Wednesday, April 08, 2009

Pilot found guilty, all other parties try to look innocent

Despair as Garuda pilot gets two years

I'm not a lawyer, so I'm not going to get into the appropriateness of the sentence or anything else, but I'm personally of the opinion that justice was not fully served and that aviation in Indonesia is not substantially any safer than before the Garuda incident.

My reasoning is that aviation accidents rarely, if ever, have a sole cause. This incident is no different. The poor decision making of the pilot was merely one link in the chain of events, one more hole in a slice of swiss cheese that resulted in the deaths of 21 people.

Where, for example, were the aerodrome operators, the airline executives, the regulators who were, in some way, also culpable for the incident?

AE-2007-015: Boeing 737-497, PK-GZC; Adi Sucipto Airport, Yogyakarta, Indonesia; 7 March 2007

The aircraft exceeded its speed limit of 250 knots below 10,000 feet, air traffic control either had no way of identifying this, or chose to do nothing.

The 1st officer did not appear to have been given the required simulator checks by the airline.

The regulator, the DGCA, had only conducted two safety audits of the airline during the previous ten year period. Most general aviation flying schools in Australia get audited more regularly than that, usually once a year.

The fire-fighting units were dispatched to to the crash site, only to find themselves trapped behind an airport perimeter fence 130 metres away. The fire-fighting units themselves did not comply with ICAO recommendations, and even if they had been able to get past the fence, were ill-equipped to perform the task required of them.

Garuda took 33 hours to provide the cargo manifest to authorities - so long, in fact, that it negated the whole point of providing it in the first place.

The runway itself did not meet ICAO standards, and the DGCA had failed to notify the ICAO of this difference.

The flight data recorder did not record all of the parameters it was required to record, as the unit was a digital unit, and unable to record the analogue input.

Pilot guilty, but is flying in Indonesia any safer?

The answer appears to be a little, but not much. The EU has still banned Indonesian airlines from flying in EU airspace, a step Australia appears unwilling to take, probably due to political considerations.

The conclusion that I draw from all of this is; until a blame culture is overcome, until there is a willingness to acknowledge inadequacies, the system cannot be substantially improved. This is true of all organisations, in all fields. Burying ones head in the sand and ignoring criticism only delays the inevitable.

The was pilot error involved in this incident - but the root causes went much deeper.


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