A Conceit of Accountability

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  • What Will EASA do?

    IF the European Aviation Safety Agency is going to uphold its own mission “to promote the highest common standards of safety and environmental protection in civil aviation,” it must take strong action when it receives the French Accident Investigators first results.

    There’s so much speculation out there regarding what this account will be that it just seems better to wait and see what it says before second-guessing it. Regardless of the details, you know the report is going to talk about 1. lightning and weather 2. pitot tubes; they may also talk about computer issues, composites and the stabilizer/tail fin/rudder also. I doubt they’ll tackle Airbus’s fly-by-wire technology.

    The only thing I don’t understand is why Airbus 330’s have not already been grounded pending the results of the investigation. With several recorded incidents of Airbus 330’s suffering near-disasterous incidents and generating data similar to what was received from the AF447 flight, it makes more sense to ground these planes now before another accident occurs. Why are they letting people fly around in a plane that is an accident waiting to happen?

    Or are paying passengers the world over just guinea pigs for Airbus to test their craft on until they get it right?

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    Wrongheaded Industry Reassessing Vulnerable Pitot Tubes vs Ice Procedures instead of Brainstorming Next Generation

    Pitot tubes use external air temperature and pressure to calculate changes in speed. Ice crystals that get caught in pitot tubes are considered a contributing factor in a dozen significant events, and the crash of Air France flight 447. As a result of ice crystal accumulation, air temp and pressure readings are false, autopilots shut off, pilots lose altitude readings and receive false warnings. In a fly by wire plane, this is disastrous. In Air France Flight 447, it killed everyone aboard the plane.

    Today’s news is full of aviation-safety experts looking for changes in procedures and more-precise checklists. There’s a lot of buzz out there about a new study. I hope that the study, as it has been explained, is not just about adapting to broken technology. I hope this is not the only study out there.

    Air France and Boeing are now examining how these ice crystals function (or more correctly, malfunction.) That seems wise.

    But one questions why the next step of the anti-icing drive will be to get consensus on how pilots should respond to pitot tube failure.

    George’s Point of View

    This is like figuring out the best way to drive on a flat tire, instead of making a tire that doesn’t go flat. Sure, pilots should have procedures, but shouldn’t a study be designed with the ultimate goal being to give the pilots a dependable speed sensor, not methods how to mitigate an oncoming disaster? Are designers afraid to trade a known quantity, even though it is flawed, for something unaffected by ice crystals? Even if it is cheaper for airlines to figure out how to muddle on with existing systems than to devise an alternative technology to pitot tubes, shouldn’t the focus of studies be on creating technology that is not disabled by ice crystals?

    Not being an engineer myself, I have no ideas on the subject—but somewhere there’s an aviation engineer with a brilliant idea of either a safe design of reconfigured pitot tubes or a completely different system. Let us hope that engineer is able to step up, and be recognized. But it may not be so simple. Apparently Airbus and Air France had been aware of chronic pitot tube problems for years and were content to continue using the same design anyway.

    Come on engineers. It’s time for a better mousetrap.

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  • Politics and the Art and Science of Crash Investigation

    Should art be mentioned here? Art is the expression or application of human creative skill and imagination. Surely this applies to investigation. It is only through imagining the sequence of what happened that what actually happened can be determined. Theoretically, scientific experimentation takes place in a vacuum, or at least in a neutral area where the laws of nature can be observed to run in a natural fashion, after which, conclusions are drawn. Attempts are made for the hypothesis to be untainted by factors such as “opinion,” “bias,” and “prejudice.” But it could not exist without human imagination.

    But imagination is far from “imaginary.” Accident investigation is not scientific experimentation, but it is supposed to be based, like science, on handling conclusions based on neutrally observed but hard facts. The problem of course, is that the accidents being investigated do not occur in the careful measured neutrality of a lab, but in the messy, busy, interactivity of the real world. The search for the truth is a crucial thing, one of interest not only to the victims or families of the victims, but also the insurance companies, banks, aircraft manufacturers, airlines, future airline passengers…the list grows. The climate in which investigations take place is far from neutral, in spite of attempts for investigators to be professional.

    If you look at the Comoros crash you can see the effects of clashes between the governmental institutions of Comoros and France, replete with name-calling, bias, and politics. This is equally true in the Air France 447 case, where political pressures exert invisible pressures. Consider the stake the country has in Air France, and in Airbus. In any investigation, it may be that the lives and careers of some very powerful people hinge on how an investigation goes, and even more so when a country like France adds the aspect of criminal proceedings.

    The well-known world regulatory organizations over aviation industry trade groups (IATA, ICAO, AEA, ATA) have developed highly regulated procedures for investigation. We can only hope that the highly regulated and complex process of investigations can continue in as even a keel as possible, in spite of the turbulence coming from all interested parties. The world waits for answers, but politics inevitably set the stage, and like the observed but unseen air currents in weather, play a part, whether invisible or obvious. While there are some protections in place, (for example, NTSB reports can not be used as evidence lest the integrity investigation be compromised), we can never fully know what goes on behind the scenes.

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  • Ethiopian Airlines: Victims’ Families Endure

    There’s always a lot of finger-pointing going on, so it really isn’t unexpected that Ethiopia accused Lebanon of misleading and hampering the investigation. We should remember that the ICAO could not be there if the investigation did not live up to the highest standard.

    It is also important to remember that any speculative conclusions, or “leaks” or preliminary investigation results are just that: speculation or investigation, or preliminary. It takes months and sometimes years to get to the cause of a crash, and this one is no exception. Eventually, no stone will be unturned.

    Remember that all of the parties involved will be conducting their own investigations–not only the governments, but also the plane manufacturers, the component manufacturers, (any party who thinks they may be sued), as well as attorneys who are looking out for the welfare of their clients.

    Many research teams are engaged in ferreting out, determining and studying the facts of the crash.

    It is a shame that after all their grief, the families have to endure finger-pointing and speculative theories masquerading as truth, smokescreens which are put out by reporters or politicians for political purposes.

    These investigations take time. There are no fast and easy answers. Look at the Air France Flight 447 crash of 2009. We’re still hearing all sorts of theories, but even in that earlier crash, the investigation is still going on; we’re still looking for wreckage and black boxes.

    And so, the families weather the storm, continuing to bide their time, enduring their grief, and waiting—patiently or not—for facts, for answers, for the truth to show itself.

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    Massive Airbus Settlement Looks to be Unsettling

    George’s Point of View

    The insurance claim for the Air France crash promises to be huge; the cost of the aircraft alone will no doubt exceed a hundred million dollars. Between the international treaty that ensures aviation passenger’s rights, the legal system, insurers like AIG, AXA SA, Allianz SE, American International Group Inc., and the companies which are going to be liable (like Airbus and who ever manufactured those pitot tubes), the claims are going to be in the hundreds of millions.

    Spouses, children and parents will be receiving compensation from the insurance, and from companies whose exact degree of liability will be decided through the courts (if not in them.)

    IF it gets to the courts.

    In situations like this, the insurance companies swoop down before the victims’ families can arm themselves with lawyers; in fact, insurance companies are a little like lawyers. Or worse. They’re like salespeople. They want that signature on the dotted line, and they want to get it for as little as possible. They want that release. To get it, they try to offer victims’ families the smallest possible carrot.

    If they can induce families to sign a release, then the families sign away any future claims that might arise from product liability. When you sign that release, you waive the right to sue.

    So I’m hoping the families don’t jump the gun here, and rush in to negotiate with the insurance companies without legal counsel on their side. When they sign those release forms, they just might be signing away justice for their loved ones.

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    India: Civil Aviation Safety Advisory Council

    Air India Airlines did not single-handedly inspire the newly formed Indian separate body to investigate air accidents, but as the committee was formed immediately after the Air India Express crash in Mangalore that claimed 158 lives, it certainly was a major catalyst. It remains to be seen if the new investigatory committee will be as efficient or reliable as the US’s NTSB/FAA which investigates all major air events in the US and some outside of the US (when requested by foreign agencies or when American pilots, citizens, service or goods are involved).

    Certainly the DGCA needs help. We have already pointed out in a prior editorial that the DGCA’s report on the Mangalore crash is overdue. The Times of India quoted the DGCA’s own statutes:

    According to Civil Aviation Requirement (CAR) Section 5 (Air Safety), Series C, Part I issued on 13 October 2006, “preliminary report by the inspector of accidents/inquiry officer should be finalized within 10 days of the accident.

    We have also located a source that claims that * all of Air India Express managerial positions are “part-time.” Does this mean that the company was deliberately set up to have no key personnel who can be targeted as decision-makers? Though why should that matter? Air India Express is the budget branch of a larger company; Air India Express is a wholly owned subsidiary of Air India which is now part of National Aviation Company of India Limited (a merger between Air India and Indian Airlines.) Someone is in control.

    Those who fly India and have high expectations of the new safety committee being effective may be in for a let down while the newly formed body finds its footing. The new, separate Civil Aviation Safety Advisory Council which has been set up to handle air crashes has no experts from Air Traffic Control (ATC) nor expert pilots. Along with the Directorate General of Civil Aviation (DGCA) chief, Dr Nasim Zaidi, the 28 member body includes Aviation CEOs including Air India Chairman Arvind Jadav, Spicejet CEO Sanjay Aggarwal, managing editor of Centre for Asia Pacific Aviation, Kapil Kaul.

    If you take a look at how the NTSB handles an investigation, you will see that a team of experts are engaged and all interested parties, including pilots, are represented, including some you might not expect. Without such input, investigation is a waste of time.

    The NTSB team of investigators handle individual aspects of the individual investigation, allocated by expertise. Each expert is responsible for a specific and sometimes overlapping portion of the investigation. Specialization like this helps develop and apply expertise in each area and prevents key points from being overlooked. Also, bear in mind that the experts involved in investigating each crash will differ, depending on the parties involved; and most of these parties are on site within hours of the crash.

    SomeAreas of investigation/investigators

    • Structures investigators (who also usually takes responsibility for the crash site, ensuring that all the wreckage (e.g. wings, fuselage, and undercarriage) is accounted for and that proper trails of evidence are followed)
    • Engines investigators
    • Systems investigators such as flight controls
    • Airline’s Operations investigators (also studying crews’ training and suitability)
    • Black box investigators
    • Accident flight’s relationship with air traffic controllers
    • Meteorologists who analyze the weather at the time of the crash to determine if it had a bearing on the accident.
    • Metallurgists who analyze the condition of the plane’s metal and the forces on it
    • Sound specialists (for eg, identifying sounds on black box tapes)
    • Fire and Explosions experts
    • Simulation experts who reproduce the events
    • Flight survival experts who analyze the forces the passengers were subjected to. (These are the people who can tell you the safest place to sit on a plane.)
    • Maintenance experts who analyze the plane’s condition–and how it got that way
    • Psychologists may examine procedures to determine if airline practices exist that cause the pilot to make mistakes, like flying different types of planes. (e.g. Different types of cockpit controls make switching planes an unsafe practice.)
    • Manufacturers representatives who study and analyze their product’s performance
    • Pilots (representatives from the pilots’ union) may be attached to many or all groups; just as…
    • Labor Unions such as the International Association of Aircraft Machinists may attach representatives to multiple groups.
    • Cooperating “foreign specialists” in wreckage reconstruction, black box decoding or interpretation. (Countries who develop special expertise in various fields are often called to join the investigation, just as the NTSB is frequently asked to join foreign investigations.)

      Plane manufacturers have their own investigative teams experienced in this type of analysis, and they stand ready to work on any event that needs their expertise. And the investigation is networked so that if and when they need additional specialists, they can tap into their own company resources.

      One should note that in the case of the Mangalore Crash investigation, the wreckage sat out in the elements for 50+ days before being collected and warehoused. In my opinion, this is carelessness; and furthermore, this carelessness is just one visible aspect demonstrating where the existing procedures are obviously not up to par. While I am sure that experts combed the wreckage, including Boeing, (they always dispatch a team when one of their planes is in a crash,) leaving the wreckage out in the elements is not a best practice for conservation/preservation of evidence. One can only wonder how all other aspects of procedure including those behind closed doors-stand up to Aviation Industry’s internationally expected best practices.

      The industry calls this massive joint investigation the “party system.”

      The parties involved include all parties affected. The more parties involved, the faster the investigation may go.

      Chairmen of each group make their report; and any groups who discover any failures or unusual effects of machinery make note in the final report given to the primary investigator. The investigator invites the individual groups to provide their angle on what caused the crash and how it might be prevented.

      If all the probable causes line up neatly, then it is a simple thing to complete the final report. When theories conflict, the final report takes longer, and tension develops.

      All of this information is supposed to remain confidential until the final report is published.

      In this “party system,” the various opposing parties tend to keep each other “honest”. Unfounded attempts at blame by one party will be met with rebuttal by another–so it is obvious that if there is no pilot representation in this new committee, pilots may end up the “dumping ground.” Let’s say, for example, that a pilot in a crash went in with bad input like an outdated map. Is this committee set up to pursue the investigation to the source of the bad input? A pilot’s association representative would be instrumental in getting to the cause, whether it might be inadequate training, or materials.

      The international community and the people of India are waiting to see how this new committee manages to regulate and oversee all aspects of civil aviation in India, and whether it helps keep India’s DGCA and the safety of India’s aviation systems on track.

      * Need separate body to probe air crashes: Patel; Economic Times, The (India), May 25, 2010

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