Saturday, February 7, 2015

#TransAsia #GE235 - The Erring Human strikes again!!!

These dramatic images have been seen splashed across all news channels over the last few days. Wednesday's crash into a river in Taipei minutes after takeoff killed at least 36 people and left seven missing. Fifteen people were rescued with injuries after the accident, which was captured in a dramatic dashboard camera video that showed the ATR 72 propjet banking steeply and scraping a highway overpass before it hurtled into the Keelung River.

The Pilots, initially hailed as heroes for avoiding crashing into a building and steering the aircraft away from populated area, are now under investigation for apparently shutting down the wrong engine. Investigators are now talking about one of the two engines on TransAsia Airways Flight 235 going idle 37 seconds after takeoff. The pilots apparently shut off the other before making a futile attempt to restart it. While at this time, no one is willing to say it in so many words, what is being implied is that the pilots erroneously shut down the wrong (good) engine and escalated a situation of single engine failure into a double engine failure, leaving the plane devoid of any propulsion!

This is certainly not the first, or the last, time something like this will happen. But one does expect qualified and experienced flight crew not to make such mistakes. So, are the crew Heroes or Zeros? Was this a "Pilot Error" accident?

As we have discussed many times before also in this blog, "Pilot Error", or "Human Error" as it should be called, is not the disease. Exactly like a sneeze, or cough, or fever, it is merely a symptom of a disease. The disease is Poor Organizational Management. Mistakes made by the designer, the executive, the regulator, the administrators and all others in the chain of Aviation Management, gradually reduce the safety margins available to the flight crew ultimately creating a situation where the crew are left with no room for error or to correct any of their mistakes.

Engine Failure on take-off is the worst of a Pilots nightmares. It is something we all train for from the very first day we learn to control an aircraft. It is something that the instructors meticulously hammer into our brains. Manufacturers develop elaborate procedures to deal with this event. Regulators check and certify these procedures as well as the training to execute them. Most simulator sessions are designed around ensuring the crew are properly prepared and trained to deal with just such events.

My question is why? Why do we need all this? Is it not sufficient to just train the pilot once and be done with it? After all, we employed a pilot who holds a valid license and is properly certified to fly our aircraft, so he should do his job well, yes?

What we forget in such a premise is that the pilot we employed is human, not a computer. And humans err. Like it or not. Love it, or hate it, but we have no option to using humans to do these tasks. And humans do err. So, it is very important for us to learn to live with these Erring Humans and to still be able to prevent a single point error leading to a disaster. That is the job of the management. That is why we need regulators. If everyone simply did what they were told, or taught, then no business would ever require a supervisor or a manager. Supervisors and Managers are paid more than workers to sit comfortably in air conditioned offices and talk big words in board meetings smartly dressed in perfumed business suits while sipping on the most expensive wines while the work-force labours outside exposed to the elements, because they are supposed to SUPERVISE...they are supposed to have an outlook and foresight to anticipate problems and ensure adequate actions are taken BEFORE an accident happens to ensure that it does not happen. They are supposed to be able to monitor trends and forecast the future outlooks and then ensure the organization is properly prepared to deal with any adverse event that can be foreseen.

Part of this job is ensuring recurrent training for the crew, to ensure that critical events are drilled repeatedly, to ensure that no one ever forgets what is most vital to be remembered, like identifying the correct engine that has failed and actions then necessary to prevent an escalation of that situation. Today, after this accident and death of over 36 innocent people, the Taiwanese Regulator and #TransAsia have stated that all ATR 72 Pilots must undergo vital emergency procedures check in the next 4 days, or they will not be permitted to fly.

The question that arises here is, why was this not ensured before the accident? Is this not what the Regulator exists for, to start with? Is this not the reason for which exist the regulations of Line and Proficiency Checks?  Is this not the reason why the Airline is supposed to have a Training Programme, managed by a Training Captain? Is this not the reason why there needs to be a Safety Management System? What were all these managers doing up until this point in time?

Do we need protection from a pilot who shut down the wrong engine? No Sir. We do not. We need protection from a system which allowed that pilot to be in that cockpit without having the minimum essential training, without having a recurrent training and checking programme, without having adequate supervision and control.

In the words of Justice Moshansky (Dryden Accident Report), "While there is no doubt that the Pilots must accept accountability for their decisions, actions or inactions, 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 should have had!"

I, The Erring Human, have struck again. This time I killed 36. And I will continue to do this. I will continue to err. I will continue to kill. If you want to stop me, you need to ensure good and professional management of the operation! You need to ensure the regulators do their job. You need to ensure the organization structure is clear and coherent. You need to ensure the managers in that organization understand and do their jobs. You need to ensure a Safety Management System, identification of hazards, tabulation of associated risks and development of adequate risk controls. This was yet another accident "Waiting...To Happen!". It was only a matter of time...

Waiting...To Happen! (English Edition)

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Stay safe,

The Erring Human.