Muscle Memory at FL430: How a Routine Action Triggered a TOGA Event

By Jason Starke

Condensed and Anonymized Version:

While cruising at FL430, a pilot intended to key the microphone for a routine frequency change but accidentally activated the TOGA (takeoff/go-around) button instead. The aircraft immediately began climbing and increasing thrust. The other pilot quickly disconnected the autopilot and autothrottle, returning to stable cruise. ATC was notified of the brief altitude deviation.

Root Cause: Cognitive Bias The pilot had 23 years of experience with aircraft where the mic switch was located on the throttle. Despite 12 years flying different aircraft, muscle memory from prior experience influenced the action during this routine procedure.

This phenomenon appears across different aircraft types – pilots transitioning between aircraft with opposite switch locations (like Boeing vs Gulfstream configurations) often experience similar errors.

Solution: Visual Verification Philosophy Adapted from Japanese railway operations (“Shisa Kanko” – pointing and calling):

“Point Before You Actuate”

• Point: Physically point at the intended control to reinforce focus
• Actuate: Then operate the switch
• Benefits:
  • Increases attention and accuracy
  • Confirms correct switch identification
  • Reduces operational errors
  • Particularly effective for routine actions where complacency may occur

This simple technique helps break automatic behavior patterns and ensures deliberate, conscious action during both routine and complex procedures.