole, nose still turned optimistically skyward.
For a few seconds, nothing happens. The airplane wobbles across the airfield unsteadily, like a colt on new legs.
At 20:45:19.3, the plane’s left wing clips an airport light pole, shearing off 18 feet of the left wing. The wings are filled with fuel; a fire starts immediately. The impact rolls the aircraft sickeningly to the left, performing a haunting 90 degrees bow and slapping the roof of a car rental building with its left wing, which breaks apart. Now fatally wounded, the aircraft continues to roll, still hurtling forward as it makes it way to total inversion.
Planes take off fast and heavy, filled with all the fuel they will need for the trip and speeding down the runway with engines at full blast to get enough lift for takeoff. It’s just about the most kinetic energy a plane will have at any point during its journey, and that’s what makes takeoff crashes so dangerous. Thanks to its high weight and speed, this plane contains as much energy as more than 100 pounds of TNT. All that energy is about to be imparted to the earth.
Three seconds later, the now sideways airliner clears airport property and slams to the the five lanes of Middlebelt Road, just beyond the airfield’s fence. It tumbles and slides as the aircraft smashes apart under its load of explosive kinetic energy.
The crash unfolds like a dream, too violent to be real. By the time the plane hits the ground most of the passengers are already dead, the impact so powerful it kills them instantly. As the MD-82 splinters, pulverizing itself into an ashy mist of angry metal shards and vaporized plastic, the fuselage grinding across the road obliterates a car and its two occupants, just unlucky enough to be passing by.
The passengers’ last moments are incomprehensible, their terror unique to the knowingly doomed, their shattered aircraft tilling the unforgiving earth. The shriek of sliding, twisting metal would have been the kind of thing most people only hear in movies.
All this death takes just about two seconds. Then an iron railway overpass mercifully brings the skidding, shattering wreckage to a halt with an almighty bang. As it dies out, the sudden hush in ringing ears is louder than the roar it replaced. The rain is already passing. No sirens have yet wailed, but fires dot the furrow the aircraft tried to carve into the asphalt.
Detroit Metro’s tower controllers can only stare. From their 200-foot perch — cursed with the best view in the house — they’ve watched this opera of carnage unfold in real time. But even in their shock, they’re doing what they’re supposed to do. One hand reaches for the red telephone, another flicks on the crash alarm. They’re calling every car.
Northwest 225 had been airborne for less than 22 seconds, not long enough for a TV commercial. Jessica Fletcher is still several minutes away from identifying the killer. But it would be long enough for the CVR to capture the sound of seven distinct impacts as the plane ground its way into the earth. From rotation, the doomed aircraft had traveled less than a mile.
The rescuers are already on the way. You wonder if there will be anyone save.
The Rescue
When the firefighters at the nearby Romulus Fire Department got the call for the crash, firefighter John Thiede remembers a pall settling over the station. Pouring rain normally means an easy night for firemen. They might have been horsing around a bit. At the news of the fire, that stopped.
“I hope it’s a small one,” says John’s buddy, Dan, maybe just to break the silence. These are the things you hope for, when you run into burning buildings on purpose.
That hope only lasted until they arrived at the scene.
Debris stretch out over half a mile. Blood pools in the street, dotted with human remains. Flaming streaks of aviation fuel — the plane carried some 6,000 pounds — glitter in the road. No one could have survived. The elegy of rain, now drizzling from the starless sky, seems to understand.
Dan corrects himself: “It looks like a big one.” No one needs to be told.
A relative often told me that he quit his job as a hospital photographer after they brought the victim of a motorcycle crash in for him to photograph — in two garbage bags. If a motorcycle wreck can do that, contemplate a plane. This accident was so violent, not a single body would be recovered whole.
But if there is, somehow, a person still living among these ghastly heaps of twisted metal, this is the time to find them. The window is short: anyone still breathing is bleeding badly, possibly suffering a traumatic amputation, and they can’t hold on for long. John and Dan start to comb the wreckage, patron saints of forlorn hope. Rescuers always are.
And yet. And then.
Dan hears a noise, keeps hearing it. John discounts it. He knows that the rescuers want so badly to hear a voice that almost anything can sound human: the sighing of the heated metal, the overlapping radio squawks, the distant, mournful sirens. John’s skepticism is wise, earned in the teeth of calamity. They have no time to waste.
But Dan won’t let up. He hears something, he’s sure. And then, just then, slim among the din — John hears it too.
It’s as soft as a stiletto between the ribs, a fragile keening, a muffled wail. It’s a tiny cry for help.
John and Dan are running now.
The hunt the sound like bloodhounds, riffling through the metal garbage, digging for the cry. There’s debris everywhere, and sound goes crazy in this metal graveyard. Who can know what they hear.
A quiet moment, a catching of breath. Then, another cry.
Over there! The seat! With a shared count of three, the firefighters lift an airplane seat clear with a practiced heave. The source of the cry must be under there.
They pray they aren’t opening a tomb. No one could have survived.
But here she is anyway, four years old and impossible.
Too small to ride without a booster seat, the four-year-old girl’s rescuers find her still strapped in to the seat they’ve lifted, her tiny body cradled in the oversized chair. That might have saved her life. No one knows for sure.
She’s coated with enough blood to be sticky, and her body is badly burned. But by some intervening miracle, some audacious cosmic oversight, the girl is still breathing. As she’s rushed to the hospital in the back of an ambulance, even the driver crosses his fingers. Exhausted lips make silent prayers to ring her fragile body: God, if you will ever listen, let it be this time.
This single ambulance, wailing into the night, will be the only one required for the people in the plane. 154 souls aboard are lost. The road will be closed for days just to clear the metal away.
The Aftermath
Wayne County’s medical examiner was horrified by the crash, saying he had never seen “such complete destruction.” He judged the girl’s survival little less than miraculous. Even the NTSB, that great untangler of aeronautical mysteries, could offer no satisfactory explanation: “The Safety Board concludes that this was a nonsurvivable accident. The survival of the 4-year-old female child can only be attributed to a combination of fortuitous circumstances.”
It would take all the king’s horses and all the king’s men, but the doctors would put the little girl back together again. She had a fractured skull and needed several skin grafts, but she would pull through. Her scars would be the only physical sign of the terror she had lived.
At first, no one knew who this little girl was. (Why do children not carry ID? Surely they need it the most?) But 24 hours later, the girl’s grandfather saw her on TV, sitting up with a sudden shock: That’s Cecelia! He knew for sure — he recognized the purple nail polish that Cecelia’s grandmother had applied especially for the trip. If Cecelia was anything like the four-year-old girls that I’ve known, she was thrilled to wear it.
Cecelia Cichan of Tempe, Ariz. was one of the 21 children on Northwest 255. She is escaped alone to tell us. Her parents and six-year-old brother numbered among the crash’s fatalities. She was found just a few feet away from their bodies. Maybe being thrown clear of them prevented her from sharing their fate. No one knows for sure.
It would take 54 days of care, but on 9 October, Cecelia would be well enough to travel. She would go live with her aunt and uncle in Birmingham, Ala., and try to put things back together. Her miraculous survival swiftly made her a public spectacle, attracting thousands of dollars in donations, and this long before GoFundMe. But despite the public’s attention, Cecelia’s new guardians signed a document in court pledging to help her “lead as normal a life as possible.” But when your whole life is ripped away from you in one rainy instant, what’s normal anymore?
Cecelia took her miraculous survival about as well as anyone can. In 2013, she spoke about the accident publicly for the first time in a documentary about the sole survivors of airliner accidents. Her included, there’s only been 14. Watching Cecelia’s interviews, I get the distinct impression that she’s coping better than I ever could. She has a tattoo of an MD-82’s silhouette near her wrist. It’s as big as her forearm allowed.
She has no memory of the event. Should we call that a mercy?
No one knows for sure.
Today, a dark granite memorial stands near the place where Northwestern 255 ground to a halt. It’s handsomely polished, 14 feet wide. The chisels needed all of it to fit the names of the dead. And yet, without it, you might never know. Cars whiz past a few feet away, heedless as the wind. Planes still roar above. The world, relentless, turns on.
The Cause: Simple Distraction
Human beings make mistakes. You could even say that’s a defining attribute of human kind. Cast your eyes back over history, and with pessimistic enough glasses, you’ll see little else. It’s something so embedded in the weft and woof of our lives that we almost don’t notice how often it happens to us. But mistakes still haunt us, a hole in our agency, a chasm between action and intent.
If there is a special horror to this crash, it is not in the devastation. It’s in the cause. The plane crashed for a reason that seems almost too prosaic to be blamed. The pilots got distracted; the pilots made a mistake. It’s horrifying to realize something so insignificant, something we all encounter every day, can bring down a jetliner.
But distraction comes for us everywhere, not matter how consequential — or inconsequential — the actions we’re supposed to be attending to.
- A train engineer, distracted by texting his girlfriend, barrels into a stopped train without even trying to brake: 68 people are sent to the hospital and property damage nears $10 million.
- A Lockheed L-1011 slowly crashes into the Everglades just minutes before midnight while the cabin crew is distracted by a burnt-out panel bulb: alligators nip at the unlucky survivors, neck deep in the night-blacked swamp, where they must be rescued by a local hovercraft brigade.
- Thousands die on United States roads every year as a result of driver distraction, with our enrapturing smartphones often to blame.
- Pedestrians are in cahoots: hundreds visit hospitals annually for injuries caused by distracted walking.
- Meatpacking lines, some of the most dangerous factory work in America, punish distraction brutally, each injury a predictable consequence of job’s unique combination of repetition, speed, and devilishly sharp knives.
- Distracted doctors do medicine wrong, and so do distracted nurses, pharmacists, anesthesiologists, radiologists and techs.
We are not at our best when we are distracted. It’s when we tend to make the most mistakes. Distraction is a gravity well for error, pulling all our wrongness. But where are that collected matter might create a star in space, our collected wrongnesses produce accidents. An accident like crashing a plane.
I am standing in the living room, hovering over the back of the couch, oil-smeared spatula still absently clutched in my right hand, kitchen towel thrown over my left shoulder. Eagle-eyed readers might be able to guess, from my regalia, which room I’m supposed to be in.
But I’m not paying attention to you or my current position — I’m watching an earnest Sam Waterson deliver a slam-dunk closing argument on Law & Order. I am so enraptured by Waterson’s vocal performance, his soaring rhetoric punctuated by his trademark, near-random fluctuations in pitch and volume, that I do not immediately realize I’m smelling something burning. By the time I do, the fire alarm is five seconds from going off, smoke hunkers over the stovetop, and my onions are absolutely done for.
This is far from the only time this has happened to me. Distraction mistakes like this are a regrettably daily occurrence for me; my psychiatrist would say the problem “rises to the clinical level.” I have the inattentive subtype ADHD on top of autism, and it’s a lot like having your distractibility knob turned up so high, it broke it off.
Constant, unending distraction is something I’ve learned to live besides, if not comfortably, at least openly. I do not have executive function so much as I have executive cocktail parties, things wandering too and fro in my attention, conversations moving in and out of hearing as I drift along the edges of a large and chattering crowd.
Because of this predilection towards exactly the kind of forgetfulness that doomed our pilots, despite my fascination with winged metal cans, I will never be able to fly one. ADHD is a disqualifying condition for a pilot’s license, and, if my experience is any guide, it damn well should be. I’ve played flight simulators: I know I what kind of pilot I am.
You know what disability doesn’t disqualify you from flying an airplane? Having no arms. There’s at least one certified pilot without them. It goes to show how absolutely critical attention is in the cockpit: it’s better that a pilot should have no arms than that their attention should wander.
But under stress, everyone’s brain becomes a little more like mine. Stress cranks up the distractibility knob by eroding the cognitive willpower we need to willfully maintain focus on a specific task. The pilots can’t lose their arms during takeoff, but they can (and did) lose their brains. When stress builds up high enough and time pressure is short enough, it’s almost impossible not to drop the ball.
Understanding Distraction
Distraction is simple. It happens when the brain gets focused on material that isn’t germane to the task at hand. This can happen in a thousand ways, from a irritating noise dragging conscious energy away from a puzzle you’re working to an errant worry suddenly clearing the decks of your attention. In all cases, the brain ends up paying attention to something it’s not supposed to be attending to.
Sidebar: The Greatest Trick Distraction Ever Pulled
Distraction is so hard to stop because it’s cognitively invisible. To you and me, distraction is bad, but to our brains, it’s just how things work. To your brain, what we call “distraction” is helpful.
To the brain, when it’s “distracted,” it’s doing a great job. It’s raising possibly relevant stimuli to consciousness for their management and evaluation. It’s spotting problems and telling you to solve them, hunting down novel, interesting inputs and drawing your attention to them, or dwelling on unfinished problems to help you finalize their solutions. Because the brain believes it’s helping, it’s a major challenge to make it stop.
It’s why the pilots never even noticed their error: when it comes to spotting our own distraction, we might as well be blind. Distraction just… happens, and we have no idea it’s even going on. It’s what makes distraction such a devious villain, such a challenging foe for the brain to overcome. We don’t know when we’re doing it, so how can we stop it? We might take a page from Muhammed Ali: “the fist can’t hit what the eye can’t see.”
Stopping Distraction (or Trying To)
Distraction’s most devious feature is not only how difficult it is to spot, but how difficult it is to stop. There’s no red flag that shoots up when you’ve started to focus on material that isn’t important, just in the same way no signal flare is fired when you make a mistake. Anyone whose had their mind wander against their will in a warm lecture hall or while driving down the highway can understand. In fact, we only notice our distraction when we have a moment that breaks the distraction, allowing us to “wake up” and notice we’re not attending to the correct information.
In this way, we can see distraction as a “subconscious” phenomenon interrupted by the “conscious” mind. In the parlance of behavioral economist Daniel Kahneman’s Thinking Fast, Thinking Slow, distraction is initiated and fed by the automatic, intuitive System 1, while distraction’s interruption comes from the deliberative, rational System 2. And that interruption takes a lot of psychological oomph: what we might call “cognitive resources” if we wanted to sound a little more respectable.
The fewer cognitive resources we have available to muster, the easier it is for us to get and stay distracted. This means when we’re tired, overwhelmed, or worried about something else — like the weather on our upcoming flight — our minds are more likely to drift from the tasks we’re supposed to be attending to, going through the motions half-consciously while our brains half-focus on something else.
There’s little doubt our pilots did not attend fully to the tasks they were performing. If they had, there would have been some moment where they would have noticed their error. Just like you check your bag or pockets for keys, wallet, and phone before you leave the house, the pilots would have checked to see they had performed all the necessary tasks before departing the airport. At least, they would have if they’d had the cognitive resources to spare on the problem. But their brains were entirely focused on solving other, more apparently pressing problems, like navigating difficult weather at a pitch-black airport.
Tragically, our pilots even lacked the cognitive resources to notice that the TAXI checklist hadn’t been performed when the autothrottle’s failure should have alerted them. As often happens in these pre-disaster moments, the pilots failed to heed the warning. It conflicted with their current schema, or understanding of the situation — that this was a normal takeoff — and therefore was not integrated into consciousness fully, leaving the pilots unaware and unable to avert the disaster they could not see was about to strike.
Thanks to their distraction, it’s unlikely the pilots ever understood what was happening to them, ever had the time to find out. Their slow, deliberative system simply didn’t have the time for them to realize their error. They only had 22 seconds, and that’s short trip when you’re fighting for your life.
Designing for Distraction
For a long time, scientists struggled mightily to find ways to stop distraction. At first, they thought they just needed the right kind of pilots. That helps — the appropriate personality is essential to managing the work of piloting a commercial aircraft — and while it does give you pilots better equipped to cope with the irregularities mistakes might cause, it doesn’t stop the mistakes from happening. And even “the right kind” of pilots can make deadly mistakes: both our pilots were respected aviators at Northwest, with a reputation for “by the book” flying.
So eventually, science threw in the towel. They admitted that humans simply cannot be trusted to fly airplanes unaided without crashing them at worrying rates. And that was the best move they could ever make, because it allowed for an insight that has saved countless lives. If human beings are bound to make mistakes, why don’t we design a world that’s equipped for that reality, a world that doesn’t punish them with death or destruction for predictable errors?
It’s why, today, we live in a world where airplanes rarely crash. It’s because we created a world that accepted the best way to make humans safe operators of complex, dangerous machines is to accept that they will make mistakes. Humans, we learned, cannot be expected to do things perfectly. So we stopped expecting them to.
If we want to design a safe airplane, we cannot design it for the perfect human that doesn’t exist. We have to make affordances for the imperfect humans that actually do exist. We have to put a little wheel on the landing gear release, to make it clear this controls the wheels. We have to make an airplane so hard to stall, it doesn’t include stick shakers. We have to program dozens of warning systems to alert the pilot to dangerous flight conditions they might be too disoriented to notice otherwise. We have to meet humans where they are: naturally imperfect. Today, we design planes around the potential for human distraction. We also train pilots on their own propensity for making the same error the pilots of NWA 255 made. To extend the immortal tagline of those shooting-star public service announcements, the more you know, the more you can stop.
While mistakes don’t stop — they just become more sophisticated — modern pilots know a lot more about how to make sure their inherently limited human brains can do something as wildly complex as pilot an airplane safely. Today’s pilots know, when the weather’s bad the the pressure is mounting, that their cognitive resources will be taxed. They know to recruit help from their copilot and fall back on their stringent training, redoubling their efforts with the grave seriousness piloting deserves. Training pilots to understand their natural limits and marshal their cognitive resources effectively is what prevents a crash like NWA 255, where the limits of the human mind are the primary cause.
By training pilots to stick to rote, written procedures with the rigor of a religious rite — military pilots even call performing their pre-flight checklists “reading the prayer” — and dividing the workload between pilots intelligently — a practice called “crew resource management” that’s saved more airborne lives than any technological improvement — we’ve reduced the rate of these kinds of accidents to effectively zero in the United States. And all major airliners have overhauled their checklists since the 80s, making them shorter and easier to navigate to reduce oversights and limit the possibility for interruptions.
All these improvements spins around one axis: accepting that human beings are just that, human beings. If you meet people where they are, it’s far easier for them to avoid crashing the plane.
But lest we think we are above failure, it conspires to slap us down again. It fact, this very accident seems to come back with haunting regularity.
It happened at least one more time in the U.S., and only a year later. Delta Flight 1141 failed to set their flaps before takeoff, clipped an ILS antenna, and skidded to a fiery stop with 14 fatalities and dozens of seriously injured. Like NWA 255, they were airborne for 22 seconds. Like NWA 255, their TOWS failed to function.
And then it happened again in Madrid in 2008, with Spanair 5022 suffering a crash so freakishly similar to NWA 255 that it feels like it must mean something. They crashed the same type of airplane with the same misconfigured flaps, caused by the the same pilot distraction and worsened by the same disabled TOWS system. But what rattles me is the number of fatalities: 154, exactly the same as NWA 255.
On some level, we can say the accident will always keep happening, a ghost caught in the machine, the product of some eternal feedback loop between complexity and humanity that we are powerless interrupt or divert. We are error-prone devices, stalked by our own imperfection even in the cockpit.
But the question for aviation, as it is in life, is not how to make mistakes stop. The question is how to stop mistakes from crashing the airplane. The answer, here, is as simple as it is difficult to enact: accept that people make mistakes, and design the world around them. But that’s what it takes to be safe: a world designed for your brain as it is, rather than as we hope it to be.
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