Comair crashed while AirIndia timely rejected takeoff

The discoverers of ‘place cells’ in the brain won the Nobel prize in 2014. Who would have ever imagined that there was a GPS-like system in the brain? When the GPS fails safety is compromised & accidents happen. The Comair CRJ aircraft took off from the wrong runway & crashed. Air Arabia A320 turned towards the shorter end of the runway and took off. An alert ATC officer saved the AirIndia A320 which replicated the Comair scenario. In addition least 4 occurrences of aircraft taking off from runways without runway lights. The crew had lost orientation and spatial awareness. They were distracted and cognitively saturated.

There have been football goals when the player has run towards their own goal instead of the opponent. Long symmetrical corridors in the hotels confuse people on which way to go. Getting inside a building without external reference and taking a few turns tends to make us lose our way.

Scientists have discovered neuroscience and psychological reason for such failures. The reasons are:

  1. Place cell spatial orientation
  2. Change blindness
  3. Expectation bias
  4. confirmation bias

Case 1 AirArabia

The AirArabia A320 taxied out to the runway and planned for an intersection takeoff at Sharjah airport. The training Captain issued instructions to the Co-Pilot under training. The taxi distance from the apron to the runway intersection is very short. The crew performed a one engine taxi out. As the Co-pilot taxied out of the apron, the training Captain performed a one engine taxy out procedure which requires starting the second engine before entering the runway. All in all every factor listed has increased the workload of the training Captain. With no aircrcraft on approach to land, the crew performed a rolling takeoff and did not hold at the taxi way.

Sharjah Airport
Near miss

The Co-pilot performs the takeoff but the Captain realizes that they had turned in the wrong direction when lining up on the runway. The shorter end. The Captain uses maximum thrust and increases the flap setting. They manage to get airborne safely as safety margins run thin.

Case 2 Comair

The Comaur CRJ taxied out to the runway which is very close to the apron at Lexington airport, USA. Following this they perfomed the taxi checks, a bit of non essential chat and the before takeoff checks. The crew did not required to hold before the runway and the ATC cleared the aircraft for a takeoff. The crew took off from the adjacent runway which is the shorter one.

Accident

The end of the runway surprised the crew and in an attempt to get airborne, the aircraft stalled. The accident killed all passengers on board.

Lexington Airport, Kentucky

Case 3 AirIndia

The Air India A320 taxied out of the apron from Chennai airport, India. The layout of the airport apron and the three runways is similar to the Lexington airport. The crew aligned the aircraft with the shorter runway instead of the longer one.& lLikewise, they did the same mistake as the Comair crew had done. An alert Air Traffic Controller noticed the error and instructed crew to reject the takeoff. The ATC averted an accident.

Chennai Airport

How do we navigate?

The Nobel laureates have discovered a positioning system, an inner GPS in the brain which makes it possible. This makes it possible to orientate in space, demonstrating a cellular basis for higher cognitive function. The experiments were conducted on rodents which revealed that there are grid-like cells. The cells will fire when the animal is in the place regardless of the direction it was facing or looking at. This can only be done if the brain has stored the relationships of the environment features to each other, independently of the animal’s location.

Place cells for navigation
Navigation

The place cell needs to know the context, which is the environment or the present position. Next, the place cell needs the direction information. The cell acts like a compass which creates, creating a sense of direction. Another insight is the importance of rotational asymmetry in the visual landscape. Rotational symmetry refers to the visual similarity that occurs if the environment looks the same when viewed from different facing directions.

Place cells also have information about the grid boundaries. The grid cells produce hexagonal patterns spread across the environment. They are thought to form the metric basis for the cognitive map something like a map grid, but triangular/hexagonal.

Setting the Sense of Direction

The most important insight is the primacy of the sense of direction in establishing a coherent sense of space. Previously encountered anchoring is used for the initial anchoring of the direction sense. Thus familiar landmarks. The system maintains the direction it was signaling when the previous environment was exited.

Head down activity

The pilot engages in a head-down activity like making changes to the flight management system (FMS). The longer the pilot remains heads down, the higher the probability of losing orientation. The initialization of place cells will be lost and a great deal of effort is required to reorientate unless the pilot has frequented the airport recently and on a number of occasions.

Sometimes there is a combination of loss of orientation coupled with symmetry of the surroundings.There are three types of symmetry.

Types of symmetry

Infinite Rotational symmetry

An infinite rotational symmetry can be problematic. They provide few visual cues as to facing direction for orientation. It has the potential to be confusing and requires a high cognitive load to process. This is because people need to keep track of their movements and cannot reorient by using the visual appearance of their surroundings in isolation.

Two-fold rotational symmetry

While rotational symmetry can be infinite, as in a circular building like the ones in the first column of the Figure above, it can also be of a lower order – twofold, fourfold, etc – and yet still be confusing. In twofold symmetry, the visual scene looks the same when viewed from opposing directions – in such cases, an uninterrupted path integration signal is needed to prevent confusion.

Sometimes this process fails – a famous example is the wrong-way touchdown of Jim Marshall, sometimes called ‘the most embarrassing moment in NFL history, in which he confused the two directions of the Kezar Stadium (Figure above, middle) and scored an own goal. (The design manual, Jeffery. K).

Mirror symmetry

Mirror symmetry, on the other hand, does not create this same problem. A mirror-symmetric environment does not have any rotationally ambiguous viewpoints (Figure above, right) and thus the visual scene can always be used for reorientation, placing a minimal load on the movement-tracking system.

Aids to orientation

What helps is different types of colors, shading, large features? A landmark far away is better for orientation as compared to a near one. The near one keeps changing faster as one moves around but the father landmark tends to be stationary.

Problems with Signage

One type of information that does not help orient the head direction system – at least not readily – is signage. Signs and text, which we developed very late in human evolution, are processed by brain regions that do not directly connect to the head direction system and need to be routed through a circuitous path that probably includes the frontal lobes. While signs can be helpful, they do not engage the navigation directly and naturally in the way that environmental geometry and landmarks do.

Takeoff without runway lights study

Change blindness occurs when a person does not notice that something is different about the visual environment relative to before the change. Research has shown that in some cases, quite dramatic changes are not detected, particularly if changes occur when the observer is not looking at the relevant part of the visual environment at the time. In this instance, the crews did not notice the difference between the airport lighting when they were boarding the aircraft versus when they taxied out for departure. At the time the airport lighting was turned off, the aircraft was parked on the apron and the crew was on board the aircraft facing away from the runway lighting and looking into a brightly lit terminal. 

Inattention blindness occurs when a person does not notice an object which is visible, but unexpected because their attention is engaged on another task. In this instance, the absence of airport lighting was noticeable, if looked for, and the crews probably had an assumption or expectation that the lighting was on. 

Expectation bias is ‘seeing’ what you expect to see even when it is not there. In this case, runway lighting being on. 

Read the ATSB report here.

mindFly analysis

Readers would wonder how such incidents./accidents have taken place. Its just so bizarre.Disciplines use of SOP’s is the key but more important is that the crew must be aware of their limitations and such phenomenon as described in the blog above.

AirArabia

The AirArabia Captain was training a second officer. The taxi route to the runway intersection was very short. The crew had to perform a one-engine taxi out in addition to the tasks before takeoff. This would require the Captain, who was the Pilot Monitoring, to be distracted with checklists, procedures, and heads down. The Co-Pilot taxied the aircraft and did not monitor the change of runway from previous flights.

The PF entered the runway and aligned for a rolling take off in the direction that they had been performing the takeoff the past few days. They did not pay heed to the change of runway. The Captain who was heads down, would not have orientated since the brain cells did not have an initialization point. Both sides of the runway have similar marking and construct. Only a look further down the runway at objects would help orientate the place cells in the brain. Further, the change blindness took place and the two-fold symmetry of the runway further complicated the issue. Without stopping on the runway for orientation, the crew performed the takeoff. Fortunately, the Captain realized a bit late in the takeoff about the loss of orientation and increased the trust & Flap setting to narrowly escape.

Comair

The Comair crew too were taxing to the runway which was very close to the apron. They were distracted by non-essential conversation and the check to be performed before takeoff. The crew was distracted and due to the head down activity, the Captain would be slow on orienting back to the surroundings especially when light conditions are poor. Expectation bias set in when the crew who had to take the second left to enter the runway, took the first one and entered the shorter runway. The crew did not hold at the taxi holding. Had they done that, the chain of errors would have broken and they would have got time to look out to orientate their place cells and environment.

Air India

The Air India Crew would have been distracted too. The taxi would have been uninterrupted. They were expecting to turn left to align with the takeoff runway and did the same. They took a tun early. The details of the incident are still awaited.

To conclude, a series of cognitive factors resulted in the occurrences. The crew must brief well so that a good mental map is built which helps in quicker orientation. Too much heads down and distraction disorientates the place cells since they lose the direction sense in the grid the brain is in. Looking out at objects at a distance will help orientate since the near ones move too quickly to notice. There must be a pause or a break before a major event so that the chain of errors if any is broken. For example, before entering the runway a pause will help. Mindfulness techniques will help in clearing the clutter from the mind. Planning ahead and having spare cognitive capacity will save the day when things go wrong.

CASA SA brief

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