We need pro-active safety
On 10-10-2009, in Viewpoint, by steve
After two aircraft collided over Zagreb on 10 September 1976, authorities in the region started to scramble, speeding up the introduction of more modern ATC equipment. The Uberlingen mid-air in 2002 highlighted several shortcomings in pilot training as well as ATC practices. Then we jump to 2009 and a crash near Buffalo in the US reveals not only that the captain of that flight had withheld important information from the airline about his previous performance shortcomings but also that the crew was operating in a fatigued state that would normally be too much for driving a car let alone flying an aircraft. A few months later, an Air France Airbus 330 crashes into the Atlantic Ocean and even without the flight data recorders, authorities point to a possible failure of the Pitot tubes on the aircraft (and an apparent failure to heed earlier warning signs from other aircraft) and possible training shortcomings limiting the crew’s ability to deal with an extremely complicated situation.
What is going on here? Mind you, the airlines and air traffic services providers involved in these incidents have safety policies and practices that meet the industry expectations. Yet, somehow those policies and practices were undercut with disastrous consequences.
“I believe there are industry issues that we must examine here”- said NTSB acting Chairman Mark Rosenker.
Aviation safety has long been predicated on learning and improving from incidents and accidents. We all remember the issues with the square shape windows of the Comet or the 737 that landed in Hawaii with half its top missing, just to name a few events that lead to important safety improvements. The Comet told us how not to design windows on pressurized aircraft and the 737 kicked off the old aircraft maintenance regimes.
After Uberlingen a host of measures were brought on the ground and the Buffalo crash has put pilot and controller fatigue firmly on the agenda of regulators the world over. Strange, but a 330 had to dive into the Ocean for the need for basic airmanship and related training issues to come into focus…
Learning from bitter experience is reactive safety.
Several years ago it was first realized that with the forecast traffic increase, if safety levels stayed as they were back then (already very high) we would end up with a major crash every day as the numbers caught up with us in the much higher number of movements.
The industry decision was to improve safety so that this nightmarish scenario would not come about. It was also said that real improvements could only be expected if we moved from reactive to pro-active safety.
Pro-active means trying to figure out what could go wrong and then doing something before it does. I am afraid we may have failed the first test.
Was there nobody worried enough about fatigue to raise the issue? Or just nobody listened? Has the less then perfect information flow that affected the Pitot tube issue not been visible for anyone? Were the shortcomings in basic pilot training so obscure that we needed a major crash to bring them to light?
Of course it is not fair to demand an answer to all those questions before the investigation is finished and final conclusions are drawn. But as they say, where there is smoke, there is fire…
It is not too early perhaps to do more for implementing pro-active safety.
