The Weekly Reflektion 36/2025

Clearly defined roles and responsibilities are a key element in assuring that people do what they are supposed to do, and what is expected of them. Unclear roles and responsibilities have been a factor in many Major Accidents. Sometimes roles and responsibilities are clear and understood, but the people involved divert their attention from what they should be doing, to what someone else is doing, or something else that they may be concerned with, and disaster occurs.    

The crash site of Corporate Airlines Flight 5966

What can happen when you get distracted?

Airlines Flight 5966 was a scheduled passenger flight from St. Louis, Missouri, to Kirksville, Missouri. On October 19, 2004, the flight, operated with a British Aerospace Jetstream 32, crashed on approach to Kirksville Regional Airport (IRK), resulting in the deaths of 13 of the 15 people on board.

The flight was at night and the crew planned to make a non-precision instrument approach in instrument meteorological conditions. This is an aviation flight category that describes weather conditions that require pilots to fly primarily by reference to instruments, under Instrument Flight Rules (IFR).

The National Transportation Safety Board (NTSB) determined that the probable cause of the accident was the flight crew descendingtoo low on approach in poor visibility. They failed to properly monitor altitude and ignored minimum descent altitudes. Controlled flight into terrain (CFIT) occurred when the plane struck trees and crashed short of the runway. An analysis of the cockpit voice recorder showed that both pilots were probably looking outside for visual indications to the location of the airport. They failed to monitor their altitude and did not notice that they had descended to below the minimum descent altitude. The crew did not make standard callouts and became distracted when they did not see the runway lights. It is likely that fatigue contributed to the poor performance and improper crew resource management (CRM).Another factor that was highlighted in the investigation was the pilots’ failure to effectively use the autopilot or monitoring systems to ensure safe descent. The airline was also criticised for lack of proper pilot training in the conditions that led to the accident.

We have all been in situations where things are not going as planned, and expectations are not being fulfilled. We feel frustrated and often look to the skies with a feeling of disdain. When we are also tired and feeling fatigued, our judgements may be impaired. The decisions we make are flawed and the consequences can be disastrous. Even though we are aware of our roles and responsibilities, have been trained and have years of experience, we are still subject to becoming distracted. Our concentration slips and we make mistakes. It is all part of being human.

‘Thinking Fast and Slow’, by Daniel Kahneman talks about System 1 and System 2 as two different ways for the mind to work before taking actions and making decisions. System 1 is fast, instinctive and emotional; System 2 is slower, more deliberate, and logical. Our ancestors did not survive by allowing themselves to be distracted from their tasks and ensuring these could be carried out safely. They developed habits that built on experience, and they ensured that these habits were passed on to their children as they matured. We need to pass on our good habits and eliminate the bad habits, before they eliminate us.