Automatons and Automations: Computers Continue to Perplex Pilots

Air Safety Week, Jan 24, 2005

Crash investigations again highlight prominence of human error and mode confusion

Ever since computers and airplanes came together, modal confusion and pilot perplexity have gone hand in hand. Now and again they hook up with grave consequences and there's an unintended outcome. Herewith we provide two such examples. The first, the June 2003 controlled flight into terrain (CFIT) fatal crash of a Canadair RJ near Brest, France, is fairly simple. The crew missed a step, stumbled, and the pilot died (see ASW, Jan. 10, for a roundup of CFIT incidents).

The second is less simple. The three-man crew of the Flash Airlines 737-300 completely lost the bubble -- and everybody died. The illogicality of what happened there has left everybody in disbelief.

The final report on the first accident, from the French Accident Investigation Bureau (BEA), was released on Jan. 7. It is available (only in French) at www.bea-fr.org/docspa/2003/f-js030622/htm/f-js030622.html, but it contains some sobering color imagery. It cries out for an English translation because there are many lessons to be learned, and they cannot be done justice via a rudimentary Internet translation service. Thus, it has to be concluded that the BEA is being very parochial in not providing one.

The conclusions we draw from the second accident are based upon a little insight and the initial factual report by the Egyptian Ministry of Civil Aviation at www.civilaviation.gov.eg/conf/files/flash.pdf.

In the first accident, the French BEA found that the crew failed to select the approach (APPR) mode prior to the approach and that they were first focused on vertical, and thereafter only on horizontal, navigation, failing to note their dangerous descent in time to avoid landing a kilometer short --despite their state-of-the-art Head-up Display (HUD). Looking at the diagrams in the report, you wonder whether pilots are capable of assimilating that level of clutter of abstruse symbology. Ponder whether the absence of a critical symbol or mode annunciator is sufficiently attention-getting.

In the second accident, a Boeing 737-300 operated by Flash Airlines of Egypt (SU-ZCF) departed from runway 22R at Sharm el Sheikh (HESH) at night on Jan. 3, 2004. The visibility was 10k+, 17 deg C, light winds and SU-ZCF was bound for Cairo and then Paris, but it disappeared off radar at 4:44 a.m. Cairo time, three minutes after takeoff. Wreckage was soon spotted in very deep water in the Red Sea, seven miles south of its departure point. The 135 passengers and 13 crew of Flight FSH604 died in a crash that was close enough and violent enough to shake the windows of the coastal resort.

The aircraft took off and climbed normally and began a left hand turn as scheduled. But at 2,000 feet the turn slowly inverted to the right and the aircraft progressively rolled until it was banked 90 degrees at about 5,600 feet. It then rapidly lost height and dived into the sea. No mayday call was made.

Terrorist activity was quickly ruled out. Looking back at 737 "accidents" over the past 30 years, it was noted that this one ranked as the 2nd worst. In terms of French nationals killed, it was the worst air disaster for France since the 1960s. Most of the passengers were French tourists.

In the days and weeks that followed, the company, founded six years previously by a consortium of Egyptian and Italian businessmen, was held in the spotlight and found wanting. The Egyptian air company Air Flash had not been allowed to land on or fly over Swiss territory since October 2002. The Swiss took this precautionary measure after spot tests made by the Swiss Federal Aviation office (BAZL) at Zurich-Kloten airport had failed Air Flash on its safety standards "due to important technical faults." The Swiss Federal Aviation office had then put a report in the European Civil Aviation database -- where it was ignored. The faults allegedly included:

* Several instruments in the flight deck were unserviceable;

* Flight crew (cockpit) oxygen masks were missing;

* Emergency oxygen bottles were missing;

* Emergency exit lights were unserviceable;

* Quite a few life jackets were missing; and

* Passenger seatbelts were partly unserviceable or unusable.

While not constituting potential accident causes, such breaches are indicative of an airline's safety culture as well as its supervisory and regulatory environment. The Swiss Federal Office for Civil Aviation (FOCA) said it had inspected one of the company's aircraft in April 2002 and found that navigation documents were missing, fuel reserves were not calculated to international standards and the signposting of emergency exits was partly "in unusable condition."

"In addition, obvious maintenance deficiencies were found in the areas of the landing gear, the engines and the aircraft steering," it said in a statement. FOCA said the inspection of a second Flash Airlines aircraft in October 2002 had revealed "essentially the same defects". After the airline failed to provide sufficient proof that it had remedied the defects, it was barred from landing in Switzerland a few days later, the office said. One Norwegian passenger filed a complaint with the Norwegian CAA that this company had seats without seat belts. This led Norwegian Tour Operators not to contract with Flash anymore. One of Flash's two 737s had an emergency landing at Geneva Airport in early 2003 (despite it being banned from Swiss airspace), following an earlier one caused by engine failure in Athens (at the end of 2002). Flash Air returned its remaining aircraft to its lessor on March 6, 2004, and ceased trading as Flash. It's believed that this Phoenix has resurfaced on the same routes in the guise of Cairo Aviation. It's called sticker-change.