The Erring Human®
This blog was started at the behest of colleagues who requested for more info on Human Error. We explored various types of Human Errors, the telltale signs of error prone conditions and how to have a degree of control over Human Error in our organizations. There is absolutely no way of eliminating Human Errors. We can at best learn to recognize and build resilience to reduce the risk of single error leading to a disaster. It can get very low, but it will never reach zero!
#GermanWings: Do we have the evidence to accuse someone of murder?
Following-up on the statements issued by the French Prosecutor as reported in the press , I wonder if the French Prosecutor has been too hasty in jumping to a conclusion? Here is how I look at the situation as is reported in the press.
The prosecutor says, I quote, "At this moment, in light of investigation, the interpretation we can give at this time is that the co-pilot through voluntary abstention refused to open the door of the cockpit to the commander, and activated the button that commands the loss of altitude … It appeared that the intention of the co-pilot, identified as Andreas Lubitz, had been "to destroy the aircraft." He said the voice recorder showed that the co-pilot had been breathing until before the moment of impact, suggesting that he was conscious and deliberate in bringing the plane down … The captain is heard pleading to get back into the cockpit, but the co-pilot, heard breathing normally until the plane crashes, does not react … You can hear the commanding pilot ask for access to the cockpit several times. He identifies himself, but the co-pilot does not provide any answer … You can hear human breathing in the cockpit up until the moment of impact … the breathing did not indicate any health problem such as a heart attack."
Firstly, the fact that the co-pilot is heard breathing is in itself an anomaly. In most cockpit recordings, it is not possible to figure out the breathing at all due to ambient noise inside the cockpit of an aircraft. The fact the breathing is heard at all, is an indication that this breathing could not have been normal, but had to be "labored and heavy" to be audible over the other noise. Please visit these links to listen to some actual CVR recordings so you can understand how much of noise is recorded and how heavily someone would have had to breathe to be audible above this kind of noise.
If any breathing could be heard over this kind of background noise, the first conclusion that I reach is that the Co-Pilot was not in normal condition of health to be breathing so heavily as to be audible on the CVR tape. The second is that if he was intentionally about to crash into a hill, there would certainly be a change in his breathing pattern…and this has not been reported. My assessment here is that Co-pilot was certainly not in normal state of health and was in all probability incapacitated.
Secondly, the cockpit door can be opened from outside by entering an Emergency Code. When an emergency code is entered, an audible noise sounds inside the cockpit and then, unless a latch is engaged by the pilots inside, the door would open after a short time delay. While the French prosecutor makes reference to noise of breathing, that in any case would have been difficult to hear, and makes further reference to Captains attempts to breakdown the door, there is no reference to any audible sounds related to his attempts to open the door from outside. So the questions that arise here are, did the Captain never attempt to open the door using his Emergency Code? If not, why not? If yes, why the associated sounds are not heard and mentioned in the Prosecutors report? Further, if the Captain did try to open the door using his emergency code, is there any evidence of the Co-Pilot blocking this attempt?
At the end, the only conclusion I can reach is that the French Prosecutor seems to have been in too much of a hurry to put the blame on the Co-pilot. There is no hard evidence to support this hypothesis. It is certainly a possibility, but at this time there is no hard evidence to label an innocent man a criminal guilty of a ghastly crime involving murder of about 150 passengers and crew members. More professional analysis and interpretation of the available data is necessary before any conclusions can be reached.
Going further, I firmly believe that because all human performance occurs inside an Organizations Policies and Procedures, any human error can always be traced to Organizational deficiencies. We have had at least three incidents of such nature before and two of those I had mentioned in my book "Into Oblivion". The first point that comes to mind here is that in all the previous cases, the termination of flight when intentional was immediate, by the pilot pushing the aircraft into a steep dive and crashing into ground within 2 to 3 minutes. So, why here the aircraft took eight minutes to impact? This comparatively long delay certainly needs some explanation.
However, following these, FAA issued a regulation requiring a crewmember to enter and be present inside the cockpit whenever one of the Pilots leaves the cockpit for any reason whatsoever. However this regulation was not copied by EASA and hence was not mandatory to be implemented in Europe until today. Today, EASA has issued a ruling that mandates this, but until now this had not been done. The EASA AD issued today 27 March 2015 is located here: http://ad.easa.europa.eu/ad/2015-04. Further I wonder what were the policies and procedures at Germanwings as regards this Emergency Code to open the door. Was this followed on every flight? Did the Captain not know this code/procedure? Was it normal on Germanwings flights for the code to be ignored or the procedure not be included in recurrent training of the crew?
As you can see, the diagram I published earlier in my book "Waiting...To Happen!" is proved correct once again…Poor Organizational Policies and procedures set in motion two chains of accident events. First leads to poor workplace conditions and creates an accident through defeating the individuals into errors and violations. The second leads through lack of adequate risk management/controls to poor defenses in terms of Technology, Training and Regulation and become causative to accidents.
Once again, the Regulatory lapses at EASA and Organizational lapses at #Germanwings have succeeded in defeating individual human performances and I the Erring Human got an opportunity to strike once again...this time killing 150!
The Erring Human.
Labels: Accidents, Aircraft, Airline, Airport, Aviation, classification, crash, EASA, Error, France, Germanwings, Human, investigation, journalism, Safety, Violation
WHAT AILS INDIAN CIVIL AVIATION?
India was downgraded by FAA to Category 2 in early 2014. Following this humiliating audit assessment, some changes have been made and now India is getting ready for a review in March/April 2015. So, this is the occasion to highlight once again what actually ails Indian Civil Aviation so that the core issues can be separated from the noise and rumors. It is only through proper understanding of the on-ground situation will it be possible to separate the truth from politically motivated rumors and ensure necessary corrective actions are taken in the right direction. After all, the first step in solving any problem is acknowledging that there is a problem, and then as a second step taking ownership of the problem for further corrective actions to be implemented.
I had covered this subject at great length in my book "Waiting…To Happen!" where, using the case study of Air India Express IX812 crash at Mangalore, an assessment of what ails Indian Civil Aviation was undertaken. All the lessons Indian Civil Aviation needs to learn can be learnt from a football club! I offered this analogy in my book where even the cover image was specially designed to convey this message. The image depicts a football goalpost with a figure in Pilots uniform instead of a goalkeeper. The person is diving to save a goal, and instead of a ball, coming-on is an aircraft. The message is clear. Pilots are no different than goalkeepers. They are our last line of defense and the only team members capable of using their hands to save a loss. However, just like the goalkeepers, in the end they are merely humans and members of a team. If rest of the team does not perform, the goalkeepers can do little to save the loss. This is also evident from the fact that major football clubs often fire their Managers, Coach or Captain in the event of a poor season performance, but rarely do we see a goalkeeper getting the axe. However, in the aviation industry, and particularly in India, we seem to have a greater focus on the goalkeeper than the team management. Following examples will help clarify this point.
IX812, Mangalore 22 May 2010. The officially conducted inquiry closed the case with a "Pilot Error" verdict. However, the facts are that the airport was neither built, nor maintained, in accordance to standards stated in the Indian Civil Aviation Regulations. Runway friction had not been checked for many years and the runway had extensive rubber deposits leading to a loss of breaking friction; RESA was non-compliant with minimum required length; surface of RESA was hard and had not been prepared to offer a deceleration; the base of ILS localizer located inside the runway strip was made of concrete and was therefore not frangible. Right wing of the aircraft struck this concrete base and was sheared off, fuel spilled and came in contact with the right engine and started a fire that spread rapidly, consuming the entire aircraft within minutes. 8 survivors have given evidence that others were alive but overwhelmed due to rapid spread of fire. Runway controller was not looking at the aircraft and even 5 minutes after the crash is heard on radio calling the aircraft and issuing back-track instructions. No crash alarm was ever sounded. ARFF responded only when someone called them and informed that they can see fire at the end of runway. By then the aircraft had fallen down a ravine. This happened because the mandatory 1000m area required at the end of runway did not exist. There is no record of the airport ever having conducted a crash exercise, which is mandatory every 2 years. No procedures existed for responding to this situation. No access roads had ever been contemplated. No coordination with local firefighting departments and local administration had ever been concluded. ARFF vehicles took 30 minutes to reach the crashed aircraft. 152 of the 158 killed had no evidence of trauma, impact or decelerative injuries. Cause of death for all of them was established due to burns and asphyxiation due to smoke in lungs. The airport had undergone a routine surveillance audit by the DGCA just two days before the crash and received a "Satisfactory" rating.
Is this Pilot error? Yes, the pilot did make mistakes. But there is also evidence that he was suffering from Hypoxia. Despite all the mistakes of the pilot, the event was survivable and would not have resulted in a disaster if the airport had been constructed and maintained in accordance to standards. Quoting Justice Moshansky from the Dryden accident report, "… while the crew must accept accountability for their decisions, it is clear that the Civil Aviation System failed them by allowing them to be placed in a situation where they did not have the support they needed and should have received."
Jaipur, 05 Jan 2014. AI890 from Guwahati to New Delhi diverted to Jaipur, after holding for over one hour, due to poor visibility. On arrival, visibility had reduced below minima at Jaipur also. Now low on fuel, pilot had no option but to attempt a landing. On touchdown in near zero visibility, aircraft burst tyres and suffered a runway excursion. Left wing of the aircraft struck a tree 52 m south of runway edge, 1340 m down the 2780 m Rwy 27. Aircraft had exhausted fuel and hence there was no fire, but if the aircraft had any fuel in that wing the result of this collision would have been similar to what happened with IX812 in 2010.
Once again, ARFF could not reach the aircraft because they had never trained to respond to an emergency in low visibility. Once again, while the airport had been assessed as "satisfactory" by the DGCA in last surveillance audit, there was no evidence of any crash exercise and the airport did not comply with standards because as a Code 4D airport, it should have had a 75 m runway strip on either side, clear of any obstruction. DGCA issued many directives with regards to Pilot training standards as a consequence of this accident, but the issues of non-standard airport, lack of ARFF preparedness and regulatory lapses were glossed over.
Issues with Pilot proficiency checks, pre-flight medicals and validity. There have been many cases where DGCA has acted to suspend licenses of pilots flying with proficiency checks due, without pre-flight medicals or with expired licenses. The issue here is that pilots are employed by an AOP holder and perform inside an organizations policies and procedures. It is the operator's responsibility to ensure employed pilots meet the regulatory standards and comply with applicable regulations. The pilots do not work for DGCA, but for an operator who holds a valid AOP. Disciplining the pilots is the job of their employer. Responsibility as well as accountability for enforcing compliance rests with the AOP holder and in the event of non-compliance, the AOP holder needs to be disciplined, through sanctions, financial penalties or even temporary/permanent suspension of the AOP. Focus needs to be on the team management, who needs to ensure that the employed goalkeeper is properly trained, holds the required certifications and plays in accordance with the rules of the game!
So, what ails Indian Civil Aviation? Research at ICAO has demonstrated that most accidents today are caused due to organizational factors. I have explained the following diagram in great detail in my book, "Waiting…To Happen!", but I believe the figure below is also self-explanatory.
Active failures (Errors/Violations) by humans constitute only 20% of the whole. All human performance happens inside an organizations policies and procedures. If these are weak/not implemented, sooner than later the humans will be overwhelmed and pushed to err. Human error is a symptom, not a disease. The disease is "Poor Organizational Management" and this is what ails Indian Civil Aviation.
Lessons from Football. We need to learn our lessons from the way we manage our football teams! Our team to manage Aviation Safety can be described as follows:
Manager: Ministry of Civil Aviation.
Coach: An Independent Accident Investigation body.
Linesman: ICAO.
Captain: National Regulator, DGCA.
Forwards: License/AOP holders "Accountable Managers".
Midfielders: Managers in an AOP holder's organization & DGCA Auditors.
Defenders: Line Management, Ground crew, Engineers, Air Accident Investigators.
Goal Keeper: Pilots.
Rules of the Game: Primary Civil Aviation Regulation.
This analogy can then be transcended down to any level of any organization. The CEO or the equivalent, even a departmental head then becomes the Team Manager and other designations below appropriate to the complexity and size of the organization.
Unfortunately, in Indian Civil Aviation today, the Team Management consists of bureaucrats with no professional experience in Civil Aviation. There is no functional independent aircraft accident investigation body akin to NTSB or AAIB. This team is playing without a coach. The team Captain, DGCA, is a bureaucrat too, selected for his civil services, and not civil aviation, skills. The Captain does not understand the complexities and strategies of the game. The DGCA also sits on the management boards of AAI and AI. This is like having the team Captain also manage the opposite team and, thereby creating a conflict of interest, interfering with his ability to regulate in a fair and unbiased manner. There is no accountability enforced on rest of the team members.
The team plays on strength of its goalkeepers and there is constant stress on them due to non-performance of other team members. This leads to a failure of the man-machine interface due to the human part of system being over stressed as is evident from the large numbers of "human error" events that have occurred in recent past displaying symptoms of the disease called "Poor Organizational Management".
The rules of the game or Civil Aviation Regulations (CAR) are flawed too. ICAO has published "Standards and Recommended Practices" (SARPs) which are very intuitive and have wide applicability. But ICAO SARPs are not legally implementable. The CARs are the law and only they can be enforced inside India. While copying ICAO SARPs, all Recommendations have been converted into Standards. This has been done across the board, without any justification and without any assessment/evaluation on their need, applicability or implications. This has resulted in the CARs being in-implementable on many occasions or leading to exorbitant and wasteful expenditure to implement something that does not add any value to the operation. This also results in wasted resources and higher operating costs, making the entire industry in-profitable and susceptible to collapse. This also then results in violations by the operators, which are then ignored because the law itself is in-implementable. The result is a system where rules are followed or ignored at will, depending on the organizations financial abilities and political clout rather than based on a risk assessment and implementation of justifiable mitigation measures. There is an urgent need therefore to correct this situation and reform the rules of the game – the Primary Civil Aviation Regulation.
To sum-up. In the end, the diagram below represents what the relationship ought to be between a Regulator and a Service Provider. This is what needs to be implemented with a strong leadership and accountability at every level in every organization. A detailed explanation has been included in my book "Waiting…To Happen!" under the heading "Dilemma of the two P's".
Labels: Accidents, Aircraft, Airline, Airport, Aviation, classification, crash, Error, Human, India, investigation, IX812, journalism, Safety, Violation
#MH370 - One year on...
It is now one year since Mh370 was lost on a routine flight. And despite all efforts, there is yet no sign of the wreckage, nor any indication of what went wrong on that night. Malaysia has released a report on the incident, and despite reading almost 600 pages, one comes no closer to understanding the event. There are pages and pages of technical information. Some that was already known, and some that is new, and even shocking. The only one thing that the report clearly highlights is the amount of confusion that prevailed on that fateful night. Analysing the communication logs, one sees a pattern of chaos; of lack of understanding aircraft overdue procedures; lack of comprehension of technology in use; and a clear lack of any organized response. It was over 5 hours before it was realized that the flight was missing and before any semblance of a search started. The fact that the aircraft had not responded to any nature of communication during this period and that it was not seen on any Air Traffic Radar system on its planned route was not considered a sufficient cause for alarm. However, this has no bearing on why the flight was lost and it is highly unlikely that even if the Airline and ATC units enroute had responded in time, the course of events could have been much different. Maybe we would have known where to look for the plane, but saving it from its fate would, in all probability, not have been possible.
The news on every TV Channel on first anniversary of the disappearance of MH 370 is that the battery for the locator beacon in the plane's flight data recorder was life expired. This means that the battery should have been changed, but was not. The data recorder batteries are guaranteed to perform for 30 days, if they are replaced on schedule. However, on expiry of this stated life, 30 day transmission can no longer be guaranteed nor can it be guaranteed that the pinger will ping on the expected frequency and maintain the expected characteristics. This then has the implication that the data recorder may not have operated at all, or may have operated at reduced efficiency. However, even this does not in any way affect why the plane was lost in the first place and even if the battery had been replaced on schedule, it would not have changed the outcome on that fateful night. Also, it is extremely unlikely that the towed pinger locator went anywhere within listening range of the pingers in the first month. So, this information does not in any way help us to understand what happened on that fateful night #MH370 was lost.
What surprises me most about this report is lack of any clear statement, even now, on a very important question that I had raised with MAS last year and also highlighted in my book: Had MAS complied with the Boeing recommendation for replacement of conductive crew oxygen hoses with non conductive oxygen hoses and to sheath & clamp the electrical wires in proximity?
As many who have read my book "Into Oblivion" would be aware, Boeing 777 serial number 28420 which was operated as MH370, was one of the 280 aircraft produced by Boeing without proper sleeving and clamping of this wire, in violation and deviation to their design approval. It is significant to note that aircraft serial number 28423, which was being operated as EgyptAir 667 on 29 Jul 2011, suffered a cockpit fire. On investigation, the aircraft was found to differ from Boeing's design. A clamp supporting the first officer's wiring to the oxygen mask light panel was missing. The wiring was not sleeved and a large loop of unsupported wire was found. The investigation determined that about 280 aircraft including all of EgyptAir's Boeing 777s were delivered with this deviation. The investigation concluded that the most likely cause was an Electrical fault or short circuit, which resulted in electrical heating of flexible hoses in the flight crew oxygen system. If Boeing produced 280 aircraft without sleeving on this wire, then in all likelihood aircraft serial numbers 28420 (MH370) and 28423 (EgyptAir 667) would have been on the factory assembly-line at the same time and therefore, would likely have been wired the same way.
Boeing had determined that it was appropriate to install sleeving in these wires and had issued a service bulletin number 777-35A0027, dated December 15, 2011 and followed it with a Revision 1, dated April 19, 2012. The bulletins contained a recommendation that in order to prevent electrical current from passing through the low-pressure oxygen hose internal anti-collapse spring, which can cause the low-pressure oxygen hose to melt or burn, and a consequent oxygen-fed fire in the cockpit, replace the conductive low-pressure oxygen hoses with non-conductive low-pressure oxygen hoses, in addition to sheathing and proper clamping of all electrical wires in vicinity of oxygen hoses.
It is not known whether or not Malaysian Airlines had complied with this on the accident aircraft. My many emails on this subject have not been answered, or even acknowledged, by the airline. I did expect to find a clear statement of compliance in an official report, but there is not even a mention of this; and this makes me wonder, Why Not?
The pictures below show consequences of this fire on EgyptAir 667, which was on ground with Airport Rescue and Fire Fighting support available just seconds away. Imagine a similar situation on an aircraft in flight...
I can only hope the authorities wake-up and come clean with the truth at least now!
Into Oblivion (English)
North and South America, UK, Europe and Australia: https://www.createspace.com/4888847.
All of Asia (including India, Malaysia and China), Middle East and Africa: http://pothi.com/pothi/book/captain-samir-sam-kohli-oblivion.
If you prefer to read on Kindle, computer or tablet device, or order from Amazon: https://www.amazon.com/dp/B00M0ENG2I
(You don't need to buy a Kindle device. Just download the free "Kindle reading App" from Amazon e-store and you will be able to read on any computer, tablet or even a mobile phone.)
Labels: Accidents, Aircraft, Airline, Airport, Aviation, classification, crash, Error, Human, investigation, journalism, Malaysia, MH370, Safety, Violation
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