Systemic failure or human error?

The writer is a faculty member at the Institute of Business Administration (IBA), Karachi and also serves as a consultant within the area of improving safety culture, and systemic failures analysis.

The PK-8303 accident cannot be solely attributed to isolated human error but instead to the dysfunctional and defective system and poor safety-culture behaviors within the overall aviation-system of Pakistan. The accident was a ‘systemic failure’, which usually occur due to prevailing conditions that give rise to errors, mistakes and violation of routine tasks performed by people operating within the system.

Systemic failures within the aviation sector can happen due to defective organizational processes, such as poor decision-making, not respecting the ATC, not following SOPs, ineffective communications, lack of leadership for safety, lack of training systems etc. Such failures can also be due to poorly designed and manufactured equipment.

Such defective organizational processes and working conditions lead individuals and teams to make errors. When it is normal not to follow safety standards, and the organization has poor safety defense systems, the organization will have an ‘accidents-culture’. As we know, in the case of PIA flight PK-8303 both the flight cockpit-crew and the ATC were not following SOPs, which is a clear sign of overall systemic level issues. If the cockpit crew were given clear warning by the Karachi Approach that they must follow SOPs and take the orbit to have the correct landing approach this accident could have been avoided.

Most importantly, the cockpit-crew never followed the flight SOPs and violated their own Crew Resource Management System. The CRM is a set of skills available for flight crew personnel to assure safe and efficient flight operation, reducing errors and violations, avoiding stress and increasing efficiency. The next investigation report will have to investigate what systemic level errors and violations or mistakes were committed by both the cockpit crew and the controllers.

Unfortunately, when there is a high-profile accident, individuals are too often assumed to be at fault, when the overall system itself may be implicated in the accident. If we want to stop future accidents and improve the health of our flight operational system we must manage and correct the ‘culture of accidents’ and stop blaming individual persons’ faults. PK-8303 was systemic failure due to the defective system of Pakistan’s aviation sector, including corruption and nepotism, and the lack of leadership for a safety culture within both civil aviation and PIA flight operations. There is a culture of bypassing procedures and corner cutting at the expense of hundreds of precious lives of Pakistani.

The question is: why did the cockpit crew not follow the SOP for standard callouts? Why were they not practising the Crew Resource Management system? We need to investigate the safety culture and safety behaviours of the cockpit crew. And is it common among cockpit crew to ignore these SOPs and ignore the CRM?

Second, do PIA pilots respect ATCs? Do they value ATC feedback and suggestions? The final decision to land is taken by the pilot and it is the pilot’s discretion to accept or reject the ATC’s suggestions. Further, there is a high social, organizational and income gap between PIA cockpit crew and the controllers. Does this affect behaviour? The Karachi Approach is part of the air traffic management system within the CAA, which is mostly performing navigational tasks till around 5 knots IAS near Karachi. Once the aircraft comes near Karachi, navigation must be changed over from Karachi Approach to the Aerodrome Control for landing.

Aerodrome Control is in the big tower building looking at the runway. At aerodrome controllers can see the landing. Aerodrome controllers are responsible for the final landing of the aircraft since they can see the landing gear from around 5 knots IAS. According to the report, the Karachi Approach warned three times that the plane was flying too high on its approach, and directed it not to land (take the orbit) “but the pilot ignored these warnings”. Which is clearly not respecting SOPs and not following the landing protocol set by the CAA and even flight operations safety protocol.

The question: was this the first time such behaviour was demonstrated by the cockpit crew? Was any warning issued to any other cockpit crew before this accident? Have such incidents been recorded and reported before? Is there a system of recording such incidents in PIA? Did PIA flight operations safety officers look at such unsafe behaviour by cockpit crew? If there were many near-misses and no learning was shared and no training was designed then we can easily predict that such accidents will happen again.

According to the report, the cockpit crew lowered the landing gears at 7221ft. The cockpit crew retracted landing gear at 500ft? We really don’t understand these actions. Why did the cockpit crew retract the landing gears? According to the aviation minister “there was no technical fault in the plane, it was completely fit for flying. The pilot and co-pilot, who were both medically fit and experienced, did not mention any technical fault to the ATC throughout the flight”. It means there were no software or hardware related issues during the flight, according to the flight data recording (FDR). If there was any software related issue, the FDR would have indicated computer related issues.

Further, Karachi Approach asked the cockpit crew to “confirm track mile comfortable for descent”? And also told the cockpit crew to take the orbit in order to correct track miles issues but the cockpit crew never told them about any problems in the computer system. This cannot simply be categorized as human error; these are systemic behaviours. We need to learn the basic safety assumptions and safety-culture norms within the PIA flight crew to fix unsafe behaviours, if we want to develop a safe and credible aviation industry in Pakistan.

However, Karachi Approach did not change flight navigation to the airport Aerodrome Control. Karachi Approach took a risky decision to seek clearance from the airport Aerodrome Controller which should not have been allowed. Why did the aerodrome controller not follow SOPs and not observe whether the landing gear was down or not down? Why did the Aerodrome Control not report the engine fire to the cockpit crew? Why did Karachi Approach not report the engine fire to the cockpit crew when they were informed by the aerodrome controller?

It seems there was a communication breakdown between Karachi Approach and the aerodrome controller and the cockpit crew. They all were working in silos without listening to each other, just to avoid blame. Perhaps such a landing was common and it had happened before.

The future investigation must look at all basic safety assumptions and SOP norms within both Karachi Approach and Aerodrome Control. Without effective communication and coordination, and following SOPs, it will be difficult to stop future unsafe behaviour. After the first failed unplanned belly landing without full knowledge of engine fire, the cockpit crew decided to take the go-around for the second landing. During that time, the landing gear came out without any technical issues but both engines lost power, the aircraft was unable to fly and then crashed.

As we have been discussing in this brief, it was not just one poor judgment by one person. There were many actions taken by the cockpit crew and the air traffic controllers which resulted in this accident. During this failure there were several critical points where actions taken by both the cockpit crew and the ATC could have stopped the accident. But since things in the last 20 minutes happened so fast and unexpected, none of the key players were expecting the aforementioned outcome. They panicked and started making the wrong decisions and ignoring SOPs.

It is common behavior during crisis situations when the operator makes more mistakes which aggravate the crisis into a disaster situation. Also we need to find out how both PIA’s cockpit crew and the CAA trained their personnel for such complex and fast changing crises, if we want to change the pattern of such accidents.

Finally, in the last 10 years four major air accidents in Pakistan were not because of human error or technical faults, but due to the failure of the aviation system as a whole.

Email: Nafghan@iba.edu.pk