In my opinion, there can be no worse outcome of an aircraft disaster than to read two years later an incomplete aviation mishap investigation report. Remembering that the sole purpose of a Safety-based aircraft accident investigation report is find the cause of the mishap, so that others can prevent this same mishap from happening again, it is not clear to me how this report will satisfy that goal.
Rather, this ET409 Aircraft Accident Investigation Report appears to report an investigation conducted by lawyers, who were trying to answer the question, “Who was at fault for the crash and therefore, who should pay for the damages?” The accident investigation board clearly blames the flight crew for making errors that led to the deaths of the crew and passengers. The legal result is that parties seeking to collect damages for their losses will have a legal basis for going to court. From a lawyers point of view, the cause of the damages and injuries has been found.
But that is the whole problem with this boards report. They neither found out the cause of the mishap nor developed any caused based recommended corrective actions to prevent this mishap from occurring again. This investigation did not find the cause of the mishap, identify the hazards that caused the event, not did the investigation discover recommended corrective action to prevent this event from recurring.
Sure, you might respond by saying, “they listed causes.” Okay, let’s look at the section of the report labeled causes. Here they are listed as Probable Causes:
1. The flight crew’s mismanagement of the aircraft’s speed, altitude, headings and attitude through inconsistent flight control inputs resulting in a loss of control.
2. The flight crew failure to abide by crew resource management (CRM) principles of mutual support and calling deviations hindered any timely intervention and correction.
Note: In my Safety opinion, these items are not causes, these are events which took place. They are evidence, facts found out during the investigation. From the findings of facts, the investigation should have analyzed how these events occurred and in place, should have recommended action, which had they occurred, would have prevented this mishap. From the analysis, the board should have concluded from the analysis that had the proposed steps been taken, that then the mishap would not have occurred. Based on this analysis and these conclusions, the board should have recommended corrective actions to be taken by the airline and any other involved party, that IF FOLLOWED, would not only have prevented this mishap from occurring, but will prevent this same mishap from occurring again in the future by eliminating the safety hazards discovered.
But that is not what this board stated. Instead, the board created a lawyers’ version of an investigation, a legal investigation, based on English Common Law, that sought to find out “Who was to blame for the damage done?” So they stated the damage and they tied it to the people who were at the scene-the flight crew. They failed to decipher that in commercial scheduled flight operations, that the flight is dispatched under company supervision and is operating under a government approved and issued and closely supervised Certificate of Operations and all those people who operate and manage the company, the regulator and every other coordinating agency of authority are equally accountable and therefore responsible for the mishap.
However, how does this rather simplistic legal investigation report help anyone now or in the future, other than to compensate victims and penalize the pilots, who are now, well, well, well, unable to be further penalized?
After two years of operating under the banner of an AIRCRAFT ACCIDENT INVESTIGATION FOR SAFETY PURPOSES, what has the board really produced? What steps or methods of prevention have really been developed by this investigation? In this regard, it is my Safety opinion that this ET409 Aircraft Accident Investigation is incomplete. The Safety purpose was not sought nor achieved.
For example, we know that the FO sat there and did little if anything to help? But why did the FO sit there and do little if anything to help? Without knowing the “WHY?”, how can anyone set up corrective actions to prevent this from re-occurring?
Let’s look at an example of what I am advocating. The facts are that the FO was a fully licensed, certified and qualified Ethiopian Airlines B737-800 First Officer. He was assigned as such by the airline crew schedulers to operate this revenue passenger flight.
So after this mishap, the question clearly is, “Was he in truth qualified or not qualified, certified or not certified, licensed or not licensed?” If in fact he was qualified, certified and licensed, what does that say about the programs that led to this qualification, certification and licensing, that as a trained, licensed, certified and qualified FO, he was unable to take any actions to save himself, far less the passengers and crew?
It quite clearly appears to the qualified observer that this first officer as pilot monitoring (PM), was not qualified to handle this situation, a situation where he had to take over from a clearly disoriented Captain, the pilot flying (PF). So no matter what any claims were made prior or since by the training department, the evidence is quite to the contrary. The training of PM and PF was not sufficient.
Additionally, the Captain didn’t seem to familiar with the plane, with the trim system, with flying on instruments. But why? Why is the important question to ask. By asking why, an investigation can figure out how to improve training for crews to handle the equipment and how to operate IMC, and how to handle the radar to stay out of rain showers. How could this pilot be released to the line by the training department, if when faced with this relatively uncomplicated situation, was unable to handle it nor ask for the FO to assume control?
The investigation should have taken a look at training for captain to find out why a captain who could not control the acft and who could not stay out of a rain shower among other things, was out there operating a line flight? Doesn’t this really call into questions the entire training, licensing, certification and qualification program? Were there line checks and some FOQA to identify problems on the line? Why was this crew so poorly prepared to use procedural knowledge to regain control and maintain safe flight?
Are we left to believe that the crew had a big meal and could not handle the plane? Does that make any sense? Does every pilot who eats a big meal, subsequently crash? If not, then this could not be the logical cause of the mishap
Everytime an accident investigation board handles the investigation as a court room destined event, the investigation fails to be completed for the Safety Purpose. As a result, no good comes from the investigation for the purpose of improving safety for the future; all that has been accomplished is to look back at the past and assign monetary damages.
You might argue that low time pilots should not be paired together. But that is an old argument from more than 25 years ago. What good does it do to restate that? Didn’t the airline safety manager ever read over any industry safety case histories of crew unfamiliar with their job due to incomplete training, falsely labeled “low experience?”
Is ICAO really not fostering safety with case histories of previously investigated commercial mishaps? If so, why not? But is that really the reason for this mishap? If so, where is the direct correlation? Remember that many events happen at the same time. That is known as coincidence, events happening at the same time. But coincidence is not the determination of cause and effect, therefore coincidental events cannot be listed as part of the cause and effects of the mishap.
Why was training not the focus of this investigation? How can any crew know what to do, if for that condition they have not been trained to the procedures listed in the airlines SOP? No, I do not mean exposed, shown a demonstration, given a “once-through” of all the dials and switches. No, in my opinion training means repetitive practice, practice and more practice until the crew get it right. Then there should be supervision to make sure that the crew continues to get it right. Then there needs to be checking to make sure that the crew keeps getting it right. All these are methods of feedback to measure the effectiveness of the training program.
In my opinion, this investigation merely stated the obvious. Worse, the board took two years to do so. How does that help safety improve? Where is the benefit? How does this Ethiopian Airline take steps to prevent this event from happening again? How is Safety served? What new was discovered that was not already known?
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Further comments:
Why did these events occur? How did they occur? These questions must be answered so that somehow the airline can figure out how to keep them from happening again. Remember, this crew was a product of the training department that qualified them. They were a product of the training program that certified and licensed them. The airline was so confident in their licensing, training, certification and qualification that they assigned them to operate this flight.
So, somehow, somewhere along the line, Safety broke down. The only way to find it and fix it is by a well done Safety Investigation that seeks to answer, “How did this mishap occur, what are the hazards discovered and how can this mishap be prevented from happening again and how can these hazards be resolved?”
The board went on to list factors they believed were contributing to the mishap:
3. The manipulation of the flight controls by the flight crew in an ineffective manner resulted in the aircraft undesired behavior and increased the level of stress of the pilots.
Note: This is an observation, not a cause of the mishap. A cause would be that the crew manipulated the controls in an ineffective manner because of inadequate training. Improved training therefore would be the analysis that would lead to a conclusion for recommended corrective action to improve training. This applied to four below.
4. The aircraft being out of trim for most of the flight directly increased the workload on the pilot and made his control of the aircraft more demanding.
5. The prevailing weather conditions at night most probably resulted in spatial disorientation to the flight crew and led to loss of situational awareness.
Note: This is illogical; no one can affect the prevailing weather conditions. Training and only training improves situational awareness. Certainly the crew was qualified to fly on instruments and at night, so being on instruments and flying at night could not be a cause of the mishap.
6. The relative inexperience of the Flight Crew on type combined with their unfamiliarity with the airport contributed, most likely, to increase the Flight Crew workload and stress.
Note: Another illogical statement. Either the crew was qualified or not, trained or not. “Experience” is a subjective term for which everyone has their own definition. The board did not set a “level of experience needed to prevent the next mishap.” If they were right, then every crew with low experience would crash everytime they took off at night, from a strange airport, into a rain shower. But they do not, so this causal factor is incorrect and not useful to support the Safety Purpose.
7. The consecutive flying (188 hours in 51 days) on a new type with the absolute minimum rest could have likely resulted in a chronic fatigue affecting the Captain’s performance.
Note: Fatigue is a problem with all scheduled line operations. And this crew may have been overworked. But if every overworked crew crashed, then the board would have found something. Instead, the captain failed to fly the plane and didn’t plan to use the autopilot at 400 feet to relieve him of workload. Again training seems to be the problem here.
8. The heavy meal discussed by the crew prior to take-off (had) affected their quality of sleep prior to that flight.
Note previous comment on this subject above.
9. The aircraft 11 bank angle aural warnings, 2 stalls and final spiral dive contributed (to) the increase of the crew workload and stress level.
Note: this is not a cause, but a mere reciting of the hard evidence. The crew was given 13 warnings to which they did not react properly. That appears very much like a training issue, the crew not knowing what to do to respond to the warnings and not the crew being distracted by the bells and whistles going off.
10. Symptoms similar to those of a subtle incapacitation have been identified and could have resulted from and/or explain most of the causes mentioned above. However, there is no factual evidence to confirm without any doubt such a cause.
Note: this actually makes some sense, as to why the crew responded the way they did. If though the board stated this, then why not make a recommendation for flight crews to eat lightly before flying?
11. The F/O reluctance to intervene did not help in confirming a case of Captain’s subtle incapacitation and/or to take over control of the aircraft as stipulated in the Operator’s SOP.
Note: Reluctance is a human factor. To overcome a human factor, procedures and checklists are needed. In this case the airline should have some form of trained and written communications procedure so that the pilot monitoring (PM) can communicate with the pilot flying (PF) that an error is being made and a recommended change to be made, with a further provision that the PM can take control from PF and return the acft to a safe flight disposition. It is more than crew resource management, it should be an SOP. This type of event can and does happen on a regular basis between PF and PM. That is why the whole concept of PF and PM was developed.
The board made the following Safety Recommendations:
1. The Operator should revise its CRM program in order to stress F/O assertiveness and leadership requirements especially in periods of abnormal performance.
Note: Rather, what is required is a PF and PM set of procedures and checklist. Assertiveness is a non-defined term?
2. The Operator should consider its classification of airports where non-technical constraints might affect flight operations and brief their flight crew accordingly.
Note: The lack of airline specific airport special notes and procedures is not cited as a fact, analysis or a conclusion in the investigation. How did it make an appearance in the recommendations? The crew reached 9000 feet in altitude, well away from the ground and the airport and the surrounding terrain. They may have made procedural errors on departure, but are these directly related to the mishap or are these errors coincidental errors and therefore not the cause of the mishap?
3. The Operator should re-examine (their) crew pairing and scheduling policies in order to ensure a less stressful cockpit environment.
Note: Policies need to be revised. It is a good idea to not pair inexperienced crew together. But the method is by a written procedure so that crew schedulers have hard and fast rules. If the airline and crew members cling to unworkable social structures and fail to find procedures to work as a team, then once again, training, based on procedures is faulty, in my opinion.
4. The Operator should consider establishing write up criteria for pilots’ training files in order to avoid the adverse effects of any mis-interpretation by the trainees.
Note: a very unclear connection between the mishap and recommendation.
5. The Operator should consider developing his safety oversight program in order to detect such potential flight crew performance.
Note: How was this operation certified to operate by Ethiopian CAA without it?
6. The Ethiopian CAA should ensure that the recommendations (made) to the Operator have been implemented.
Note: Ethiopian CAA had already certified this operator at its current very low level of Safety. Could they suddenly be expected to improve their oversight? Not likely, in my opinion. Rather, the board should have provided very clear procedures to enact the changes needed. For example, a FOQA, an ASAP and other human factor based already established programs should have been cited. But notice that nowhere in the report did the board show how these programs would have prevented this mishap or future mishaps of this nature. Is this investigation really complete? In my opinion, various human factors safety programs are needed, but a competent CAA would have already required them.
7. The Ethiopian CAA should re-examine the regulations concerning crew pairing policies.
Note: see previous comments above.
8. ICAO should re-examine the international requirements for the identification, training and reporting of subtle incapacitation symptoms and (causes).
Note: Is ICAO really accountable or just advisory for physiology? Are there not many sources world wide for this type of information? How is it that this is or should be news to this airline?
9. The Lebanese Government should establish requirements to ensure that responses to such accidents are made systematically without reliance on foreign ad hoc assistance.
Note: Admin issues, not Safety Hazard issues related to this mishap.
10. The Lebanese DGCA should re-evaluate the working conditions of the ATC personnel.
Note: How was this related to the cause of the mishap
11. The Lebanese Government should consider establishing administrative and logistic support for (accident) investigations (such as this).
Note: Admin, not Safety.
My conclusion is that there is a lot more to be done with this Safety Investigation of the crash of ET 409, in order to complete the Safety Purpose of preventing the same mishap from ever occurring again. I hope that this is helpful to airlines around the world who are trying to drive the number of mishaps with their airline down towards zero. Good luck and let me know what you think via the comments section of this blog.
Safety Forecast 