A Killing Syndrome of Four Letters
A killing syndrome of four letters
By HÃ©ctor HÃ©reter
Special for Air Crash News and Information
Right after 46 passengers and crew of Santa Barbara’s flight 518 were killed on February 21st on a desolated and cold mountain slope in the Venezuelan Andes, it became evident for many that Venezuelan pilots do as they wish, disregarding all local and international set of flying regulations.
Their attitudes demonstrate a lack of professionalism and excess of self confidence, mostly among the most experienced pilots who think of themselves as infallible. This leads to bad judgment and unfortunate decisions, in some cases with tragic results, as in flight 518.
Just as The Peter Principle states in a hierarchy members are promoted so long as they work competently. Sooner or later they are promoted to a position at which they are no longer competent (their “level of incompetence”), with potential to create conflicts, or worse still, disastrous endings.
“The level of pilots arrogance in our country is amazing” says a high Venezuelan airline executive who prefers to remain in anonymity. “They do as they please regardless of regulations set by authorities or the airline the work for, and there is no nobody that can restrain them from following that behavior”
“And this is common among all the airlines?” we asked.
His answer gave us chills: “You better believe there is God who will protect you and start pray to him so you reach your destination in one piece every time you board a Venezuelan plane.”
The 518 flight is a vivid example of what is known here as the “3IA” syndrome: Impatience, Imprudence, Indiscipline and Arrogance.
Human error is a major, recurring issue in most aviation accidents. The National Transportation Safety Board (NTSB) has consistently cited triplane’s crews as the major cause or factor of accidents, exceeding the proportion of accidents related to aircraft or environmental causes by a large margin. The human factor in modern aviation is a source of concern, since humans are the ones to suffer from the 3IA syndrome: aircraft equipment, engines, navigation and in-flight safety devices have become so good that human beings are the constant weak link in aviation safety.
NTSB HUMAN ERROR CHART
Unprofessional Attitudes 47%
Visual Perception Misjudgment 19%
Pilot Technique 21%
Inflight Judgment or Decision 5%
Improper Operation of Equip. 6%
Unknown Causes 4%
Santa Barbara’s crash started with a series of events that led to a disastrous end.
In first instance the pilot who commanded the ill-fated airplane, Captain Aldino Garamito, was called at last minute to substitute for the designated pilot grounded at the Vigia airport because of bad weather. Garamito who was an experienced pilot with 9 years in Santa Barbara, was hastening to return to his home near Caracas.
The first “I” of the 3IA syndrome: Impatience
In this point enters another law, Murphy’s law. Anything that can go wrong, willâ€”and at the worst possible moment When an event begins badly and is not corrected on time, the subsequent decisions that are taken follow a mistaken path. Due to the change of pilots, SB flight 518 already had two hours of delay which increased the pressure on (and impatience of) the pilots. Such impatience was demonstrated when initiating the return to Caracas, the flight: 1) didn’t wait for the airplane’s avionics to calibrate, 2) didn’t follow procedure of preparing a pre- flight check list, 3) took a flying route prohibited by the National Institute of Civil Aeronautics (INAC the Venezuelan equivalent of FAA). This “non-approved air path” saved them 15 minutes on their way back to MaiquetÃa International airport.
This last decision, aside from being impatient, demonstrates imprudence, a lack of discipline and a failure to follow the set of flying rules established by the aeronautical authorities and Santa BarbaraÂ´s Corporate policies.
Several experts in the Venezuelan civil aviation agree that the most experienced pilots become victims of excess of confidence, developing among them a sense of “infallibility and rules don’t apply to them”. Minutes before the airplane collided with the mountain, copilot, Denis Fereira, said to Garamito “we just made another yucca”, That’s a Venezuelan idiom meaning that they were repeating a mistake.
Posted in “Vigilante AÃ©reo”, a blog dedicated to analyze airplane crashes in the country, were the last words ever exchanged between pilot and copilot just before they slammed the mountain wall:
“Sir. this is not the route”, says copilot Fereira.
“Relax, I know what I’m doing,” and then sarcastically adds, “Are you scared?”
The big gray barrier of mountains appears in front of them. They set the engines to full power.
The fatal affirmation of “Relax, I know what I’m doing.” and asking “Are you scared’?” is the last letter of the syndrome.
“A” for Arrogance and excess of confidence, ends the life of 46 people in a desolate and the cold Andean slope at 12,000 feet.
By HÃ©ctor HÃ©reter