Back to basics

The University of Southern California’s engineering professor and aviation safety expert, Najmedin Meshkati, also reflecting on the quote, suggests that the aviation industry and its regulators have become “star struck by technological solutions” as a result of aircraft such as the 777 having fatality-free records in commercial service. “We have become complacent by thinking that technology will solve all the problems,” he says.

Faith in the curative powers of new technology aircraft however has been shattered over the past 12 months with the loss of a string of latest generation glass cockpit aircraft such as the Air France A330 in June last year, the Ethiopian Airlines Boeing 737-800 in January off Beirut, Afriqiyah Airways A330 in Triploi in May followed by the Air India Express 737-800 in Mangalore just two weeks later. While it is early days, all but the Air France tragedy, have pilot error as a likely cause.

For instance evidence suggests that the pilots of the Afriqiyah Airways A330-200 may have mistaken a major road that runs toward and then veers to the right of the airport, for the runway. The aircraft crashed 900m short of the threshold of Runway 09 and 200m to the right, just beside the road.

Runway 09 does not have an ILS and the VOR navigational aid was suffering from interference at the time and the pilots also may have had their vision impaired by a combination of the rising sun and ground haze. At least one other aircraft – an Alitalia MD80 – went a round because the runway was unsighted.

Just two weeks later Indian crash investigators were focusing on the speed and touchdown point of an Air India Express 737-8HG that crashed at Mangalore-Bajpe Airport, killing 158 of the 166 passengers and crew onboard. Reports suggest that the aircraft touched down half way down the runway.

The two-year-old 737-8HG, was piloted by an experienced Serbian-born captain who had landed at the airport 19 times previously, skidded off the 2,450-m. runway, plunged down a 60m gorge and burst into flames.

De-skilling

Meshkati believes that all the gee-whiz technology may be masking a deterioration and “de-skilling” in basic flying ability and the lessons learned by generations of pilots “may be lost to the new breed of pilots.”

That view reflects a comprehensive NASA Research Centre paper based on Royal Air Force Institute of Aviation Medicine data by Dr. Marianne Rudisill in 1995 which surveyed over 1,000 pilots from 20 airlines and aircraft manufacturers about pilots’ attitudes and experience with flight deck automation.

The strength of the study was that most respondents had flown types from basic cockpit types such as 727s through to Glass 2 types such as A320s and 747-400s. The study found that the general consensus was that “safety is increased with automation but automation may lend a false sense of security, particularly with inexperienced pilots.”

Pilots reported that there was a higher sense of “insecurity” during an automation failure and there was a general temptation to ignore raw information and “follow the green/magenta line.” The most worrying aspect was that pilots said their colleagues were “becoming complacent and relied too much on the automation but that was often because airline SOPs mandated reliance on automation.”

Major Charles F. Spencer, Jr., USAF, in a paper Cockpit automation and mode confusion in 2000 that combined Rudisill’s findings, subsequent works and his own 20 years in civil flying in automated and non-automated aircraft, found “mode confusion” to be a major issue and claimed that “ergonomic design had not kept up with cockpit design.” Spencer found that pilots misunderstand the behavior of cockpit automation. “Usually, the result is benign inconvenience, but it has occasionally ended in tragedy.” Spencer’s paper called for a new approach to alerting pilots with a four tiered aural alerting system.

Airbus VP Training Capt. Jacques Drappier, in a presentation on the subject of erosion of manual flying skills in highly automated aircraft said the jury is out on the subject. “From a safety standpoint automation gives a maximum of safety. However it must go along side manual flying skills. We must maintain these flying skills and the way is through training.” Drappier also raises the issue about the speed with which co-pilots are reaching captain status with some gaining the left seat in four years with fewer than 3,000 hours as first officers.

“Can we really believe that these youngsters have mastered the skills necessary in this time? Learning based on the experience alone is not sufficient and we, the industry, have to put in place specific training to answer this question. Of course, they show the necessary skills in their test today, but we need a complete rethink about what we are training for, and to shift the balance away from repetitive and devalued traditional “checking” to development of pilots through continuous and competency-based learning, to operate in the modern environment with modern equipment.”

Drappier notes that many of the recent accidents appear to be related to flying skills “but when you look more closely it is competency.” He says, “We are addressing this with Flight Safety Foundation, and Boeing in the Training and Qualification Initiative which looks at training based on recent experience not flying of 30 years ago.”

Technology impact

This is not to downplay the tremendously positive impact technology has had on aviation safety. Enhanced Ground Proximity Warning Systems have played a major role in this improvement.

Since 1996, 40 CFIT accidents have occurred and virtually all have involved aircraft not equipped with EGPWS/Terrain Avoidance Warning System technology. Last year there were seven CFIT accidents, five of which occurred to aircraft lacking EGPWS/TAWS. Of the remaining two, one involved an aircraft with an inoperative warning system.

Nevertheless troubling trends are there for those inclined to seek them. It is true that over the past three years, the human fatality rate has reduced from 0.23 to 0.18 per million departures for western built jet aircraft, but the hull loss rate has been creeping up over the same period. In 2006 it bottomed at 0.65 per million departures, climbed to 0.75 in 2007 and hit 0.81 losses in 2008. 2009 was better at 0.71. IATA member airlines were better at 0.62.

The numbers however are grimmer for Eastern-built equipment with a global accident rate for 2008 of 12.11 and even worse in the Middle East and North Africa with a massive 112.68 per million departures.

Meshkati, who has conducted the industry’s longest running (25 years) human factors in aviation safety course at USC, says aviation needs to do some soul-searching and come up with a paradigm shift to move safety forward. He also warns that “regulators need to improve their safety culture” and says there is a “gap between the regulator and the industry.”

“There are three major players – manufacturer, operator and the regulator. For years, we have focused on the first two. Now we need to turn our attention to the regulator. States have a critical role to play in shaping their regulator’s safety culture for improving the safety of the overall aviation industry. This could be the next Holy Grail for safety improvement for the aviation industry worldwide,” he says.

Meshkati’s views are supported in IATA’s 2008 Safety Report showing that regulatory oversight was a factor in 69% of the 109 accidents in 2008 and the major factor in Africa (29% of accidents), Asia/Pacific (47%), Latin America (44%) and even the US (18%). Globally in many major accident categories, regulatory oversight was a dominant factor according to IATA as under:

1. CFIT – 67%
2. Runway excursions – 31%
3. Ground damage – 31%
4. Undershoot – 20%
5. Gear up landing – 38%

Black spots

The challenges of improving this third leg of the safety stool are illustrated by the experience of Indonesia, whose airlines were all banned from flying into the EU for some time after a spate of accidents.

In a letter to the Jakarta Post, in early 2009, retired Air Chief Marshal Chappy Hakim, former chairman of the Indonesia’s National Team for the Evaluation of Transportation Safety and Security, claimed that “the safety awareness of all the national aviation stakeholders needs urgent attention”, and added that “the root of the problem [of Indonesian aviation] is the disobedience to the flight rules, regulations and instructions.”

Flight Safety Foundation President Bill Voss claimed at the time that the country’s Director General of Civil Aviation “has funding problems and a severe shortage of safety inspectors to monitor airlines. When it comes to inspectors, they’re still well short of what they need. It’s a significant shortfall.”

Australia’s Civil Aviation Safety Authority and Transport Safety Bureau have been working with the DGCA and the EU ban was lifted for Garuda and three other airliners last year with Garuda passing an IATA Operational Safety Audit.

Voss notes that the recent run of accidents is not confined to countries such as Indonesia. He also points the finger at Europe and the US. “We have had Spanair and Colgan Air. These are accidents that we should be able to prevent given the knowledge we have. There have been several hundred warning signs and we are talking of simple things.”

He believes more sharing of data between safety programs needs to occur. He points out that NASA’s Aviation Safety Reporting System contains 55 instances in the US since 2000 of incorrect setting of flaps on MD-80 series aircraft. This type of error is suspected of having led to the crash of the Spanair MD-82 which killed 154. The Spanair accident, in which a flap setting warning horn did not sound, appears to be identical in circumstance to the loss of a Northwest Airlines MD-82 at Detroit in 1987 with the loss of 154.

Basic Errors

A review of safety date for 2008 and 2009 lends credence to those who are concerned about deterioration of flying skills and/or competency. Of the 109 airline accidents in 2008, IATA says that manual handling/flight control and non-adherence to SOPs were factors in 38% and 33% of crashes respectively. Similar numbers apply to 2009 with 26% of crashes being runway excursions.

Something as fundamental as call outs was a factor in 13% of accidents in 2008.

In 2008 flight crew errors were a dominant factor in the seven accidents in Africa with non-adherence to SOPs cited in 57% of cases, and of those, 50% were intentional. Handling skills were a factor in 43%.

The record in the CIS showed the same deficiencies. In the 10 accidents in the CIS in 2008, 56% involved non-adherence to SOPs and 60% of those were termed intentional non-adherence.

Not surprisingly perhaps was IATA’s finding that in 80% of the CIS accidents there were deficiencies in safety management. In one fatal accident last year involving a 737-500, the flight crew reportedly loss spatial orientation during a night approach through clouds.

The cockpit crew had only recently transitioned to Western-built aircraft and apparently was not familiar with the function of the attitude indicator on the aircraft.

Even in a mature market such as Europe the problems showed up. There were 17 airline accidents in Europe in 2008 with pilot crew errors cited as the major contributing factor in 40% of all the accidents and non-adherence to SOPs by the flight crew cited in 27%.

The accident investigation into the crash of a Turkish Airlines 737-800 in February 2009 is focused on a faulty altimeter linked to the autopilot. Notwithstanding this failure, information regarding the cockpit crew’s response caused Boeing to issue a reminder to all operators “to make sure flight crews pay close attention to all primary flight controls during critical stages of a flight.”

In the US, in the 24 airline accidents that occurred in 2008, IATA says that pilot crew handling errors were factors in 45% of accidents and non-adherence to SOPs a factor in 18% of accidents. Voss reiterates that “we are talking about simple things.” He then asks: “What sort of data do we need to stop this?”

Low hanging Fruit

Stopping aircraft on landing is the top priority of IATA which identified runway excursions as the major cause of accidents for 2008 with 28 and 23 in 2009.

Over half of the accidents – 57% – resulted in a hull loss and 14% involved fatalities. As previously reported, runway excursions historically have not received the attention of incursions, although excursions comprise 96% of all runway accidents, 80% of fatal runway accidents and 75% of related fatalities according to Flight Safety Foundation.

In comparison, runway incursions account for less than one accident per year on average.

According to a new report from the Australian Transport Safety Bureau that cites Flight Safety Foundation data, in 42% of approach and landing accidents, the decision to continue a final approach was a contributing factor, while 78% of all ALAs could have been avoided by a timely go-around.

According to IATA data, high incidences of ALAs and regulatory oversight were almost always linked. Last year IATA has developed a Runway Safety Toolkit which will address not only runway excursions but incursions and runway confusion.

Meshkati urges safety regulators to take the lead in developing a more safety-focused culture to improve basic airmanship as technology by itself cannot solve or remove all human factors from the safety equation.

He quotes from Yale University Professor Emeritus Charles Perrow’s book Normal Accidents: Living with high risk technologies: “The dangerous accidents lie in the system, not in the components and the inherent system accident potential can increase in a poorly-designed and managed organization.”