Lessons from EK521 – Experience counts

There was a post yesterday on PPRUNE that is one of the most carefully crafted posts that I have seen in the Middle East forum.

The post considers that changes over time within both the airline, and the airline industry, that might have contributed to the EK521 incident.

Rightly it attaches no blame to the flight crew – it is more a statement of how experience is less valued as the aircraft themselves move to greater automation.

It is in many ways a throwback to the old concept of flying by the seat of your pants. Understanding what the airplane is doing and why.

Everything I hear from within the airline suggests that there are many experienced pilots who are generous with their time and advice. At the same time there are many new pilots with limited experience and hours.

Arguably the issue of experience does not just apply to EK521. The same discussion could be made around Air France 447 and Indonesia AirAsia 8501.

The author is anonymous – which is probably necessary for anyone to post sensitive material on PPRUNE.

But this should not be sensitive; this should be an open discussion.

Anyway – read this – then read it again to digest what the writer is saying.

“The dust has more or less settled on 521 and there is relative clarity on what occurred. More interesting is of course the “why”. Here is my tuppence worth.

In a nutshell it appears a go around was attempted and for various reasons thrust was not applied until too late. We can argue the details of incorrect procedure, lack of knowledge, reliance on automation, flaws in training and even, it would appear, the age of crew! I believe that is all superficial.

I also believe that this accident would not have occurred in this airline 10 years ago. To explain let’s consider the history so far. There have been incidents that came very close to catastrophic accidents but ultimately the accident was avoided. To name a few:

• Windshear resulting in ground contact- recovered
• Loss of control on a go-around – recovered
• Stickshaker turning base – recovered.
• Insufficient thrust on takeoff with tail contact and overrun – recovered
• Gross loading errors – all recovered.

In some incidents mistakes may have been made but ultimately there was no loss of life or hull. The crews recovered.

So why was this different? One could say the statistics will catch up in the end. That’s fatalistic. I believe the root cause is lack of experience. But not a lack of experience that can simply be laid at the feet of the crew on the day. That would be unfair. It’s an overall decline of experience that has been systematically introduced through a number of avenues in a bid to reduce costs.

The experience factor is complex. Many have argued experience does not automatically mean greater proficiency. I would agree. Many would argue extended and improved training can offset lack of experience. Again I would agree. However we need to stand back a look at the system holistically.

It is no secret that the company has been reducing the experience criteria for entry so this element is obvious. That on its own may not be an issue but combining this with other factors results in a dangerous synergy. It is not easily explained and even less easily understood by those who haven’t flown or even those who have, but no longer do. There is a world of difference between knowing and doing as any pilot who has been off flying for some time can testify.

Historically in mature and stable airlines people join with whatever experience is demanded. However they come under a protective envelope of a general experience that migrates downwards. Call it “trickle down experience”. It comes from more experienced pilots, trainers and even swirls around at the bottom levels. It is built up through flights, watching, discussing, training, and social occasions.

But if you gut all levels by the attrition of experienced pilots, trainers and peers that must be quickly replaced, soon the flow is reversed and you are left with “trickle up inexperience”. This is because the opportunities for experience exposure are exponentially reduced. One experienced training captain leaving and being replaced with a inexperienced one denies a lot of pilots those little gems of technique and knowledge while exposing them to some level of lack of knowledge and understanding. This is then passed on. Accelerate this process and pass it on for a few “generations” and any solid background of experience is rapidly diluted.

There are only a few degrees of separation between touching experience or inexperience.

Other factors affect this experience level too. Workload has a direct effect. Flying reasonable hours allows the diligent pilot time to study manuals, consider scenarios and even chat with his colleagues. It’s what pilots do. Ask any wife. When hours are pushed to the limits prescribed for fatigue then how much of the self study and improvement is going to happen? These days I think we have pilots that don’t even understand how important this is. They assume their improvement will occur at training sessions and by grinding out the hours. The spoon fed follower of the magenta line.

Putting schemes like distance learning and constant manual/document revision in place reinforced by decrees that the pilot is responsible is unrealistic and fails on a managerial level to address the problem. It is little more than an effort to shift responsibility. It may avoid blame but wont avoid the errors. At the very least formally allocating time to these endeavors would be a step in the right direction. The pilot swamped by work hours, constantly on the limits of fatigue and also trying to address the issues in their own life can hardly keep up with the flow much less be in a mental state to absorb it. Who is to say 521 couldn’t have been avoided had the crew had a bit more time to spend in the books or chew the fat with more experienced pilots?

Additional handling sessions to address highly compressed training courses is a step in the right direction and is to be commended. However it is never going to mitigate the rips in the very fabric of pilots abilities that has been advanced in the industry over the years. The problem is deeper. Training can do much but against a background of cynical, disenfranchised and overworked pilots with diminishing experience and real experience opportunities, it is a band aid. Somehow hoping an age limit will allow time to smooth this over is farcical. The real worry is that some in authority actually believe this will address systemic flaws with a broad brush. I would blush to be associated with such lack of professional understanding.

I sincerely hope 521 was an unfortunate accident not to be repeated. How lucky it was that it didn’t hit the ground harder and fireball. Or stall and roll off to impact the apron on the left. Or hit a 380 clearing down taxiway M. Or come down in the built up area beyond the airport. Maybe innate experience itself prevented those outcomes, but that’s cutting it fine!

Nonetheless I remain convinced that the systemic errors are still rife and remain unaddressed. I pray they are not demonstrated in more tragic circumstances. That was the warning. It should be heeded.”

The best experience is where one has made mistakes, owned up to them, reviewed them and learned from them. Perhaps the issue for airline management is the need to absorb the experience of senior pilots within the culture and working practices of the company.

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