AirBlue crash report: An expected waste
We love to be experts, be it speculation behind the reasons for an avalanche or an aviation disaster. But unfortunately some of our experts fail quite miserably. Their reflection on events and their opinions are not only shallow but unworthy of being called an 'expert opinion'.
The Civil Aviation Authority (CAA) has recently released the investigation report of the AirBlue crash. Now I must proclaim that my expertise in aviation accident investigation does not go beyond watching National Geographic's investigations of air disasters. However, having watched multiple seasons of that series, I understand that the purpose of an investigation report is twofold.
The first is to pin the responsibility of the disaster. Secondly, and more importantly, it is to investigate the underlying factors that caused the responsible person or machine to behave in that particular way. This helps in mitigating that particular risk in the future.
The recently released report on AirBlue crash was no better than an earlier investigation report prepared by a policeman consisting of only “gawahon kay biyanat” (statement of the witnesses).
It was simply a statement of facts, lacked qualification for most of its observations and was meaningless when it came to its principal purpose, which is:
Will this investigative report help us understand the reasons behind the disaster and aid in making future air travel safer?
I am sorry to say that it does not serve that purpose.
Now I am not sure if we can even call them experts. Apparently, all these CAA 'experts' did was listen to the cockpit voice recorder (CVR) and analyse the data in the flight data recorder (FDR) to create a story of the flight's final moments. Bravo! Investigation complete, culprit found - who is also dead, so he can't even retaliate.
Aircrash investigations start from here. Why would a highly experienced pilot with over 25,000 flying hours under his belt behave so irrationally and unprofessionally? Moreover, why wouldn't a first officer stop him from acting in this illegal and unprofessional manner and rather choose to become his accomplice?
The report is totally silent on this account. Is it because the pilot is dead and therefore can be blamed, but further investigation may end up focusing on someone who is alive?
The report does not explain or assure why another pilot would not behave in a similar manner in the future. The recommendations of the report are downright funny; construct the new Islamabad Airport ASAP (as soon as possible). So the fault was with the airport and not the pilot? But the report stated that it was the pilot’s fault!
Meanwhile the same investigators have another horrific crash on their hands, the Bhoja Air crash, which apparently happened due to an undetected weather phenomenon called microburst.
Federal Aviation Administration (FAA) of USA mandates that all the planes are supposed to be equipped with Doppler radars which detect microburst and help the pilot in avoiding it. A similar crash was covered in an episode of "National Geographic Air Crash Investigations" (Season five, episode four: Slammed to the Ground)
That crash happened way back in 1985 and subsequent investigations and research helped aviation get safer by understanding the microburst phenomenon and its deadly nature. The last statement of the episode says that microburst related air crashes are now a thing of the past.
Unfortunately, we in Pakistan have a tendency to repeat the past ad nauseum. I suspect that once again the CAA investigators will blame the unprofessional behaviour of the pilot as the cause - because he chose to fly through a microburst (while every pilot knows that flying through a microburst while landing is an almost certain crash). And if the plane did not have a microburst detecting equipment installed (which is a standard worldwide), why was it issued with an airworthiness certificate?
Coming back to the tragic AirBlue disaster, all the loved ones of the crash victims who have read the report must be cursing the pilot. Even the first officer's family must be cursing the pilot who foolishly caused the crash and caused everyone to die.
My question remains the same. Why would such an experienced pilot behave in this manner?
The investigators should dig deeper into the history of the captain; they must reconstruct the details of his last few days and his flying habits by interviewing people who had worked with him over the last 36 years.
Some things are in the air and have to be felt. A pilot at the end of his career may know that if some hidden metric of performance exists in the airline to judge his productivity in this manner, he may see the axe fall on his job the next year. The investigation must not stop here but should be continued. The Bhoja Air tragedy has merely made it more imperative.
The same question must be asked about the first officer. Why didn't he choose to take over? Was it because he was an ex-air force pilot where seniors have to be obeyed to death?
The Hofstede power distance can be one factor which created a status generalisation issue (as reported by Milanovich and Driskel in their study of Status and Cockpit Dynamics). However, airlines are aware of these cultural issues in cockpit communications and many measures have been implemented in the training regime to offset this problem. Still this issue reared its ugly head.
The report must find out the reasons behind the first officer's behaviour. At the moment it has been written in a manner which has exonerated the first officer and implicated the pilot only.
There is a conflict of interets here. Investigation needs to be carried out by an independent investigator because the fault can lie with anybody in the entire spectrum; pilot, airline, regulator or controller. For this reason, the US agency for aircraft investigations, National Transportation Safety Board (NTSB), is a body independent of FAA (US aviation regulator).
However in Pakistan, regulator (which is ground controller as well) becomes investigator. Naturally they want to avoid blaming themselves and pin all the blame on the pilot or at maximum, the airline. The higher ups of the Ministry of Defence need to take notice and create an independent investigation body which should investigate further and try to make future air travel safer.
This report, for sure, is nothing more than a waste of money and effort.
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