Most important, says aviation safety advocate: Re-examine how airline industry monitors aircraft.
Much went wrong during the investigation of Malaysia Airlines Flight 370, and millions around the world watched each development. After the Boeing 777's disappearance, en route from Kuala Lumpur to Beijing, global media descended on Malaysia — and as with every airline tragedy, numerous false leads emerged, along with dissemination of misinformation and widespread myth-making.
These are some of the lessons that should have been learned, and what should be done differently in the future.
Lesson No. 1: Focusing primarily on terrorism can obscure other threats. Statistically, considering sabotage at the expense of other theories is not only wrong — it’s very wrong. What really causes airline accidents? Despite tremendous progress in both technology and human factors, pilot error remains the leading cause. According to the extensive database compiled by PlaneCrashInfo.com,there were 100 large commercial airline accidents worldwide between 2000 and 2009. More than half were primarily caused by pilot error. Here’s the breakdown:
Lesson No. 1: Focusing primarily on terrorism can obscure other threats. Statistically, considering sabotage at the expense of other theories is not only wrong — it’s very wrong. What really causes airline accidents? Despite tremendous progress in both technology and human factors, pilot error remains the leading cause. According to the extensive database compiled by PlaneCrashInfo.com,there were 100 large commercial airline accidents worldwide between 2000 and 2009. More than half were primarily caused by pilot error. Here’s the breakdown:
- Pilot error: 54 percent
- Mechanical failures: 24 percent
- Sabotage (explosive devices/shoot downs/hijackings): 9 percent
- Weather: 8 percent
- Other human errors (air traffic control/improper maintenance/etc.): 5 percent
This is not to say MH370 didn’t succumb to sabotage from forces inside or outside the 777. But many airline tragedies are not always what they seem during the initial stages of investigation, so it’s critical to consider all possibilities.
Lesson No. 2: There’s a critical window to find survivors. One of the most sustaining and dangerous falsehoods about commercial aviation is that mishaps on airplanes are all-or-nothing affairs — that no one walks away from an airline disaster. That’s far from the truth, and it’s a dangerous mindset. Thirteen years ago, the National Transportation Safety Board conducted an extensive examination of U.S. airline accidents between 1983 and 2000 and found that 95.7 percent of occupants survived; put another way, 51,207 occupants of domestic airline crashes lived.
And that was before several high-profile events during which all occupants survived, even when the aircraft were destroyed, including 309 onboard an Airbus A340 in Toronto and 155 onboard anAirbus A320 on the Hudson River in New York City.
I spent time with several engineers at Boeing who explained that survival rates have improved by focusing on three main goals for occupants: surviving an accident’s impact; surviving a post-crash fire; and safely evacuating. Significant achievements have happened in all three areas in recent decades, yet the “all-or-nothing” myth still lives. Little wonder the NTSB stated: “Public perception of survivability may be substantially lower than the actual rate of 95.7% for all [large airline] accidents.”
Lesson No. 3: Who’s in charge, anyway? Despite what many American journalists believe, the NTSB doesn’t always take command. During this crisis, multiple news reports questioned what would be uncovered by the NTSB, a U.S.-based independent government agency respected worldwide for its accident investigation methodology. However, the NTSB’s role in Malaysia has been somewhat limited, as per international treaty defined by the International Civil Aviation Organization, chartered by the United Nations. Because ICAO urges participation from nations that manufacture or certify aircraft, the loss of an American-built Boeing 777 made the NTSB a party to the investigation.
On March 8, the United States sent an NTSB team accompanied by representatives of the Federal Aviation Administration and Boeing to Kuala Lumpur. On March 12, the NTSB stated it was “providing technical assistance to the Malaysian authorities” and planned no further public statements. However, news reports indicated Malaysian authorities were resentful of foreign intervention in their investigation, so it remains unclear how this affected the contributions of the NTSB and other international agencies.
In the end, this search was conducted by more than two dozen nations, including China, Japan, Vietnam, Australia, Great Britain and the United States. But the lack of effective coordination should be closely examined and not repeated.
Lesson No. 4: Next of kin need to be treated with respect. Unfortunately, the airline industry has a spotty record when it comes to consistently meeting the needs of the loved ones of passengers missing, injured or killed in tragedies, with some carriers performing much better than others. In the years to come, Malaysia Airlines may be best remembered for its poor treatment of family members, culminating in the ludicrous decision to notify them via text message that all aboard were lost.
In recent years, grass-roots organizations founded by survivors and victims’ families fought to improve such relations, and in 2011 the NTSB sponsored a conference to share best practices and lessons learned. But despite such efforts, not all those lessons have been learned. Just last month, the U.S. Department of Transportation fined Asiana Airlines $500,000 for failing to comply with the Foreign Air Carrier Family Support Act of 1997.
After the crash of Asiana Flight 214 in San Francisco last July, the airline failed to adequately communicate with next of kin, and took five days to implement an effective outreach program.Though it defended its decision to send text messages based on wanting to distribute the message as urgently as possible to some families it could not otherwise reach, Malaysia Airlines should have given greater consideration to communications.
Lesson No. 5: Do we still need “black boxes"? Over the past two weeks, countless references have been made to the search for the 777’s “black box,” even though there are two boxes (and they are orange). Cockpit voice recorders (CVRs) and digital flight data recorders (DFDRs) are insulated, wrapped in stainless steel or titanium, and are designed to survive high impact, fire, seawater and nearly all types of catastrophe (leading the late comedian George Carlin to quip the entire airplane should be made of the same materials).
However, black box myths abound:
- Myth: These devices are always found. Consider: Air France Flight 447 disappeared over the Atlantic Ocean in June 2009, but the boxes weren’t found until two years later, in May 2011. And in the case of the two aircraft that hit the World Trade Center on 9/11, the recorders were not recovered from either plane.
- Myth: Finding them is easy due to the locator beacon. In fact, the beacon has a life expectancy of about 30 days.
- Myth: The data are always retrievable. In many accidents — even in recent years — both types of recorders have been compromised due to severe damage, even mutilated beyond repair. That’s why other technological solutions have been proposed.
In 2007, the NTSB’s “Most Wanted Transportation Safety Improvements” list recommended the FAA require installing “crash-protected image recorders in cockpits to give investigators more information to solve complex accidents.” The NTSB cited several high-profile airline crashes where such technology would have aided investigations, but quoted the 2009 response to this recommendation: “the FAA indicated that it does not plan on taking any further action at this time to mandate the installation of cockpit image recording systems.”
The estimated cost of such recorders is less than $8,000 per airplane. Gabe Bruno, a former FAA inspector turned whistleblower, says, “The FAA will never require anything that costs the industry money, unless the industry agrees. The industry might have some self-interest in new data technologies, but as always will try to find ways to zero-base those costs as much as possible. When it comes to safety vs. cost/benefit projections, the dollars always seem to win.”
Even better would be technology that didn’t rely on recovering data from accident scenes. In 2010 the Institute of Electrical and Electronics Engineers proposed replacing the “black box” with a “glass box” — i.e., technology that would transmit data continuously and in real time to a ground-based system. This is more than a proposal — Star Navigation Systems of Canada already has developed such a product. But once again, cost is a factor.
Lesson No. 6: Can’t commercial aircraft be better monitored worldwide? Well, yes and no. While there are limits to global coverage provided by civilian radar (and there are altitude gaps as well), it’s also clear that the armed forces of several nations had access to radar and satellite data concerning MH370, and safety experts questioned why so many of these findings took so long to come to light.
The estimated cost of such recorders is less than $8,000 per airplane. Gabe Bruno, a former FAA inspector turned whistleblower, says, “The FAA will never require anything that costs the industry money, unless the industry agrees. The industry might have some self-interest in new data technologies, but as always will try to find ways to zero-base those costs as much as possible. When it comes to safety vs. cost/benefit projections, the dollars always seem to win.”
Even better would be technology that didn’t rely on recovering data from accident scenes. In 2010 the Institute of Electrical and Electronics Engineers proposed replacing the “black box” with a “glass box” — i.e., technology that would transmit data continuously and in real time to a ground-based system. This is more than a proposal — Star Navigation Systems of Canada already has developed such a product. But once again, cost is a factor.
Lesson No. 6: Can’t commercial aircraft be better monitored worldwide? Well, yes and no. While there are limits to global coverage provided by civilian radar (and there are altitude gaps as well), it’s also clear that the armed forces of several nations had access to radar and satellite data concerning MH370, and safety experts questioned why so many of these findings took so long to come to light.
This saga was punctuated by several revelations, including news that both the 777’s transponders stopped transmitting radio-frequency signals, an occurrence aviation experts assert can only be caused by manual disengagement or catastrophic failure. Yet the aircraft’s ACARS — Aircraft Communications Addressing and Reporting System, which transmits nonvoice messages to and from the ground — continued operating after the transponders shut down. In other words, it remains unclear exactly which communication channels remained open, and for how long. One of the most profound changes to evolve from MH370 may be a re-examination of how the airline industry monitors its aircraft.
Lesson No. 7: High altitudes require wider search patterns. If MH370 did encounter a fatal event high over the Indian Ocean, it was a statistical anomaly. According to a comprehensive study from Boeing of jet airplane accidents worldwide between 1959 and 2012, only 9 percent of fatal incidents occur during the cruise phase of flight. Conversely, there’s no overestimating how critical the early and late stages of flight can be: 11 percent of fatal accidents occur during parking and taxiing, 24 percent during takeoff and climb, and 56 percent during descent, approach and landing.
Lesson No. 8: Media coverage flailed on the likely causes. Ever since MH370 first went missing, 24/7 cable news and Internet sites developed a voracious appetite for experts to weigh in. Unfortunately, a lack of answers fueled wild speculation and “conspiracy theories” that included alien abduction and a portal to heaven. What’s often overlooked is that investigators live in a world of theorizing, conspiratorial and otherwise. (Ironically, many of the same media outlets admonishing viewers and readers to ignore “conspiracy theories” simultaneously promulgated them.)
Lesson No. 7: High altitudes require wider search patterns. If MH370 did encounter a fatal event high over the Indian Ocean, it was a statistical anomaly. According to a comprehensive study from Boeing of jet airplane accidents worldwide between 1959 and 2012, only 9 percent of fatal incidents occur during the cruise phase of flight. Conversely, there’s no overestimating how critical the early and late stages of flight can be: 11 percent of fatal accidents occur during parking and taxiing, 24 percent during takeoff and climb, and 56 percent during descent, approach and landing.
Lesson No. 8: Media coverage flailed on the likely causes. Ever since MH370 first went missing, 24/7 cable news and Internet sites developed a voracious appetite for experts to weigh in. Unfortunately, a lack of answers fueled wild speculation and “conspiracy theories” that included alien abduction and a portal to heaven. What’s often overlooked is that investigators live in a world of theorizing, conspiratorial and otherwise. (Ironically, many of the same media outlets admonishing viewers and readers to ignore “conspiracy theories” simultaneously promulgated them.)
And just as generals often continue to fight the last war, there’s a long history of journalists covering the last airline accident, a trend that reached the peak of absurdity when TWA Flight 800 exploded off Long Island on a hot July night in 1996 and a television reporter questioned if the cause was de-icing. As with any Super Bowl pool, some pundits may have been right, but many others were wrong. VIDEO
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