These crashes should never have happened

April 04, 2021
The scene from the PIA crash.

A flight crew ignore air traffic controllers’ pleas, forget to lower the landing gear, and ignore multiple cockpit warnings resulting in 97 deaths(above), while another crew landed their plane well down a rain-soaked runway in a storm with a tailwind, the resulting crash, miraculously, only killing three.

Just two of the dozens of accidents in the past five years that should never have happened.

The culprits? Declining pilot skills due to computer automation, cost-cutting, and substandard regulatory oversight in some countries.

That is the worrying tale of aviation safety today where automation, which should make flying safer, is deskilling pilots and leading authorities into a false sense that everything is safe, while some airlines slash their cost by reducing pilot’s simulator training hours to the bare minimum.

READ the full story here.

READ: Qatar Airways a standout for COVID-19 safety

Now the chorus of concern about aviation’s failing report card has been joined by the world’s most respected body – members of the Royal Aeronautical Society (RAeS) Flight Operations Group with a new study that calls for better training and an urgent raising of regulatory oversight, as well as global standards.

As far back as 2009, just before the loss of Air France AF447, in the mid-Atlantic which claimed 228 lives, University of Southern California engineering professor and aviation safety expert Najmedin Meshkati said that the aviation industry and its regulators had become “star-struck by technological solutions”.

AF447 was an overnight flight from Rio to Paris and plunged into the Atlantic after a combination of automation failure and pilot confusion put it into a death spiral.

Prof. Meshkati warned at the time that he believed that all the wizardry of modern technology was masking a deterioration and de-skilling in basic flying ability and that the lessons learned by generations of pilots “may be lost to the new breed of pilots.”

Fast forward 12 years to 2021 and Captains John Leahy, Robert Scott, and Alex Fisher, assisted by other experienced members of the RAeS Flight Operations Group are issuing a similar blunt warning in their new study around air crashes.

“Airline Pilot Training – It is time to revisit the basics,” warns that “many recent airline accidents have shown clear evidence of a common cause, whether from fatal crashes or devastating hull losses without fatalities.

“That common cause is the inability of the pilots, in far too many cases, to cope with the situation they faced. Sometimes it was when the automatic systems failed, requiring them to fly manually. In others, they were trying to deal with what should have been a relatively benign situation and they simply did not cope.”

Pilots insecure

Tragically, the problem is not new.

In 1995 a NASA Research Centre study based on Royal Air Force Institute of Aviation Medicine data from more than 1,000 pilots from 20 airlines and aircraft manufacturers about pilots’ attitudes and experience with flight deck automation found that “safety is increased with automation, but automation may lend a false sense of security, particularly with inexperienced pilots.”

Very concerning was that pilots reported that there was a higher sense of “insecurity” during an automation failure and a general temptation to ignore raw information and “follow the green/magenta line (computer indicators).”

The most worrying aspect was that pilots said their colleagues were “becoming complacent and relied too much on automation but that was often because airline Standard Operating Procedures (SOPs) mandated reliance on automation.”

And that aspect has not changed, according to a 2019 International Air Transport Association pilot survey, which found that only 36 per cent of respondents said that their airline policy supported manual flying without restrictions.

In its 2019 “Aircraft Handling and Manual Flying Skills” report, IATA said that “use of automation does not strengthen pilots’ knowledge and skills in manual flight operations and in fact could lead to degradation of the pilot’s ability to quickly recover the aircraft from an undesired state.”

The RAeS study expresses concerns that pilot training has changed greatly, particularly in the last two decades. They said in a recent interview with “pilots need to be trained to fly on instruments once again, in all conditions of weather, ‘G’ forces and distracting illusionary factors, and have complete confidence in their ability to do this. That skill deficit is the one most in need of urgent reform.”

The RAeS study into recent air crashes claims that pilot training “is now shorter in duration, with less flight time on real aircraft, less exposure to the resultant stress of actual flight and much of it, computer-based.”

That claim is backed up by a former Airbus check and training captain who told Agenda that while airlines such as Cathay Pacific Airways will do “at least twice” the recommended training, others would do their own because they didn’t even want to pay for the basic Airbus training.

“Pilot training has suffered because of cost-cutting,” he said.

“And with the airline industry losing US$120 billion last year the problem is only going to get worse.”

And the ability to handle unforeseen events was front and center for the crew of Qantas flight QF32 led by Capt. Richard de Crespigny, which suffered a catastrophic failure of its number 2 engine shortly after take-off from Singapore in 2010.

The crew had to nurse their crippled A380 for two hours while dealing with over 50 system failures and a raft of confusing information before landing back safely at Singapore. The Australian Transport Safety Bureau which conducted the accident investigation noted that the well-trained Qantas crew had saved the A380.

Confusing training

The RAeS paper warns that there is a wide variety of training methods used globally and there isn’t universal agreement on which ones are better than the others.

“In some cases, culture influences the decisions on which ones to use, and in others, the decision can be financial or even based on the recommendations of regulators or plane manufacturers,” the study found.

Deep concern is also raised about poor training. “Many pilots are rushed through inadequate training courses with the emphasis on getting them through quickly and as inexpensively as possible,” the RAeS study claims.

“This environment does not encourage the development and maintenance of the skills and knowledge that are essential to safely and competently operating today’s complex aircraft, something that is borne out by the accident reports,” the RAeS study said.

This issue is highlighted in IATA’s 2020 safety report with Captain Rubén Morales, chair, of IATA accident classification technical group warning that “when we look at the contributing factors present in 2020 accidents, manual handling is at top of the contributing factors associated with flight crew errors. Other areas of concern are deficient safety management systems, regulatory oversight, and selection systems, all of them latent conditions present in the system before the accident happened. These latent conditions have been present consistently year after year, highlighting the need for improvement in these areas.”

Regulators substandard

The role of each country’s regulator, which oversees their airlines, is coming under much greater scrutiny with the global compliance of the International Civil Aviation Organization (ICAO) audits ranging from only 56.32 per cent for Aircraft Investigation to 81.23 per cent for Airworthiness with an overall average just 69.8 per cent.

ICAO is the UN governing body of aviation and there are eight audit areas: Legislation, Organisation, Licensing, Operations, Airworthiness, Accident Investigation, Air Navigation Services, and Aerodromes.

Incredibly 23 countries were below average for all eight audit criteria, while a further 22 only achieved one or two above-average passes.

Again cost-cutting is to blame with many countries starving their regulator of the required funds to properly oversee their airlines.

Even in the US, the Federal Aviation Authority has suffered because of Congressional cuts over the decades.

These dismal results are played out in the IATA 2020 safety report which found that over the past five years in fatal accidents Safety Management at 71 per cent and Regulatory Oversight at 65 per cent were the leading latent factors.

Flight crew errors and manual handling/flight controls were the top contributors at 56 per cent and 50 per cent.

These poor regulatory issues are also a major factor in the European Union and US Federal Aviation Authority banned lists, with 98 airlines from 24 countries blacklisted from European skies and all airlines from 24 countries barred from the US.

Capt. de Crespigny, who with his colleagues, landed QF32 safely, said that many pilots have lost confidence in flying manually because automation has taken much of their hand flying skills away.

He says that pilots of older aircraft such as the 707 and 747-100/300 series had excellent flying skills.

“They usually flew their approaches and landings without using autopilots and auto thrust because these systems were often too inaccurate or unreliable. These pilots built a mental body model that included their aircraft – they wore and manipulated their aircraft like it was a fitted glove,” Capt. de Crespigny said.

The author, with Captain Richard de Crespigny and Gerard Frawley, then Publisher of Australian Aviation on the final leg of QF32 in 2012 from Singapore to Sydney.

Is there a solution?

The authors of the RAeS study urge:

  1. Some industry regulators need to review and raise their standards.
  2. CEOs and boards of airlines must review their own standards and not hide behind poor regulation.
  3. The chief pilots and training managers must speak up and be heard by the chief executive.
  4. Some training colleges need to improve training standards.
  5. The pilot training establishment needs to wake up to the lack of basic instrument flight capability and take immediate steps to correct it.
  6. Airlines need to understand that just passing a flying training exam doesn’t prove that a pilot is totally up to the standard they demand.

Capt. Robert Scott of the RAeS Flight Operations Group is blunt on the problem.

“Over the last two decades, we have seen what can only be described as a ‘Dumbing Down of the Airline Pilot’. The intellectual and physical skills once required of the pilot have largely been replaced by an emphasis on soft skills and automation management. The pilot who once cynically challenged sources of information now readily accept information from a variety of sources, many computer-generated, without question. We know from bitter experience that when this information is flawed it is often not recognized as being useless to safe flight path management.”


Some pilot mishandling and loss of control accidents

Aug 7, 2020: Air India Express 737 lands well down the rain-soaked runway at Calicut and plummets down a cliff. 21 of 190 occupants die.

May 22, 2020: Pilots of Pakistan Airlines A320 ignore multiple warnings and ATC instructions, land with undercarriage up but then take-off before crashing killing 98.

Feb 5, 2020: The pilot of a Pegasus Airlines 737 lands in Istanbul in a storm and tailwind, and the aircraft slides down embankment killing 3 and injuring 180.

Feb 23, 2019: The Pilot of Atlas Air 767 freighter became disoriented after automation failure killing all three crew.

May 5, 2019: The pilot of Aeroflot Superjet made a landing at too high a descent rate after a lightning strike, killing 41.

Feb 18, 2018: Pilots of an Iran Aseman Airlines ATR 72 attempted a landing at Yasouj airport in Iran in bad weather against company policy. Killed 66

Jan 23, 2018: Pilots of Pegasus Airlines 737, overran the runway at Trabzon in Turkey in bad weather. Miraculously all 168 on board were uninjured.

March 19, 2016: Pilots of a FlyDubai 737 set an incorrect aircraft configuration and suffered a loss of situational awareness at night. All 62 aboard died.