Aviation Accident Investigations
The Investigation Process
Aviation accident investigations are a frequent point of discussion. WHY?
- The public has an almost insatiable appetite for reporting when an airplane crashes. This interest is disproportionate to the risk associated with flying; automobile, bus, truck and rail accidents occur more often and involve more people.
- Airplane crashes are complex. The NTSB employs a very disciplined method to examine the evidence and then assess probable cause.
- The life cycle of these stories tends to be long. The Board investigators do not speculate as to possible, much less probable causes.
- There is a large cadre of talking heads who are willing to make assumptions and to speculate on what happened. There is a coterie of experts who limit their expert commentary to known facts and are extremely reluctant to make even informed guesses. The TV audiences and the network producers prefer the former over the later.
The interview published by AeroTime provides incredible insight into the process and why a great reporter seems more restrained in her/his explanations. Christine Negroni is the expert being interviewed. She has written for New York Times, Seattle Post-Intelligencer, Air and Space, Fortune, Airways and RunwayGirlNetwork. Ms. Negroni has written two well-recieved books, Deadly Departure (2000) and The Crash Detectives: Investigating The World’s Most Mysterious Air Disasters.
Here is the full text of the interview; it is so good that it would be inappropriate to try to summarize it:
Your enthusiasm for aviation is undoubtable. Could you tell us where it all started?
In 1996, I was working for CNN and there was an airplane accident in New York. The airline was TWA and the airplane was Boeing 747. It was on its way to Paris and it exploded shortly after taking off. Because I worked for CNN in New York I went to the scene of the accident and I covered it for CNN. And then I wrote a book about it. There was a lot of talk about TWA Flight 800 explosion being a crime; that this was committed by the Iranian navy, that a terrorist brought a bomb aboard the airplane, that the American Navy had shot a missile and accidentally hit the airplane. So, there were a number of theories that what really happened was being covered up.
When I covered the crash for CNN I got the impression that some things that happened to the airplane were not being covered well. So, I wrote a book explaining why I did not believe it was a criminal act and why I believed a fuel system design problem had caused the accident. And when I finished writing the book I realized that I had a very keen interest in the intricacies of airplane aviation accidents. So, I started specializing in that subject – first for CNN and then I went to work for an aviation law firm in New York, actually investigating aviation accidents.
Then 9/11 happened, so I was very much drawn into the world of terror and terror financing and terror and aviation so I sort of learned about it on the job, so to speak. I did that until 2008 when I went back and began working as an aviation journalist full time. And that’s when I started writing more about aviation safety. I would write for different publications and ABC News.
Then ABC asked me to go to Malaysia, when Malaysia Airlines Flight 307 disappeared, to help them with the coverage.
During the investigation, during the analysis of all the material you possess, trying to make it into something readable, something understandable for common people who are not specialists or enthusiasts of the field. There must be some difficulties which arise. What are the main ones?
I read a book once called, “Made to Stick” and the book talks about something called the “curse of knowledge” that is when you know so much you cannot talk to people from a basic level. I am not brilliant but I know about aviation safety, that I know, that is my little subject. The biggest challenge is to avoid the curse of knowledge. To start off at the level of understanding of people who get on a plane to take a vacation or to go to a business meeting but who don’t understand the intricacies. They see the pilot, they see the plane, they think “okay, the plane breaks or the pilot makes a mistake, it’s that simple” but of course it is not that simple.
There are many, many factors beyond that. There is the system of the airport, the system of the airline and the computer technology, the way the computer interacts with the human, the way the gate agent rushes the pilot: “Hurry, hurry, we have to take off”, the schedule. So many factors contribute to things going wrong that in trying to explain aviation disasters and aviation accident investigations it’s very important to first start giving people an idea of the complexity of the system so they don’t oversimplify. Because that reinforces the idea to the general public that there is either a human who screwed things up or a bad machine. That it’s one or the other but of course it’s not.
You were writing about and comparing disasters. Did you notice any patterns in terms of mistakes in safety done by airlines? Do you notice any common mistakes, which are not common to airlines but just common mistakes?
The most common mistake is that we tend to believe that if it is a human problem, it is a human mistake, we have to put some computer overlay to prevent the human from making the mistake and I think what happens there is that we constantly separate the operator of the airplane from the airplane itself. In between the two, in between the man and the machine are increasingly greater layers of technology. And so the more separate the pilot gets from the aircraft and not just the pilot but the mechanic, the air traffic controller, it has happened with all of these what they call high-consequence environments, the more opportunities for the two to fail to interact well. But in high-consequence environments really terrible things can happen. It’s not like when you and I make a mistake.
The more technology you put between the human and the machine they operate, the more complex it is to sort out and fix those errors. This can happen even with the crash detectives when they discover mistakes and want to fix them. So, when I say that, that’s a long way of saying, I think that plugging holes in human performance can be a common mistake.
You have written about a lot of disasters, which one is the biggest mystery for you?
I think Eastern 980. It was a 727 that was going to La Paz Bolivia from Asunción, Paraguay. It went to La Paz and then was flying back to Miami. The plane was being operated by two pilots new to flying over high mountains, so they were accomplished pilots but they have never flown over this particular terrain and it is very mountainous there. And they had done a flight down and now they were doing the flight back. Because they were new to the route, they were required to have an experienced pilot with them in the cockpit. But only for the first leg.
So, on the way back that experienced pilot was sleeping in the passenger cabin. So, these pilots with little familiarity with the terrain were on the way back and they flew into the side of a mountain.
It’s not mysterious to me that they could have made a mistake flying on a new route at dusk, that’s not mysterious to me. But what’s mysterious to me is that none of the leads were followed and there were many leads as to what might have happened, including errors in the calibration of the navigational equipment. And you know, these pilots, were not inexperienced flying through the mountains of South America. And there was some contraband onboard the plane. There were highly placed political people on the airplane, they were flying into the country with a bad record of corruption. So, there were a lot of things, a lot of leads, and yet when the investigation was completed the Bolivians said that the plane crashed because it flew into a mountain. It was an American airline with American pilots, an American diplomat and American government worker on board, the Americans said: “Well, that’s their investigation” and they did not do anything else.
So, to me, it’s very quizzical that the American government did nothing to fully investigate this accident or come up with more definitive cause. That’s to me the most mysterious. And in my book, I talk about at least six or seven mysterious air disasters that did have some element of official cover-up involved. This is probably the biggest one.
In your book, you claim a lot of airlines and pilots learn from the mistakes created by the people responsible for the tragedy. So, maybe there are some common mistakes, which are still, even though we’ve learned from the experienced, overlooked by manufacturers or aircraft operators or pilots?
So, I’ll say just once again, an overreliance on technology that does not interface well with the humans is a big one. Another one, I’d say, what is a tendency towards complacency. Every day pilots get in the airplane and fly the route, you know, five, six, eight times a day on short-haul or long fifteen hour flights on long-haul and I think to them it’s just a job. It really is just a job. To us, of course, it is “you’ve got to pay the most attention!”, but to them, it’s just a job. And I think that keeping their alertness up, their attention to detail, their understanding that even though flying is very safe, a lot depends on their constant vigilance and judgment, I’d say that one is a tough problem. And always communication, communication, communication. We haven’t learned enough about communication over years, we make the same sorts of communication errors, thinking what you said was what you said without confirming.
I just wrote a story last month for The New York Times about the problems with air traffic control and pilots not speaking English as they should under ICAO guidelines and of course that’s obvious, but what was less obvious, and I found also quite interesting, is that English speakers don’t think it’s a problem for them. But of course, it is, because if an English speaker is not using aviation terminology, in other words, ICAO English they are not using, the international aviation language. The Chinese pilot or the Lithuanian air traffic controller needs to hear the English they know, not the English of some guy from Texas that he speaks when he is with his friends. The inability of native English speakers – the Americans, Brits, Australians, their inability to understand that they’re part of the problem, means they are part of the problem. It shows how important and how unresolved the question of communication is in the air safety.
Let’s talk about the Egypt Air Flight 804 crash. In December 2016, Egyptian officials, who are still very criticized for withholding information, stated that there were traces of explosives found on the bodies of the victims, yet in the beginning of the May French officials declared that there were no traces on the bodies. What do you think happened?
The investigation has been marked by conflicting information being released both within Egypt and from France, which is involved due to the airplane having been produced by Airbus. It is hard for the public to have confidence in the investigation under these circumstances. Because this plane appears to have been brought down by a fire or explosion getting to the bottom of what happened is important. So far both a criminal act and a battery fire have been suggested as possible factors in the crash. It is important to know if either is responsible for the catastrophe,
Having said that, I feel the Egyptians are being disparaged by the international aviation community in a way that is inappropriate. Remember the Metro Jet accident? The plane exploded in the sky and landed in the desert and immediately, I mean, I don’t even think Egyptians had even arrived at the scene, the British and the Americans were both saying it was a terrorist attack. It happened in a way that was striking to me. This attitude that other governments could hijack the information stream from the Egyptians was so fast and so curious. I do not believe you would have seen that between two European countries or with America or Australia and the media was full of information about how “Egyptians couldn’t run the investigation, that would’ve been a lie”. It seemed purposeful and it seemed very anti-Egypt right off the bat. And I’m not sure why that is.
In my book, I make a very strong case for the fact that no investigation is handled separately from the political considerations of the country involved. The French have the Airbus factory there, that’s their product. The Americans have Boeing, that’s our product. We have American carriers, American manufacturers of engines etc. There are a lot of political and economic considerations that come into play. The crash investigators can talk all they want about the purity of their investigations, I’ve seen too many investigations when political considerations do come into play. I’m suggesting that the speed with which the Western governments began to criticize the Egyptians was phenomenal and inexplicable to me and didn’t do the investigation any good.
Share this article: