A look at how human intervention has been responsible for many air accidents.

Sudden death in sports is a penalty shoot-out but the expression seems to have taken an alarming turn where some pilots opt to take their own lives and several hundred along with them. Starting with the SilkAir crash in Indonesia to the Germanwings crash in the French Alps, lives have perished due to air accidents caused by human intervention. Failure to understand the ‘Human Factor’ has resulted in inhuman actions. Lack of transparency and denying the truth to save face, is making the sky an unsafe place to tread. Flying is still the safest mode of transport but the regularity of pilot suicide resulting in mass murders is something to be taken note of seriously.

On December 19, 1997, all 97 passengers and a crew of seven were killed when the SilkAir MI-185 crashed. On August 25, 1999, Aircraft Accident Investigation Commission (AAIC) of Indonesia stated: “Wreckage investigation and the flight data recordings indicate that, at impact, the horizontal stabiliser had a nose-down trim which was different from the last known trim setting for cruise flight at the stoppage of the flight data recorder recording, which could indicate a manual input from the cockpit. However, at this point, the AAIC is not yet able to establish who was responsible for the input.”

SilkAir in a statement, said: “There were indications that at the time of the accident the pilot-in-command was facing financial problems, and had experienced several company disciplinary actions. SilkAir is saddened and disturbed to learn that human intervention may have caused the crash of MI185.” AAIC and Singapore covered up this finding when the final report came out. The National Transportation Safety Board of the U.S., one of the accredited members in the investigation, countered the final report: The accident can be explained by intentional pilot action.

a) The accident airplane’s flight profile is consistent with sustained nose-down manual flight control inputs.

b) During the accident investigation, the Human Performance Group found through interviews with several SilkAir personnel that the captain was upset by the events that resulted in the loss of his Line Instructor Pilot position. HPG had also noted that the captain had lost three of his colleagues on December 19, 1979. “The accident (in Palembang) occurred on the same date as the 1979 RSAF crash in the Philippines; the extent to which the PIC was affected by this event could not be determined.” The HPG report states, “There were some indications that the captain’s behaviour or lifestyle changed prior to the accident.”

On October 31, 1999, EgyptAir Flight 990 crashed killing all 217 on board. The National Transportation Safety Board determines that the probable cause of the EgyptAir flight 990 accident is the airplane’s departure from normal cruise flight and the subsequent impact with the Atlantic Ocean as a result of the relief first officer’s flight control inputs. The reason for the relief first officer’s actions was not determined.

The relief F/O was supposedly reprimanded for inappropriate behaviour with female guests at the hotel often used by EgyptAir crews. An EgyptAir official said to be responsible for the alleged reprimand was a passenger on Flight 990. The details of the reprimand included the removal of relief F/O’s privilege of flying any flight to the United States, and that Flight 990 would be his last.

More than 10 years later, the Air India Express’ fatal Mangalore crash has a hidden reason. On March 17, 2010, Capt Glusica had been called to the Flight Safety Department of Air India Express regarding a ‘Hard Landing Incident’. While the Chief of Flight Safety had stated that the counselling was carried out in an amicable and friendly manner, it was given to understand from his colleagues that Capt. Glusica was upset about the counselling. This ill thought-out reprimand resulted in the captain making a smooth touchdown, albeit very late, resulting in the fatal overrun.

While Silkair and Egyptair accidents were deliberate human interventions where reprimand was a trigger, the AIE accident was a result where reprimand contributed to the captain’s fatigue induced wrong action.

In November 2013, Mozambique Airlines flight TM470 crashed killing all 33 on board. On December 21, 2013, Mozambique’s Civil Aviation Authority reported that the cockpit voice recorder and flight data recorder revealed that the captain was alone on the flight deck and banging on the flight deck door could be heard on the cockpit voice recorder. The autoflight systems (autothrottle and autopilot) were engaged. There were sounds and clicks consistent with a person knowledgeable of the aircraft systems commanding the engines to idle thrust and selecting the autoflight systems into a descent at 6000 feet per minute. Numerous warnings and alerts were not responded to.

On March 8, 2014, the Malaysian Airlines flight MH 370, disappeared with 239 persons on board. On March 15, the Malaysian Prime Minister Najib Razak hinted that the government believed it was possible a “deliberate action by someone on the plane” was behind the MH370 mystery. The change of course and subsequent path taken by the aircraft up to a point south of Andaman Islands was not due to any malfunction of the aircraft system. The inputs to the aircraft computers are deliberate and can only be done by a person who knows the system like the back of his hand. The co-pilot was a novice on the B777 and there can be no doubt that the captain has taken this deliberate action. The aircraft is somewhere at the bottom of Indian Ocean and there will be no survivors.

On March 24, 2015, a Germanwings Airbus A320 crashed in the French Alps killing all 150 on board. The co-pilot locked the captain out of the cockpit and deliberately descended at high speed into an area with high terrain and steep ravines. The Mode S transponder indication on the ATC radar confirmed that the lower altitude of 100ft was set manually from 38000ft to commence this rapid descent. The Cockpit Voice Recorder (CVR) has provided enough evidence that the co-pilot intentionally took the aircraft down. The medical history of the co-pilot, who had shown suicidal tendencies, puts a big question mark on safety and why the airline and the regulator turned a blind eye.

On May 26, 2010, just four days after the fatal Mangalore crash, another Air India Express flight nearly went down when the co-pilot FROZE at the controls and put the aircraft in a 26° nose-down dive from 37000ft. The official DGCA report covered up the event and did not institute any fresh medical evaluation of the pilot’s mental state. There may be a few such cases in the Indian sky. The introduction of any new rules on psychometry testing is not likely to throw light on such cases. We, in India, passively accept non-compliance of regulations, fudging and manipulating rules and systems, and place importance only on an airline’s political and commercial aspects. Even the medical fitness of some pilots is questionable and raises doubts on the integrity of the system.

The immediate exposure by the French prosecutor on the deliberate action of the Germanwings pilot that killed all on board should be the eye-opener for all the earlier events on loss of more than 700 lives due to human intervention in air. Regulators and airlines should understand that stress can drive a human being to unreasonable decisions that could result in fatal action. Adding new rules while blatantly ignoring existing ones, is not likely to make the sky safer. The human factor is a very important subject. The need of the hour is to encourage pilots to be open about their medical and mental conditions and for the Regulators and the airlines to assist in overcoming any problem.

These cases show that an additional crew member in the cockpit does not ensure safety.

May 17, 2009: An examiner pilot of Spicejet let his untrained son occupy the right-hand seat with a trainee captain under check on the left-hand seat on the Delhi-Hyderabad-Coimbatore-Delhi flight

.October 4, 2009: Panic gripped Air India flight IC884 early today when a mid-air fight allegedly broke out between the two pilots and cabin crew members

.October 20, 2009: A Jet Airways flight 9W-332 from New Delhi to Mumbai was at 3700 feet on ILS, when a check pilot occupying the observer’s seat in the cockpit, as a passenger, pulled a circuit breaker causing the Enhanced Ground Proximity System (EGPWS) as well as the engaged autopilot and the flight director to fail. The airplane entered a descent in excess of 1000 fpm up to 400ft above ground, before th-e captain took control and landed the airplane safely

.April 12 2013: An Air India flight AI-333 from Bangkok to New Delhi with 166 passengers and nine crew members. The first officer had taken a toilet break and a flight attendant had been asked to enter the cockpit according to standard operating procedures to monitor the captain and had taken the first officer’s seat. The captain then ordered a second flight attendant to the cockpit, left his seat, instructed her to take the left-hand seat, briefed both flight attendants how to operate the aircraft on autopilot and left the cockpit. When one of the flight attendants accidentally disconnected the autopilot about 40 minutes later, both flight crew rushed to the cockpit and recovered the aircraft.

The writer is a former Airline Instructor pilot, former member of Civil Aviation Safety Advisory Council who has given presentations in International Aviation Safety seminars, NASA & ICA.