Objections to Accident Report
This refers to the article “Spiral Dive,” written by Mark Lacagnina, in the March 2012 issue of AeroSafety World. Ethiopian Airlines would like to express its deepest disappointment with the misconception and fallacies presented in the article based on a very controversial and one-sided report published by the Lebanese Ministry of Public Works and Transport in relation to the Ethiopian Airlines Flight 409 accident.
It is our firm belief, and we hope you will agree, that balance and accuracy are of paramount importance in the preparations leading to the dissemination of such a sensitive matter to the public. We are greatly saddened with the inaccuracies and the lack of fairness and balance reflected in this particular article.
The so-called investigation report contained numerous factual inaccuracies, internal contradictions and hypothetical statements that are not supported by relevant evidence. It didn’t include the crucial evidence for investigation such as the recovery of the wreckage, security footage, autopsy and toxicological records, baggage screening X-ray records, terminal CCTV [closed-circuit television] records, and examination of the victims’ bodies before burial. Accordingly, Ethiopian Airlines had already expressed its strong opposition to the investigation report released by the Lebanese Ministry of Public Works and Transport. We have enclosed comments made by the Ethiopian Civil Aviation Authority on the investigation report for your review.
The purpose of this letter is to provide you with vital information related to the ET 409 accident and, most importantly, to enable the truth to emerge about the probable cause of the accident. By doing so, our objective is to contribute to the enhancement of international aviation safety.
Therefore, we kindly request that you reflect our objection regarding the investigation process of ET 409. It is information of profound importance which our customers throughout the world have an inalienable right to know, and its release will unquestionably acknowledge the professional act of honesty and integrity of AeroSafety World magazine.
CEO, Ethiopian Airlines
The editor replies: Standard procedure here is to base articles about accidents/incidents on the official final reports — in this case, the final report published by the Lebanese Ministry of Public Works and Transport. The report did not include the comments submitted by the Ethiopian Civil Aviation Authority (CAA), a party to the investigation, which said that the accident investigation was “guided and monitored to prove and justify” speculative public statements by government officials about the causes of the accident before the investigation was begun. Rejecting the Lebanese report’s conclusion that “inconsistent flight control inputs” by the flight crew led to a loss of control of the Boeing 737 on departure from Beirut, the CAA said that recorded flight data, air traffic control data and witness accounts show that “the most probable cause of the accident … was the breaking-up or disintegration of the aircraft as a result of an explosion in the air at 1,300 ft because of a possible shoot-down, sabotage or lightning strike.” An executive summary of the CAA’s comments is available at www.mfa.gov.et/Press_Section/ExecutiveSummary.pdf.
Who Makes SMS Difficult?
I would like to share with you my perspective on William Voss’s article, “SMS Reconsidered”.
I have great respect for Flight Safety Foundation and Mr. Voss. I agree in principle with the comments made by Mr. Voss in this article, but would like to elaborate on a couple of key points.
In the opening paragraph, the following two comments are exactly on target but there is more here than is evident on the surface.
“We also knew that all these consultants couldn’t possibly know much about the subject and would be forced to regurgitate the ICAO guidance material that was being put out.”
Our industry does not have a requirement for certification of safety personnel. In the absence of organizational guidance or certification, it’s not hard to understand that anybody can, and will, slap their logo on the same old “me too” acceptable means of compliance published by regulators and industry organizations.
“It was obvious that the process people dealing with ISO and QMS would embrace the concept of SMS and treat it as another process exercise.”
Business processes are both important and useful. The problem with the aviation SMS process is twofold:
- Business aviation, in particular, is relegated to applying business processes designed for other industries due to the lack of a solid aviation process framework.
- Many operators start out with the “me too” templates and skip the most important part of designing a proper SMS — defining their system, identifying their hazards, and setting quantifiable goals.
I discuss this problem in my blog post titled: “I have an SMS, now what do I do with it” airsafetygroup.com/i-have-an-sms-now-what-do-i-do-with-it.
In the second paragraph, the comment, “They are reassured by the fact that all they really have to do is fill out the right form and show up at the weekly meeting” is correct in its assessment of what’s happening, and is so very wrong, with regard to SMS process.
Most operators have a stack of useless reports that don’t measure anything of value. These operators skipped the step of identifying their actual issues, setting quantifiable goals, developing mitigation, measuring and tracking.
In the third paragraph, the comment, “Before SMS was made complex by the consultants and process people, it was meant to do one simple thing — allocate resources against risk” is a little misdirected. Have a look at FAA Advisory Circular 120.92A, “Safety Management Systems for Aviation Service Providers,” and tell me again who makes the process difficult. Without picking on the consulting industry, I will give you this: The lack of useful or understandable information from the civil regulatory agencies and aviation organizations allowed operators to be frightened into doing something, even if it was wrong. That being said, again, anybody can sell SMS, and they do. It is not necessary to understand either the SMS or ISO process to sell “me too” templates to unsuspecting operators who are trying to do the right thing.
The closing questions posed by Mr. Voss are exactly correct, but let me put the SMS process spin on them:
- “What is most likely to be the cause of your next accident or serious incident?” (Have you identified your hazards and developed a risk profile?)
- “How do you know that?” (Are you collecting hazard information and are you analyzing it for potential outcomes and severity?)
- “What are you doing about it?” (First, what do you want to do about it [goals], then have you developed mitigations/corrective actions?)
- “Is it working?” (Are you tracking your results?)
- Answering these questions requires factual information, which can only be obtained through a structured, repeatable process.
In closing, there are two obstacles standing in the way of effective implementation of an aviation SMS:
- Translating the academic hypothesis and terminology into easily understandable requirements and breaking the risk analysis process into steps that make sense to our everyday operations.
- Making the paradigm shift from “check this — done,” to “what do I need to do to solve my problem?”
Air Safety Group