Monday, May 31, 2010

Air India plane crash in Mangalore - probable cause

For those who aren't aware, an Air India aircraft crashed on May 22 2010, resulting in the deaths of 158 people. The accident took place in Mangalore, a city in southern India.

Essentially, the aircraft overshot the runway and plunged into a valley that lay just beyond the runway. Weather conditions were apparently not ideal; moreover, the runway is what's called a "tabletop" runway, leaving little room for error.

As I watched news of the accident unfold, I hoped that a probable cause was NOT that the co-pilot warned against landing, and being over-ruled by his commander. Why did I hope this? Because a rather similar thing happened 33 years back, resulting in the world's worst aviation accident (more on this later). If it was a probable cause again, it would mean the lessons hadn't been learnt.

Unfortunately, my hope doesn't appear to match reality. According to a newspaper report, the co-pilot of the Air India aircraft twice urged his commander to not land, but go around and try landing again. The co-pilot was over-ruled, and the commander tried landing the plane - with terrible results.

This problem - of the co-pilot or junior crew members being over-ruled by the flight commander - is not a new one. In fact, the airline industry has a type of training called CRM (Crew Resource Management) to ensure that commanders don't make arbitrary decisions. Yet, it happened on the Air India flight.

Worse, this happened 33 years back and was a factor in the world's worst aviation accident, in which 583 peopled died. In that accident, two 747s (belonging to KLM and the now defunct airline, Pan Am) collided on a runway in Tenerife, Spain. The flight engineer on the KLM asked his captain if they were indeed cleared for take-off, and if the Pan Am had cleared the runway. The captain brushed aside his engineer's warning, and continued taking off - with the Pan Am still on the runway. (The Tenerife disaster is a case study in my book).

Of course, disasters are not just the result of a commander over-ruling a junior. Typically, multiple factors are involved. In the Air India case, the airfield itself has issues; in the KLM's case, fog covered the runway, so visibility was poor.

That said, the human factor is a hugely significant one - and it's important to remove the human factor in these accidents. Specifically, it's important to remove the fear-factor - or the power-abuse factor - in cockpits. CRM is meant to neutralize these issues - but it doesn't. Why not? Simple. Because CRM does not take into account the power imbalance between a boss and his subordinate.

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