Just as the flight data recorders from Air France Flight 447 were first being read–a few weeks shy of the two-year anniversary of the aircraft’s fatal plunge into the Atlantic Ocean four hours after takeoff from Rio de Janeiro en route to Paris–I started receiving calls from reporters asking for comment on word leaking out that pilot errors had caused the aircraft to stall and crash, killing all 228 people aboard. My first thought: how cruel to the families of the dead pilots to scapegoat them by leaking derogatory information about their handling of the flight’s final minutes, even before the investigation was completed, data analyzed and conclusions officially reached.
But how convenient, as well. The rush to blame the pilots conveniently grabbed the media’s attention away from possible problems with the Airbus A330 and the actions of its manufacturer, the airline and the French government in response to reports of issues with the pitot tubes. If the pitot tubes stop functioning for whatever reason–including becoming clogged with ice or other substances–airspeed indicators in the cockpit will be inaccurate and information relayed to the computers flying the aircraft will also be inaccurate. It’s not hard to imagine that confusing data in the cockpit could have led to confused actions by the crew. So while talking heads argued about what the pilots should or should not have done, focus drifted from why Airbus, Air France and the DGAC (the French equivalent of the FAA) may have failed to replace faulty pitot tubes in a timely manner. The very same pitot tubes might have been responsible for the confusing data the pilots were forced to wrangle with.
An Easy Target for Larger Failures
Scapegoating the pilots in this case got me thinking of other recent accidents in which pilots became the scapegoats for systemic government and corporate policy failures. Take the Continental/Colgan accident in Buffalo. Colgan was quick to pin blame on the pilots for their piloting errors. At the same time, it ignored the circumstances that led to improperly trained, qualified and fatigued pilots being in the cockpit in the first place. Continental disavowed any responsibility for the accident–even while the smoldering wreckage still bore the airline’s logo. And passengers could be forgiven for assuming that Continental’s name on the ticket and logo on the aircraft meant Continental safety and standards in the cockpit.
In addition, the FAA was quick to convene a safety summit after the accident, but it did nothing beforehand to ensure one level of safety actually existed for Part 121 air carriers, regardless of whether they are a major airline or a regional. Maybe the FAA failed to learn from NTSB accident reports that have found numerous circumstances in which commuters did not operate to the same standards as legacy carriers. And certainly the FAA was aware of fatigue issues related to a commuter pilot’s long duty days.
And just recently, the FAA Administrator was quick to blame controllers for falling asleep on the midnight shift, without looking at whether the FAA’s own policies were also to blame. After all, when he decided to put just one controller in the tower did he ignore what was common knowledge for many inside and outside the FAA: that controllers in many towers routinely took turns napping on the midnight shift? And was he unaware of several well publicized incidents in the 1990s where controllers at different centers were caught taking turns sleeping in their cars on midnight shifts, for as long as several hours? Didn’t the FAA have an obligation to find out why its employees were sleeping on the job before mandating solo shifts? And does anyone at the FAA really think that an extra hour of rest is going to keep controllers from nodding off on the midnight shift? It sure seems to me that the FAA is ignoring its own extensive research on fatigue.
As a consequence of the Administrator’s rush to blame the controllers, who probably did not come to work alone in their towers to fall sleep, he gave a pass to airliners that intentionally landed at DCA without a clearance and without any knowledge of why the controller failed to respond. (And contrary to what some have opined, the airport did not become an uncontrolled field because the controller failed to respond.)
Perhaps not unexpectedly, the airlines, glad to have saved the fuel and hassle of circling or diverting, saw no safety problem in the decision to land without a clearance. In addition, by so publicly pointing the finger at the controllers who fell asleep, the Administrator implicitly let the rest of the FAA off the hook for the policies and procedures that allowed over-scheduled, fatigued controllers in the towers in the first place.
So all this rush to place blame–usually on the dead pilots who cannot defend their actions–is not conducive to a proper evaluation of the factors or policies leading up to accidents and incidents. And it makes preventing future accidents that much more difficult. In fact, the NTSB was created in part to look at accident and incident investigation from a broader perspective than what had been the CAB’s tendency to blame every accident on pilot error and to look no further.
The value of accident investigations–such as those conducted by the NTSB–is the level of detail that is analyzed. All sectors of the aviation industry must champion a methodical, broad-based approach that rejects a rush to judgment based on preliminary data if we are to truly learn from the past and prevent accidents in the future. While pilot errors are frequently a part of the causal chain in an accident, it serves no one well, least of all passengers, when judgments are made in haste or to cover up failures by a company or its regulator.