Global move against criminalization and victimization of pilots, post accident/incident.

 
Criminalization/Victimization of Pilots

Question

I have a question to ask which has been lingering in my head for a long time. When an aircraft meets with an accident/incident, is it only the flight crew at the controls responsible for the situation they ended up in and further face criminal and administrative proceedings?

Why do the investigating agencies/ regulators arbitrarily suspend license of the crew even before the final investigation has been completed to determine the root causes?

In the words of Prof. Patrick Hudson of the Delft University and a pioneer in safety culture, ” the pilot is the first person to reach the site of the accident”. That is a true statement and I would like to add that the other contributors to the accident/incident follow suit.

Every pilot who meets with an accident/incident has been certified competent/proficient by the training and checking methodology used by the operator and approved by the regulator. Therefore there are a number of individuals and entities involved in the process of conducting a flight.

Recent events and symptomatic knee jerk reaction

The spate of runway excursions and other incidents in India with Spicejet and Air India Express pilots at the controls saw the regulator suspending the flying license of quite a few pilots, as reported in the media. The final investigation is not yet complete and blame has been apportioned and punitive action taken.Is it justified to do so without determining the route causes and the contributory causes. The knee jerk action to suspended the pilots license is addressing the symptom and not the root causes, therefore they continue to reoccur.

This policy of suspension of license goes against the State Safety policy to foster and assist stakeholders in developing comprehensive Safety Management Systems (SMS) and develop preventive safety strategies for
the aviation system in an environment of a “just culture”.

Central to the establishment of a safety culture, and with particular regard to reporting systems, is the underlying requirement for a ‘Just Culture’. A Just Culture has been described as ‘an atmosphere of trust in which people are encouraged (even rewarded) for providing essential safety-related information, but in which they are also clear about where the line must be drawn between acceptable and unacceptable behaviour’. Marx identified four behaviours as giving potential for unsafe acts to arise:

  • Human error
  • Negligent conduct
  • Reckless conduct
  • Intentional ‘wilful’ violations

Under the assumptions of Reason’s model once more, within the majority of circumstances, it is the sequence of events that will ultimately give rise to an accident as opposed that of an isolated event alone. It is therefore imperative that the boundary as to what constitutes ‘acceptable’ and ‘unacceptable’ behaviour be drawn. Accordingly, it is equally imperative that both individuals and organisations should understand the role to be played if this culture is to develop and succeed. It is therefore generally accepted that to discipline the perpetrators responsible for the vast majority of unintentional unsafe acts would not be beneficial; instead such acts would require alternative methods, such as retraining, to eradicate their occurrence. Wilful acts or those of gross negligence however must not be tolerated and may not expect impunity from prosecution. 

Root causes analysis

Ishikawa fishbone root cause analysis

As you can appreciate from the above diagram, it is not easy to apportion blame or liability on one person or the flight deck crew alone.

ICAO assembly resolution 35-17 against misuse of safety data

The protection of safety information from inappropriate use is essential, since the use of safety information for other than safety-related purposes may inhibit the future availability of such information, with an adverse effect on safety.

Read here the full text.

In March 2006, Council approved, as part of Amendment 11 to Annex 13, the legal guidance for the protection of information from safety data collection and processing systems, which was incorporated into Annex 13 as Attachment E.

Read here: Flight safety foundation joint resolution regarding decriminalization

Two Swiss ATC controllers convicted

Punitive/Non-punitive or administrative action against erring flight deck crew

 ICAO Annex 13: OBJECTIVE OF THE INVESTIGATION

3.1 The sole objective of the investigation of an accident or incident shall be the prevention of accidents and incidents. It is not the purpose of this activity to apportion blame or liability.

 Causes. Actions, omissions, events, conditions, or a combination thereof, which led to the accident or incident. The identification of causes does not imply the assignment of fault or the determination of administrative, civil or criminal liability.

Contributing factors. Actions, omissions, events, conditions, or a combination thereof, which, if eliminated, avoided or absent, would have reduced the probability of the accident or incident occurring, or mitigated the severity of the consequences of the accident or incident. The identification of contributing factors does not imply the assignment of fault or the determination of administrative, civil or criminal liability.

Any investigation conducted in accordance with the provisions of this Annex 13 shall be separate from any judicial or administrative proceedings to apportion blame or liability.

Note.— Separation can be achieved by the investigation being conducted by State accident investigation authority experts, and any judicial or administrative proceedings being conducted by other appropriate experts.

Procedure

Preliminary report by the Inquiry Officer should be finalized within two weeks of the incident/serious incident or as stipulated in the appointment order and in the format of ICAO Annex 13 . It shall contain the requisite information including any safety hazard, either in human factor, Aircraft factor and/or any other relevant factor that is prima facie evident during the early stages of investigation such as lack of piloting proficiency if any or any unwarranted disregard of safety requirements, in case these are obvious to enable framing and implementation of immediate corrective safety measures.

The Final investigation report should be finalized in the format as stipulated in ICAO Annex 13. The body of the final report should comprise the Factual Information; Analysis; Conclusions & Safety Recommendations. The causes should include both the immediate and the deeper systemic causes. The recommendations should be for the purpose of accident prevention and any resultant corrective action.

Punitive action

If punitive action is required for the lapses in accordance with Sub-rule (14) of Rule I937, the concerned person shall be issued with a show cause notice in the form of a memorandum.

The following information shall be reflected in the memorandum:
a) Background of the occurrence in which the erring person is found blameworthy detected during spot check, surveillance or routine inspection/investigation of accident/incident and may relate to inadequate/improper maintenance action, improper certification or any
action resulting in accidents, incidents including ground incidents, delays/cancellation attributable to the concerned person’s actions.
b) Brief reason for blaming the erring person and the details of rules, regulations or procedures which have been violated.( ICAO Annex 13 clearly states that the objective is not to blame anyone.)
c) Applicable rule of the Aircraft Rules, 1937 (Rule 19 of Aircraft Rules as the case may be, in light of which the memorandum is issued).
d) Time period to offer comments to the memorandum by the erring personnel and also action of concerned DGCA directorate in case the erring person fails to offer his comments.

mindFly analysis

The investigation tells us why an accident/incident took place in addition to what happened, which in most cases would be most obvious. The intention is not to blame anyone or apportion blame but to prevent similar occurrences from taking place again. Therefore a thorough investigation is necessary which analyses all the contributory causes and their role in the occurrence. The above paragraph of punitive action states that a brief reason for blaming the erring person shall be given. This is against where safety culture starts, which does not blame a person.

It is only after a detailed investigation that we can find out if the there was a deliberate violation and how it pans out with the tenet of just culture. Suspension of license amounts to blaming the crew without giving them the details of the case and a chance to defend themselves. Punishment without determining the root causes has never acted as a deterrent. Humans are affected by physiological and sociological factors. They play a huge role in the way they behave.

Read my article on ‘Cognitive lockout” which has been printed in the UK Flight Safety Magazine. It throws more light on the cognitive part of why flight crew continues carry out an un-stabilised approach thereby risking a runway excursion. It is imperative that we understand the cause of occurrences from a human behavioural point of view. A technical investigation will not look into the human factor angle due to which the errors will keep repeating themselves.

Vistara lands with “Mayday Fuel”situation, challenges of diversion

 

While we can speculate and debate endlessly, the crew at the controls would know the challenges they faced while diverting from Delhi to Lucknow airport on 15th July 2019. The flight which is typically 2 hours lasted 3 hours and 56 minutes and landed with 200kgs in tanks.

I have highlighted in my blogs and the same had been witnessed when Gatwick was shut down due to drone activity.

  • Airlines are not carrying the mandatory fuel to cover the completed go-around procedure
  • Diverting from a busy airport/airspace can practically take additional time and fuel since the air traffic controller needs to separate the diverting aircraft vertically and laterally/longitudinally from the 40-50 other aircraft in the airspace.
  • Choice of available alternates dwindle fast in the event of poor weather or mass diversions due to unavailability of parking space at alternates.
  • A direct flight as the crow flies may not be available. The safety risk assessment while formulating the fuel policy must address these points.
  • The regulator who approves the fuel policy must accept the risk post approval.

The Mumbai – Delhi Vistara A-320 Neo UK944 landed at Lucknow on 15th July after diverting, with about 6 minutes of fuel remaining. The aircraft would have departed Mumbai with the regulation fuel and possibly some extra fuel, looking at the forecast and actual poor weather at Delhi airport. Takeoff Mumbai 09:47 Z

Entered Hold 11:12Z at Delhi

Exited hold at 11:26 Z, hold time of 14 minutes.

The final approach at Delhi was carried out at 1150Z followed by a go around.

Arrived Lucknow at 12:40Z and landed at approx. 1320Z.

Following are the MET reports for Delhi, Jaipur and Lucknow

Screen Shot 2019-07-16 at 10.46.09 AM.png
Delhi Met report
Screen Shot 2019-07-16 at 10.45.40 AM.png
Jaipur Met report
Lucknow weather forecast and actual

While it is futile to speculate at this moment, the facts will only be known post investigation. The initial diversion could be on account of strong tail winds or poor visibility associated with rain showers.

Lucknow weather

Lucknow had a forecast of rain and visibility decreasing to 1500m at the forecast time of arrival at Lucknow in the event of a diversion. The question arises is how much extra fuel did the crew uplift?

The interesting point I would like to highlight here is the route that the aircraft took to divert to Lucknow. While there would be sufficient fuel at the point the diversion was initiated from Delhi, typically fuel from Delhi to Lucknow and 30 minutes of fuel to hold over Lucknow. Ideally the aircraft would have landed at Lucknow with 30 minutes of fuel remaining in the tanks but in this case the aircraft landed with about 6 minutes of fuel left.

Flight Path

Flight path VS direct line (blue) to Jaipur & Lucknow
Satellite weather image

While the prevailing en-route weather shows widespread moderate to heavy rain , the reason why the crew took the aircraft south of Delhi towards Agra before turning left towards Lucknow airport. This flight path significantly increased the flight distance and the fuel burn. The blue lines represent the shortest diversion routes available to two closes alternates.

What should also be noted that west of Delhi was much clear of weather and airports like Jaipur, Udaipur could have been better choices. Its not known how much support the crew were getting from the airline IOC/Dispatch to form a correct picture of the available weather.

Past accident due low fuel

In 2014 Air India A-320 met with an accident after diverting from Delhi due low visibility and attempting to land at Jaipur which had prevailing low visibility too. Read final investigation report.

Air India accident Jaipur 2014

mindFly analysis

Operating to busy airports can be challenging with some unique situations that must be considered during the risk assessments. While all airlines consider the risk and uplift the additional for the flight getting into the busy airspace surrounding the airport, no airline considers the risks of getting out if a landing is not successful.

Additional fuel is carried for holding for poor weather or air traffic delays. Critical fuel as required by regulations, that of a missed approach segment is not carried by airlines and the regulator has failed to check the same in repeated audits.

While a diversion may be assumed a walk in he park, that of setting course to the chosen alternate airport, the difficulty of weaving out of the hair of other incoming and out going air traffic is not considered. This incident may help highlight similar issues if found relevant.

With increasing complexity of airspace reserve fuel must be increased.

Allowed to touchdown late but not as per calculations

 

It may sound too simplistic but from a conservative point of view, after touch down the aircraft should be stoppable within the physical proximities of the runway. The current landing distance calculations are based on a touchdown within the first 1500ft but the touchdown zone markings extend till 3000′ on a typical runway.

Contributory causes

The pilot is allowed to touchdown latest by 3000′ on a runway length 7800′ and above leaving a distance of 4800′ in a worst case scenario. A risk based safety margin must be adopted by the operators especially considering the long landing distance data.

Landing distance

Actual Landing Distance

Flight Test Conditions


(1) The braking coefficient of friction obtained from not less than six landing tests conducted in accordance with FA.R 5 25.125 and subject to the additional provisions listed below should be used to establish the ground
braking distances.
(i} The landing should be preceded by a stabilized approach not to exceed an angle of 3° down to the 50-foot height and at a calibrated airspeed not less than 1.4 Vso (stall speed)·
(ii) The average touchdown rate of descent should not exceed 6 feet per second. Longitudinal control and braking application procedures must be such that they can be consistently applied to yield a nose gear touchdown
rate of descent that does not exceed 8 feet per second.
(iii} The runway should be level, smooth, hard-surfaced, and
well-soaked.

Touchdown Zone

European Action Plan for the Prevention of Runway Excursions – Released Edition 1.0 – January 2013 reveals the following:

The parameters affecting the landing distance are published in the Flight Operations Manual. Flight crew should have a good understanding of the sensitivity of the landing distance to these parameters in order to make
sound go-around decisions. The following data shows the effect of relatively minor deviations from a baseline calculation of landing distance for a wet runway. The reference condition is a reasonably attainable performance level following normal operational practices on a nominal wet
runway surface. The reference QRH data on the bar chart below is based on:
1500 foot touchdown
VAPP=VREF+5, 5 knot speed bleed off to touchdown
Sea Level, Standard Day (15 C)
No wind, no slope
Recommended all engine reverse thrust
Braking Action – Good, consistent with FAA wheel braking definition of a wet non-grooved runway.
The vertical line represents the dispatch requirement that is 1.92 times the dry runway capability of the aeroplane.

European action plan Version 1

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