There are a couple of truisms learned from participating in/observing aircraft accident investigations:
- Quick early analyses of what went wrong are almost never right and
- with modern technology, most tragedies are the result of multiple failures.
An aviation safety consultant, a retired captain, a former instructor pilot of a Boeing 737, a specialist in wet runway operations training, and a member of the Civil Aviation Safety Advisory Council was interviewed by dna’s Shahkar Abidi.
The article begins badly when the expert “suspects”; most of the recognized experts in accident investigation do not use words like “suspect” or “speculate.”
Ranganathan then sticks to “known’s” and carefully labels what he is describing. He relates what is the standard push back procedure as followed internationally and permitted by the CAAI. He does not attempt to state what happened in Mumbai on December 15.
The aviation safety consultant then states what he thinks “could have gone wrong,” what a “safer” procedure was and whether a “lack of training” could have resulted in this horrible accident. Each of those dialogues involved assumptions or unarticulated conclusion. Those tautological techniques would not be tolerated by a professional accident investigator. The headline is an “if…then” statement and the predicate of the dependent clause compels the causative conclusion.
The last minutes before an aircraft pushes back, a lot is going on inside the cockpit and on the tarmac. Standards operating procedures, as audited by the CAAI, should minimize the confusion, but something terribly wrong happened and a life was lost.
An investigation would not be confined to what happened on the tarmac. The team of investigators would include the audits of the CAAI by foreign authorities[i]—not a good record of CAAI’s surveillance here. Other records to be reviewed would extend to the airline’s SOPs for push backs, training by AI in general and as to the personnel involved in this accident, the carrier’s documentation on push backs (were there other similar failures, any records of that event, interviews of all involved about what they saw, heard or remembered, any video or audio tapes, etc.).
[i] It will be interesting if this accident causes the FAA to reconsider its upgrade of the country’s status to Category I, especially in that the grant was conditioned on the correction of four deficiencies.
As these true experts work their way through the facts, they note possible scenarios and look for ways in which to corroborate the details of that possible causation train. Necessarily that exercise results in reassessment of previous fact trails. Multiple iterations are the norm for these analyses and the potential theses are narrowed down by those repetitive reviews. Occasionally, at late stages, new hypotheses develop. As the science of this methodology becomes more sophisticated, the ultimate probable cause links a number of implausible, seemingly implausible elements.
These recitations should show that instant speculation actually is a disservice to the process. Maybe Ranganathan was misquoted.