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 .
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. , 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 which is precisely what the pilots of AirAsia Flight 8501 faced.
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.