“LET’S WAIT FOR THE ACCIDENT REPORT” – THE MUCH HEARD STATEMENT IS A BUREAUCRATIC APPROACH TO ACCIDENT PREVENTION

Aeroplanes and flying has its own share of personal risk. Despite mitigation measures, aircraft accidents do happen. More often, every accident is nothing but a new strain of a similar accident that would have already happened earlier. In that sense, accidents are not unique. However, every accident brings in a new dimension to learning. Just like the doctors / scientist look for a vaccine for each strain of a disease (Corona being the finest example), the aviation community, in their pursuit to avoid accidents, also look for fixes for unique issue arising from each accident.

After every accident, it is commonly said by authorities “Let’s wait for the accident report before we say anything”. Is it an avoidance measure to escape accountability until the human psyche of limited retention (usually 3 days) kicks in? Or is it the case that they have nothing to say? Regardless, blunt as I may seem, the fact is that we don’t need to wait for that long. Waiting longer than required is akin to pushing aviation safety out of the window. Lets see how.

In aviation, the cause of accident better be “known” and necessary corrections done. It is important to quickly identify “what happened”. This exercise must happen immediately after the accident as it is the most important aspect in the chain of accident prevention. This is usually the job of a ‘Go Team’ of experts within the country’s Accident Investigation Board. The urgency arises from the fact that the most telling clues for investigation lies at the accident site and must be noticed / recorded before it is disturbed (for various reasons including resuming operations or clearing up the site). The tell tale marks are enough to corroborate with evidences and testimonies of first responders to tell what went wrong. A ‘Go Team’ has an eye for identifying factors leading to an accident. A “Go Team” is like the policeman from the local police station who reaches the crime site before it is disturbed. Trust my words, the assessment of a Go Team is rarely wrong especially if the accident happens in an airport or its vicinity.

Some countries have a formal Go Team (NTSB of USA) while others rely on local resources. Unfortunately, civil aviation in India has not imbibed the formal model like USA. The fact that Indian authorities want us to wait until the final report publication indicates that we do not have the practice of initial assessment by a Go Team. To that extent, all I can say is that safety is yet to be understood by us in its full form yet.

Does the ‘Go team’ concept works? Yes, it does. NTSB (USA) is a good example to follow. Is their understanding good enough to form an opinion within a day or two of accident? Yes, ofcourse, if done professionally they will be able to point at the category and likely cause (there are only seven to ten categories). How fast can the stake holders know as to what happened? Not more than two or three days in case of onsite accidents, longer for offsite occurrences. Does Indian aviation have a Go Team? Not really, as far as Civil Aviation is concerned, however, Indian Air Force has one for itself

Can we understand the Go Team concept that IAF has? In IAF, a dedicated team is posted in Air Headquarters in New Delhi, which is a Go Team in true sense. The team is airlifted to the accident site by special plane within hours of an occurrence. The team is suitably staffed with its own set of pilots, Engineers, ATC officers, and other professionals who have field experience and are specialised in accident investigation. They work independent of any influences. Upon arrival at nearby Airbase, they take a briefing from the local IAF Commander and proceed to the site. They carefully sift through the crash site for tell tale signs. For example, the throttle position at the moment of crash tells the investigator the powered up status of engines and the intent of the pilot. They obtain first hand information from pilot and passengers, ATC officer, first responders, Squadron Engineers, eye witnesses and others. The raw inputs are considered most authentic. They examine the technical documents. They work relentlessly with a mission until the information leads to a clue. Usually, in a day’s work, they form an impression that is relayed to the top brass of IAF for onward transmission to the Government. That’s precisely why the IAF is able to give within a day or two it’s preliminary understanding of ‘what happened”. Also, 99 percent of times their understanding is correct and endorsed by Court of Inquiry that follow in due course.

The ‘What happened” information allows IAF to take immediate corrective steps to avoid another similar accident. Safety is taken so seriously in IAF that in extreme cases, entire fleet is grounded if a cause remains ‘Unknown” or if serious flight safety issues are flagged.

The process of Accident Investigation are similar worldwide in military as well as civil aviation. The Board of Inquiry by Civil Aviation (AAIB) or a Court of Inquiry in case of IAF, essentially dwell deeper into “why it happened” and spells out measures to avoid such similar accident. They go into the nitty gritties with a scientific approach (as taught to a trained investigator) and quantify parameters that led to accident. The civil Inquiry Board has representations from the aircraft designer, aeroplane manufacturer, operator / airliners, regulatory authority, aviation psychologists, aviation medicine specialist to name a few. . Representatives from Pilot Union / Engineer / Flight Attendant associations are also allowed, as the need may be. A full spectrum of specialist ensures that every aspect of the crash are examined and addressed. The board usually has experienced permanent members who can moderate and dovetail the opinion of each specialist into a meaningful and actionable final report.

Despite similar approach, we see a glaring difference between civil aviation and military aviation Accident Boards. Military reports typically take a month or two to be formalised serving the very purpose to quickly identify causative factors and institute remedial measures.

However, given the working arrangements of civil AAIB, the investigation of civil aviation accidents take many months and perhaps years. The final report of civil accidents is published much later when the accident is almost forgotten or looses priority even in the eyes of the civil aviation authorities. The inordinate delay (although justified) is the matter of concern and the bone of contention here.

Since the Accident reports cannot be expedited, there is an urgent need to change mindset of authorities and airlines with regard to interim declaration of ‘what happened’ to the extent that air traveller is assured safety of the flights under similar circumstances.

Incidently, the accident of Air India Express flight IXC 1344 in Calicut Airport on 7 Aug 2020 has triggered a debate on the ethics of making preliminary remark by the competent authority on “What happened’. In this particular case, based on the professional input, the Director General (DGCA) rightfully made the initial assessment known to assuage public concerns. This was in line with the globally accepted norms. In his considered opinion and given the authority vested in him, he gave his understanding that the likely cause is a pilot error. However, the Pilot Unions (interest groups) are up in arms and have taken strong objection to the departure from the usual norm of – say nothing until all is forgotten and until another accident happens!!!. This posturing by pilot’s union and use of social media campaigns is seen by commoners as arm twisting the authorities (DG DGCA in this case) to suppress truth about the profession of piloting and the underlying safety concerns. This is not a good trend to say the least.

Suffices to say that 80 percent of aircraft accidents happen due to human error – afterall flying aeroplanes is a risk laden profession as is the case of Surgeon Doctor or a soldier in the battlefield. The grace is in accepting facts and letting the common man know the causes and the mitigation steps taken to ensure flight safety.

As I said, the purpose of quickly knowing ‘What happened’ is essentially to avert a similar accident the next hour or the next evenng!!. This follows from a scientific premise that – if the stake holders (pilots, ATC etc) did all that they were supposed to do under the given external triggers (like weather, time of day etc), yet the accident happened, then it could happen with the next flight too if the similar external triggers arise. Therefore the knowledge of ‘what happened’ and removal of the catalyst of crash assumes greatest significance in accident avoidance schema.

Returning back to the case in point – Do the authorities, airlines and Pilot unions know what happened in case of IXC 1344? Ofcourse they do. Infact, the basic data is in public domain to which common man has equal access. Call it a bane or a boon, the technology of ADS-B which internet sites like FlightRadar24 use, gives the accurate and almost instantenous speed, height and position of an aerolpane until the last moments. The ATC radar data supplements the ADS-B data. A lot more information is accessible to the aviation bodies or interest groups Believe me, for the purpose of ‘Basic assessment’ this much of data and information is as good enough.

I guess, the traditional system of supressing information by saying “ please wait for the Accident Report” doesnt work any more. This is especially true in the modern days – given the technological reach of common man. The present trend is infact detrimental as it fuels the media to make conjuctures to gain TRP. The lack of credible information from authorities forces media to rely on so called experts. Worst of all, common man tends to rely on generic solutions from Google and gets flight anxious. The common man also quenches his thirst for information from the youtube updates by civil aviation pilots. The exuberance of civil aviation pilots amongst youtubers has always been counter productive.

What’s the way ahead? There is a pressing need to form a robust ‘Go Team’ within the Accident Investigating Board which reports the preliminary understanding of cause of accident. The ‘Go team’ assessment can be make public by the competent authority, obviously with the needed caveats. It is the obligation of the airline and the regulatory to assure the citizens and families of victims with bulletins on findings that would be update regularly. It is scientifically proven that a true news ( however bitter or harsh) is more palatable for families of victims. This will also leave the ‘interest groups’ to allign with facts instead of misleading the public. A true statement will usually be subject to constructive criticism leaving little scope for TRP making by the media. A transparent approach leaves little for gossip and speculation. Air traveller is more likely to trust and respect aviation professionals.

The bottomline – An accident happens when one or more events in the chain go wrong – often referred as ‘Swiss Cheese Model of accident’. Our endeavour should be to find out the weakness earliest to avoid a possibility of a similar accident the next hour.In addition, to know “what happened” is in fact the right of every passenger which must be complied by the public authority. This is the mantra of aviation safety too.

About the Author

The author, Wing Commander K Dinesh is a former Indian Air Force officer. Presently, he practices as an Aviation Safety Consultant with focus on Flight Anxiety removal for air travellers through his venture Cockpit Vista in Mumbai, India (www.cockpitvista.com). He can be reached at cockpitvista@gmail.com

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13 thoughts on ““LET’S WAIT FOR THE ACCIDENT REPORT” – THE MUCH HEARD STATEMENT IS A BUREAUCRATIC APPROACH TO ACCIDENT PREVENTION”

  1. Completely agree. There’s an urgent need to know and disseminate truth. For that as you have suggested a professional team is a necessity.

  2. Right to Equality (Articles 14 – 18)
    The right to equality provides for the equal treatment of everyone before the law, prevents discrimination on various grounds, treats everybody as equals. It is also mentioned in our Preamble. The types of equality are:

    Natural
    Social
    Civil
    Political
    Economic
    Legal
    The Right to Equality is one of the Fundamental Rights enshrined in the Constitution of India.

    But I think it is just theoretical. Still the bureaucracy treats the others slavishly. It is because of the political supports. There is nothing like patriotism or nationalism. System has rotten and just to collapse.

  3. So true! This would stop double guessing and lead to lesser media trial. It can also give clues for risk mitigation and concrete preventive action can be initiated till final report is published.

  4. Pretty enlightening dinesh. ‘What happened’ as you said, should be the guiding phrase for 1st investigators. Its worth sharing and useful for public at large. Keep writing ✍?

  5. There is no justification for the DGCA to use the language that was used and to be in a tearing hurry to ascribe the cause of accident. In order to reassure travelling public, the DGCA should set its own house in order, follow the best international practices. Their mantra of shame and blame the pilots instead of looking at systemic causes leading to accidents is at best knee-jerk and does little to reassure the public.

    1. That’s precisely what the article advocates – creation of a ‘Go Team’ within India’s AAIB (in line with NTSB) who will formally announce their preliminary understanding of ‘what happened’ so that corrective measures can be adopted immediately. A Go team assessment for a onsite (airport accident) shouldn’t take more than a day or two. A formal briefing will also kill all speculations and media trial.

      Also, the profession of Aviators, Surgeon, Soldiers, fireman etc are risk laden. Suffices to say that mistakes do happen. I suggest we leave it to AAIB the job of figuring out all that.

  6. The Indian mind set is “out of sight, out of mind”, so delay the investigation till people forget it and focus attention on some other issue, then manipulate according to the designs that situation demand, find scapegoat(s) fix them close investigation.

  7. Once again a beautifully written piece with required details and clear thoughts.
    You have hit on key issues and aspects very correctly.
    Hope your recommendations and thoughts are needed to.
    Keep it up buddy.

  8. Very pertinent issue brought out very comprehensively.
    Infact the daring speed at which the rescue operation was carried out, brought back a couples of decades old memories of your daring rescue attempt at Delhi .
    One day you should put it in public domain .

  9. Aquaplaning could have reduced the effectiveness of the braking system if the simulation conditions are correct. Maybe the reverse thrusters could not be engaged fully as aquaplaning would become worse leading to loss of direction. This could have the aircraft turn turtle with casualties worse. However incase you lost considerable portion of the available ASD by landing ahead of the initial markers the aquaplaning could cause critical failure.

  10. Hi Dinesh,

    Great write up with apt recommendations. But this is India and the change that you are envisaging would take some time, specially when the Airlines Industry itself is undergoing stress test due to Covid19. However Hope and Faith has brought mankind from hunter gatherers to where we are today. I would urge you to make a social movement on the “Go Team” concept for India. Regards and Best in Life to you.

  11. Hope the suggestions given is heard by right people in right sense and acted upon. Atleast in future if such Go Team concept be implemented in India it would mark in scientifically addressing accidents.

  12. An accident site is akin to any investigation site like in case of a murder. It is important to gather data as fast & & on as is basis before the scene of crime is disturbed. If the crime scene is contaminated then the forensics may lose their way to reach the right conclusion.
    Therefore, the idea of Go Team needs to be seriously implemented if we are really concerned about preventing accidents by learning from our past mistakes. The NTSB & the IAF track records justify the gains beyond any doubt.
    It is really surprising that the pilots guild as well as the airline’s have failed to get this implemented till date.
    The author really deserves kudos to be at pain to explain that burying the facts & significance thereof through lapse of time is not in interest of anybody. The time buries the facts & the incompetence of the system & thus avoidable. May be it is not wise to speak about the errors before the conclusion is reached but then it does not make sense to hide & bury the facts by way of the lapse of time & increase the chances of next calamity, which is avoidable.
    It appears that the mindset is driven by the fact that the author has competence in reducing the fears & anxiety of the flight passengers therefore better information flow management is in the best interest of all concerned.

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