NTSB Safety Alert SA-025 - Avoid Nonoperational Use of Portable Electronic Devices

SAFETY

ALERT 025 May 2013, Rev. December 2015

HIGHWAY

MARINE

RAILROAD

PIPELINE

AVIATION

Distracting Devices? Turn Them Off!

Avoid Nonoperational Use of Portable Electronic

Devices (PEDs) Before and During Flight

The problem

Nonoperational use of PEDs by pilots (including cell

phones, smart phones, tablets, and laptop computers) can divert attention from activities necessary for safe operations, both in the air and on the ground.

Nonoperational use of PEDs has been documented during

• preflight planning and preparation,

• cruise, and

• maneuvering flight.

PED-related distraction has played a role, or at least been present, in accidents involving improper fuel management,

loss of positional awareness, loss of automation mode awareness, collision with obstacles, and loss of control.

Related accidents

On August 26, 2011, a Eurocopter AS350 B2 helicopter, N352LN, impacted

terrain following an engine failure near the airport in Mosby, Missouri. The

helicopter experienced fuel exhaustion because the pilot departed without ensuring that the helicopter was adequately fueled. The investigation

determined that the pilot engaged in frequent personal texting, both before and during the accident flight. The pilot and a flight nurse, flight paramedic,

and patient were killed. ( CEN11FA599)

1 The report for this accident, which includes concurring and dissenting statements, is

accessible at http://www.ntsb.gov/investigations/AccidentReports/Reports/AAR1302.pdf .

The reports for the other accidents referenced in this safety alert are accessible by NTSB case

number at http://www.ntsb.gov/_layouts/ntsb.aviation/index.aspx. Each accident’s public docket is accessible at http://www.ntsb.gov/investigations/SitePages/dms.aspx .

Figure 1. Photograph of the

accident site. (CEN11FA599 )

2 / NTSB Safety Alert 025 / May 2013, rev. December 2015 On October 21, 2009, a commercial airline flight was

operated with no radio communications for 1 hour

17 minutes and overflew its destination when the

flight crewmembers neglected to tune in to a new

radio frequency as directed by air traffic control and

missed numerous company messages advising them

of the problem. Evidence indicated that the flight

crewmembers became distracted, in part, by their

simultaneous use of personal laptop computers

and conversations and activities unrelated to the

operation of the flight. No one was injured in this

incident. ( DCA10IA001 )

On December 30, 2007, a Cirrus Design SR-22 impacted terrain during a low-altitude fly-by of a

friend’s residence. The pilot was speaking on his cell phone during the fly-by when he encountered

turbulent wind conditions and initiated a rapid climb; the airplane experienced an accelerated stall,

resulting in loss of control. The NTSB found that the pilot’s diverted attention while using his cell

phone contributed to this accident. The pilot was killed. ( LAX08FA043 )

On February 23, 2006, a Cessna 182D collided with power lines, located 100 feet above ground

level, while flying over an interstate highway in night visual meteorological conditions. Evidence

indicated that the pilot was speaking by cell phone with the driver of a nearby tractor-trailer,

a friend, who was traveling on the highway in the same direction as the airplane. The pilot was

killed. (NYC06LA073 )

PED-related distraction has played a role,

or at least been present, in accidents involving

improper fuel management, loss of positional awareness,

loss of automation mode awareness,

collision with obstacles, and loss of control. Figure 2. Northwest Airlines Flight 188. (DCA10IA001 )

NTSB Safety Alert 025 / May 2013, rev. December 2015 / 3What can pilots do?

Recognize the potential for distraction arising from

nonoperational use of PEDs.

Avoid nonoperational use of PEDs during preflight

planning and preparation to focus your attention on

these critical tasks.

Turn PEDs off before engine start if they have no

operational purpose during the flight. Ensure that PEDs

that are used in flight are not used for purposes other

than those intended to support the flight.

Establish your own sterile cockpit procedures to

reduce distractions. Avoid the nonoperational use of

PEDs when the sterile

cockpit applies.

4 / NTSB Safety Alert 025 / May 2013, rev. December 2015Interested in more information?

On February 12, 2014, the Federal Aviation Administration (FAA) issued a final rule, titled “Prohibition

on Personal Use of Electronic Devices on the Flight Deck, ” to prohibit flight crewmembers in Part 121

operations from personal use of PEDs while at their duty station on the flight deck while the aircraft is being

operated. The final rule can be found at http://www.gpo.gov/fdsys/pkg/FR-2014-02-12/pdf/2014-02991.pdf .

On April 26, 2010, the FAA issued an Information for Operators (InFO) bulletin, titled “Cockpit Distractions, ”

addressing this issue. This InFO bulletin can be found at http://www.faa.gov/other_visit/aviation_industry/

airline_operators/airline_safety/info/all_infos/media/2010/InFO10003.pdf .

The NTSB’s Aviation Information Resources web page, www.ntsb.gov/air ,

provides convenient access to NTSB aviation safety products. This Safety

Alert and others can be accessed from the Aviation Safety Alerts link at

www.ntsb.gov .

The NTSB is an independent federal agency charged by Congress with investigating every civil aviation

accident in the United States and significant accidents in other modes of transportation—highway, marine, railroad, and pipeline. The NTSB determines the probable cause of the accidents and issues safety

recommendations aimed at preventing future accidents. For more information, visit www.ntsb.gov.www.twitter.com/ntsb

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