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Anatomy of an accident

The first flight of the Wright brothers was on December 17, 1903 and the first accident was only 12 seconds after takeoff. This is the proximity that exists between a flight and an accident.

With time, technology made aircraft so safe that today air travel has become the safest mode of communication. While aircraft became technologically advanced, the pace with which humans were trained to catch up with these high-tech machines was probably not enough.

Many countries really worked hard in the last 50 years or so to improve human performance. However, just like all other disciplines, this investment in human resource varied from country to country and culture to culture.

The accident that took place in Karachi is going through its initial investigation phase. A good investigator always believes that the cause of an accident mostly lies months or years before the actual accident happens. Accidents don’t just happen over a day, their roots are established due to persistent oversight and compromised accountability.

Any accident investigation in general, and air crash accident investigation in particular, reaches a stage where the investigators either slow down or come to a halt facing a very important question – the ‘why’ part of the investigation. The flight data recorder tells the investigators ‘what’ happened, ‘how’ and ‘when’ it happened but it is the CVR or Cockpit Voice Recorder which tells ‘why’ it happened. Not only that but the invisible factors going through the mind of pilots also help in figuring out the ‘why’ part; this of course is the job of Human Factors specialists who understand human psychology in stress.

It is important to note that during day-to-day flights also whole flight proceedings are recorded, which not only include engineering self-monitoring data but also the recording of pilot actions.

This means that whenever a pilot makes an error – no matter how small it is on the flight deck – it is recorded on the aircraft flight data recording and monitoring systems. So much so that before the aircraft lands at its destination the data is already available with the authorities on ground. For some airlines, this data is retrieved after landing when the aircraft is handed over to engineering.

The question is: what happens to this data? The data has predetermined parameters and a pilot must follow those parameters and limits while flying the aircraft. If a deviation or violation is noted then that deviation is communicated to flight operations by the flight safety department, who are the custodians of that data. After that, a small investigation is carried out so that such a trend is immediately arrested through the efforts of the flight standards and training department. This is a historically established and well developed system evolved over the years to ensure the safety of passengers globally.

Many investigations result in a blame game where the last person involved is blamed, whether it's a pilot or an engineer. This system of investigation is incomplete because it does not identify the systemic errors of supervision and management oversight.

Aviation psychologists do believe that when a person makes a mistake, especially if that mistake is a violation of procedures, then it is not the first time that they are doing it. Also it is believed that in an organization if one person is doing something without check and balance, then there are very strong chances that other people will also be doing it – indicating a poor safety culture in that organization. The question is: who or what allows the safety culture to get destroyed?

The aircraft data, which is downloaded after the flight has the answer. If the accountable managers of safety and operations do not do their work and do not give proper feedback to correct such pilots then as per human nature the habit patterns will continue to erode. So much so that no one in that organization will be held responsible.

It is immensely important to know that aviation is based on a block-building approach of managerial hierarchy. If any of those managers are not doing their job then the safety culture will immediately collapse and the results will be deadly.

While investigations of this crash will take place, we hope that blaming only a pilot is not resorted to. We hope that all those who were responsible are identified. It is important that the data is collected not only for this flight but the data of all previous flights is also investigated so that we find the truth behind the culture of an organization. We also hope that the ICAO Annex 13 which deals with aircraft accidents is fully applied and implemented. It is a very important point to note that a judicial or criminal investigation is undertaken if people are found guilty of criminal negligence – whether they are in the management or in the operations team.

PIA has a glorified history. We hope that this history may have an even better future but that will not be possible until a pure accountability culture is present in the organization. Airlines cannot exist without a safety culture. Airbus which is also part of the investigation will also shoulder the responsibility of correctly highlighting the gaps in safety procedures, if any, during the course of events of this accident.

Towards the end, another important role or probably the most important role rests with the regulator, that is, the Pakistan Civil Aviation Authority (PCAA). Most importantly, accidents in aviation can also be a factor of promotions and upgrades based on favoritism, where quality of training can be compromised. If there are gaps in the safety culture or training standards then the oversight of the regulator of those gaps will also be questioned.

The writer is an airline captain of Airbus A320 and an aviation psychologist. He is also a certified investigator of ‘human factors in air crashes’.

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