AINsight: Airplanes Crash
for a Reason
- April 26,
2019, 10:49 AM
Business is booming for air safety
investigators around the world. Following a period of relative calm in 2017,
the safest year on record for passenger airlines, there has now been a steady
uptick in both accidents and fatalities. In fact, according to statistics
collected by the Air Safety Network, the number of accidents since the end of
2017 is now above the five-year average. Two Boeing 737-8 Max accidents since
October 2018 have not helped; collectively, these events have accounted for the
loss of 346 lives.
So, why do airplanes crash? There are some
usual suspects such as “gravity beats lift” or “drag defeats thrust,” but to
really determine cause, investigators subscribe to an accident-causation model.
Personally, I like James Reason’s Swiss cheese model of accident causation
since it is a useful tool to explain very complex events.
However, the first step is to view each
event with a wide lens and understand, as aviation safety researcher Sydney
Dekker suggests, that “accidents are not accidents at all, but a failure in
risk management.” To become even more open-minded, think of them as a “failure
in imagination”—that’s how the 9/11 Commission report described the deep
institutional failures associated with the 2001 terrorist attacks.
Reason’s Swiss cheese model gained
popularity because “it illustrates that although many layers of defense lie
between hazards and accidents, there are flaws in each layer that, if aligned,
can allow the accident to occur.” By taking this approach, Reason’s model
explores both active and latent failures and the four failure domains:
organizational influences, supervision, preconditions, and specific acts. This
model is a good way to look deeper into the human, technological, or
organizational aspects of an accident.
Focusing on the information released to date
from the two 737-8 Max accidents, let’s explore some of the latent and active
failures. Latent failures are those that lie dormant for weeks, months, or even
years. These failures are waiting for an opportunity. Active failures involve
unsafe acts that can be directly linked to an accident.
Understand that this exercise is to
demonstrate the complexities of determining cause and is not intended to
speculate on the actual cause of either accident, which will come out in the
final reports from the respective investigative bodies.
The 737 Max accidents are wrought with
latent failures. Organizational influences involve the manufacturer, regulator,
and/or operator—in some cases a combination of two or more. As an example, the
requirement to achieve a common type-rating is driven by an airline's desire to
cut training costs. Aircraft manufacturers (all of them) want to sell
airplanes, so to satisfy the needs of the customer the 737 Max has a common
type-rating and requires minimal differences training—by video or bulletin, not
in the simulator.
And as aircraft become more complex and
automated, the philosophy from OEMs has shifted over the years to provide
less-detailed information in training materials. As an example, during my
Boeing 727 training, the systems course would “build” each system. In contrast,
during my 747-400 training, the systems portion was more related to “operating”
each system.
Other organizational influences identified
focus on the regulator. In this case, the FAA’s organization designation
authorization (ODA) program has been harshly criticized by lawmakers. During a
Senate aviation subcommittee hearing in March, Senator Richard Blumenthal
questioned “the system that led to outsourcing safety” to the manufacturers and
added, “The fact is that the FAA decided to do safety on the cheap
and put the fox in charge of the hen house.” Not exactly, and this is a bit of
irony.
The origins of this “outsourcing” are based
on past FAA reauthorizations that required an expansion of the ODAprogram
due to a lack of appropriated funding. FAA Administrator Dan Elwell,
in defense of the program, stated that to cover all the functions of ODA,
the agency would have to add 10,000 employees at a cost of $1.8 billion.
Another latent failure identified in the
Ethiopian Airlines accident was a low-time first officer flying a complex
aircraft; this would be classified as unsafe supervision. Even though the first
officer was current and qualified to fly in the Ethiopian “system,” 200 hours
of total flight time is not enough, especially when things go wrong.
The cognitive skills, crew interactions, and
situational awareness required to handle complex emergencies are developed over
time. In the U.S., the unsafe combination of those was highlighted during
the Colgan Flight 3407 accident, and the ATP/1,500-hour rule was enacted
to protect the traveling public.
In the case of the 737 Max accidents, much
has been written about the maneuvering characteristics augmentation system (MCAS)—the
system that “misfired” during each event. It’s intentional that MCAS has
not been mentioned until now.
MCAS version 1.0 with its single point
of failure (one bad AOA sensor input) is considered another latent
failure—all it would take to become active is a failed or bad sensor to make
the system go haywire. In retrospect, it doesn’t take a lot of imagination to
see how the design of this system could go bad.
As described, these latent failures—most
with strong organizational influences and many with economic ties—were brewing
in the background for decades. All it took was an active failure of a poorly
designed system to start a chain of events that would find each hole in the
Swiss cheese model. MCAS and the 737 Max simply exposed several
latent failures that were—and still are—present in the system.
Pilot, safety expert, consultant, and
aviation journalist Kipp Lau writes about flight safety and airmanship
for AIN. He can be reached by email.
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