Accidents: The Pilot as Last Defense
For a number of months now, I've been reporting on the November 2009 Norfolk Island ditching of a Westwind jet. The Australian Transportation Safety Board's investigation of this accident has been widely regarded as a mess, criticized equally by the Australian pilot community, the press and lately, by the country's Senate. As we reported over the weekend, the ATSB's report (PDF) was cited for numerous omissions related to how regulators oversaw Pel-Air, the company that owned the Westwind.
Thorough as the Senate report is, I found one phrase in it that suggests it wasn't written by pilots. Or maybe by pilots with a different view of PIC responsibility than I have. In citing numerous deficiencies in how regulators oversaw Pel-Air, the report said these failings left the pilot "as the last line of defense against an accident."
I found this utterly jarring and the report repeated it several times. The gist of it is this: It's the regulations and operations specs that make flying safe, the pilot is only there if those don't cover all exigencies or novel situations otherwise arise. It's not quite the dog-and-autopilot concept, but it's close. To a degree, it's a semantical distinction, but an important one, nonetheless. To take it to an extreme, when you put on your PIC hat, you are the first thing and the only thing between you and your passengers and an accident—not instruments, not traffic boxes, neither radar nor datalink weather, GPWS, glass panels or BRS parachutes or ATC. And definitely not regulations and ops specs, although they undeniably play a critical role in safety.
Those things provide a basic structure by which to frame decisionmaking, yet they don't help with the novel situations which are perfectly legal, but, if not entirely unsafe, are only safe with no margins worthy of the name. The Pel-Air flight fit that latter description to a T. Given the weather forecast, fuel loads and distance, it was legally dispatched to a remote island with notoriously difficult-to-forecast weather, at night, with the closest airport some 400 miles away and hopelessly beyond fuel range. There was no legal requirement for an alternate, thus one wasn't filed or planned. The pilot had little or no dispatch support from his company and the weather reporting system was sketchy at best.
So at the outset, what the Senate calls the first line of defense—the regulations and op specs—was functionally non-existent, which is the core of the scandal here, in the Senate's reasoning. The Civil Aviation Safety Authority knew all this because it had investigated Pel-Air in depth. Yet it scape-goated pilot error as the primary cause of the accident. The pilot was hardly blameless; you can decide for yourself how to apportion responsibility. As is the case with so much in flying, survival—or at least accident avoidance—turns on pilot instincts and skills and all the regulations and cockpit gadgets do is provide entertaining diversion and, okay, some helpful data. If all that stuff fails to keep you from extremis in the first place, you fall back on your lowest level of training and hope it's high enough.
What informs the skill and instincts in part is knowledge of previous accidents. That's where many regulations come from, too. It's no exaggeration to say the rules were written in blood. Systemic safety evolves from unbiased understanding of accident causes and on this point, the ATSB dragged the entire safety edifice backwards. In blaming the pilot for the accident, it failed to account for known failings in CASA's oversight that, in an ideal world, might have shaped or at least informed his judgment or simply flat-out prohibited the flight in equipment suited to the task only if everything went just right but profoundly inadequate if it didn't. This kind of flawed accident investigation sows mistrust and is an absolute menace to advancing safety based on documented experience.
I suspect the Australians will have their hands full fixing this because the Senate report gives the impression that it's a cultural shortcoming within the agencies themselves. At least the investigation into the investigation gives them a good start.