Major Anderson: "This moment, this flight"

Flying Safety, March, 2002 by J.S.T. Ragman

The aviation world was focused on a 747 pilot, a typhoon, and a collision on takeoff roll. I was focused on myself, an altimeter error, and 299 people aboard a 777. Same day, same hemisphere, two pilots, two errors, one lucky, and one not so lucky.

My first flight safety article had been published fifteen years earlier. I had "talked the talk" and "walked the walk" on flight safety for twenty-plus years, and I had covered the flight safety bases in the Air Force business, as well as the airline business. I routinely left my ego at home with my wife and two sons. I had taught "error management" at a major airline for two years, and I had long ago accepted and internalized the reality that I was human, that I would make errors, and that job number one was to catch those errors before the consequences kicked in. I had indeed made, and caught, many an error.

I was comfortable. I would make errors. I would catch errors. Such was life. As I sat in my hotel room and viewed the rescue scenes on television, I realized that perhaps I had become too comfortable. Sure, I would make errors. But, I would catch my errors. There would be no consequences.

Until the "big one." Rolling down a closed runway on takeoff roll. Or flying with an improper altimeter setting, on radar downwind, in instrument conditions, in mountainous terrain. I was the lucky one. The face staring at me from the television screen had not been so lucky.

We had encountered a TCAS-system problem earlier in the flight. As a corrective action, we had selected my transponder as the primary. We had completed the In Range Checklist passing through 18,000 feet on the descent. The altimeter remained 29.92 inches of mercury. Transition to local altimeter would be as directed by local air traffic control. The ATIS had broadcast an altimeter setting of 978 millibars. We had both dialed in 978 on our nifty, high-tech, electronic flight instruments. We were cleared to 4000 "feet" with an altimeter setting of 979 millibars. I was the flying pilot. I selected 4000 feet and reset the altimeter to 979 millibars.

And now for the error: I had reset the altimeter to 979 millibars, but I had not punched the altimeter reset knob to transition from 29.92 inches to 979 millibars. We were in the descent, in the soup, with my flight director taking me to my 4000 foot altitude setting, at 1250 feet per minute.

An amber "standard" caution appeared on my primary flight display. I never saw it. An amber "baro disagree" caution appeared on our center display. Neither of us ever saw it. I passed through 3200 MSL on my fellow pilot's altimeter. He never saw it. I was a few hundred feet and a few moments from terrain, and approach control never saw it. My transponder was primary, and incorrectly showing us at 4000 feet.

The jumpseater caught it. I punched my altimeter reset knob, noted my altitude at 3200 MS:, disengaged the autothrottle, kicked off the autopilot, and climbed to 4000 MSL.

I had made many an error in my day. I suspect I have made several errors each time I have headed out to fly. And I had caught them all. Until today. I had not caught this one. A checklist had not helped. The high-tech instrumentation had not helped. The air traffic controller had not helped. The crew concept had not helped.

I have always viewed complacency as a four-letter word of the worst kind. Lives are at stake. Complacency kills. Yet I had become complacent. But in an odd way, I had not become complacent to error. I knew I would commit them. Rather, I had become complacent in my belief that I would always catch those errors. Not so.

As I continued to view the rescue efforts amidst the typhoon, my mind wandered back through twenty-plus years of flying. This has been my "big one." This had gotten my attention, it had frightened me. I began to run through the excuses: Circadian rhythm, back side of the clock, long flight, mixing C-130 systems/procedures and 777 systems/procedures, non-standard ATC procedures, an inattentive fellow pilot, the transponder line in the chain of events.

The excuses were just that: Excuses. My mind came to rest on the ramp at Vance Air Force Base, Enid, Oklahoma, 1980. I was the student. Major Anderson was the instructor. His words were ringing true: "If you ever find yourself in an aircraft in which you are not thinking about this flight, this moment, you will be missing something: Altitude, airspeed, heading, bingo fuel, something. Think: This flight, this moment."

Simply put: I had not been thinking "this flight, this moment." I was relaxed. I was on downwind. I was looking forward to the layover. And I was indeed "missing something."

It got my attention. It was a lesson I do not want to learn again.

This moment, this flight.

("J.S.T. Ragman" is the pen name of a C-130 pilot and unit commander in the Air Force Reserve. He is also a Boeing 777 pilot for a major airline.)