Aviation
accident investigations have a tendency to cite pilot error as the runaway
cause of many crashes, even when a variety of other (potentially more damaging)
factors were at play. This is unfortunate for a number of reasons, none the
least of which is placing the lion’s share of the blame on pilots allows for
other serious, complicated issues to be left out of the conversation.
Aside
from helping us better understand what or whom was at fault for a disaster,
aircraft accident investigations produce information that should be used to try
and prevent a similar accident from happening again. Manufacturers can make
changes to their aircraft. Airlines can change their staff training or
maintenance practices. This is arguably the most important function of an
aviation accident investigation: to learn from past mistakes so actionable
steps can be taken to avoid a similar tragedy. We can’t go back and save the
lives that were lost in the accident that sparked the investigation itself, but
we can implement necessary changes to mitigate the risks of a similar incident.
There
are a number of reasons as to why so many aviation accident investigations arrive
at pilot error as a definite factor or the cause of crashes. Rather than
discussing the why, this blog is going to explore the costs of chalking up
aviation accidents to pilot error (or any single factor when a number of other
factors are involved). If you are curious to learn more about why aviation
accident investigations are quick to blame pilots, check out this blog by Baum Hedlund aviation attorney, Ron
Goldman.
AirAsia Flight 8501 Investigation
Last
week, Indonesia’s National Transportation Safety Committee issued its final
report on the December 28, 2014 crash of AirAsia Flight 8501 that killed all
162 people onboard. The Airbus A320-200 plane crashed into the Java Sea less
than an hour after departing from Surabaya, Indonesia on the way to Singapore.
Crash
investigators said AirAsia Flight 8501 encountered a problem when pilots heard
an alarm in the cockpit four different times. The alarm sounded when an
important computer system, that helps control the rudder, failed.
The
first three times the alarm sounded, the flight crew responded in accordance
with standard procedure. The fourth time the alarm sounded, however, “someone”
removed and reinstalled a circuit breaker. Why would this action be taken? It’s
kind of like someone trying to turn a computer on and off to try and correct a
software issue, only this happened on a flight system at thousands of feet
above the Java Sea. Investigators were unable to find audio or video evidence
to confirm who reset the circuit breaker, so the investigative report says
“someone” removed it.
The
circuit breaker reset function turned the autopilot and auto-thrust systems off
and the pilots did not turn either of them back on. This left them to fly the
plane manually with a degraded and unfamiliar fly-by-wire system. Without the
use of automation, the rudder control issue put the Airbus A320-200 into a
steep bank while pilots flew higher, eventually putting the plane in a stall
condition. According to the crash report, the flight crew was unable to react
appropriately to these issues, which ended with the plane crashing into the
Java Sea.
Pilot Error? Or Something More…
The
report on the crash listed several contributing factors, including the failure
of the rudder system and the pilots’ response to the failure. Most of the media
outlets that picked up the story focused on the pilot response, which led to a
number of questions that played up the idea of pilot error as the runaway cause
of the AirAsia crash…
·
Are
pilots overly reliant on automation?
·
Should
pilots receive more manual flight training?
While
it is true that the AirAsia pilots could have reacted to this catastrophe
differently, they may never have had to deal with such adversity had the rudder
issue been addressed prior to the ill-fated flight. According to CNN,
the mechanical error on the crashed Airbus A320-200 plane had occurred on the
ground and in-flight at least 23 times in 2014…that’s 23 times in less than 12
months. It appears that the maintenance in response to
the issue adhered to protocol, but the faulty component—a crack in the
electrical soldering—was never repaired.
So
what we have here is a repeated history of the same problem on the same plane,
but that problem for some reason, was never classified as a
repetitive item. “At the time, it was considered minor damage,” said Nurcahyo
Utomo, a member of the AirAsia crash investigation team and a retired pilot.
“It was not a concern at the time.”
But
if the rudder issue had been classified as a repetitive item, the source of the
problem might have been repaired, and this disaster might have been averted.
All
of this isn’t to say that the AirAsia pilots are without fault in this
catastrophe. Many airline pilots in the U.S. would argue that the mechanical
issue that the AirAsia pilots faced shouldn’t have been serious enough to cause
a crash. However, the response of the AirAsia pilots made the crash all but
inevitable.
Both
men were likely surprised by what happened after the circuit breaker was reset.
Whoever it was that pulled the circuit breaker likely wouldn’t have done so if
they knew what effect the action would have on the aircraft. Even though flight
transcripts indicate that the pilot took control of the situation when
autopilot and auto-thrust systems were off, he failed to take full control of
the plane from the co-pilot. With neither the pilot nor the co-pilot in full
control of the plane, the Airbus A320-200 plane went into an aerodynamic stall.
U.S.
airlines require pilots to practice recovery techniques from “unusual
attitudes,” also referred to as upset recoveries. AirAsia apparently didn’t
feel that this type of attitude training was a needed requirement for pilots
because Airbus planes are designed with electronic protections to prevent
unusual attitude upsets. The problem is that these protections can be rendered
meaningless if mechanical failures force the plane into what Airbus calls "Alternate Law,"
which is precisely what the pilots of AirAsia Flight 8501 faced.
What Now?
Yes,
the AirAsia pilots faced adversity that could have been avoided…if the
mechanical failure didn’t happen. And they could have handled the mechanical
failure more appropriately…if they had received proper training. Crash
investigators, the media and the public shouldn’t be reductionists in the wake
of a tragedy like the AirAsia crash. By narrowing the focus on pilots (or any
other single factor when a series of factors are at play in a crash), we won’t
be able to learn from the failures that played into the disaster, and lives
will be needlessly put at risk.
What
can prevent a crash like this from happening again? Ensure that all of the
variables that played into this disaster are accounted for, then acted upon.
This includes a number of recommendations to the airline and Airbus as well.
AirAsia could have and should have been able to address the safety issues cited
in the crash investigation before tragedy struck last December.
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