Airlines do not seem to be learning from each other's safety errors. Is it their fault, or is there something lacking in the industry?
Crews flying into Agana Airport, Guam, have been alerted again to the fact that the approach can be highly dangerous. It is fortunate that this time no-one died, but it is also remarkable that the industry has such an incredibly short memory for safety issues - even specific, serious ones - and appears not to be able to profit from experience.
It has just come to light that, on 17 December, a Philippine Airlines (PAL) Airbus A330 scraped power lines on Nimitz Hill, Guam. The crew were carrying out a go-around in response to a ground proximity warning system (GPWS) alert that saved the aircraft and those on board from the fate that befell a Korean Air Boeing 747-300 on 6 August 1997. In that accident 228 of 245 people on board died when the aircraft, on approach to runway 06L at Agana, hit Nimitz Hill.
There are so many similarities between the circumstances surrounding the Agana approaches on 6 August 1997 and on 17 December five years later that it begs the question as to why agencies like the US National Transportation Safety Board (NTSB) bother to investigate and report in detail on accidents. The theory is that the industry learns lessons from the process. Identifying the lessons was the NTSB's job after Nimitz Hill in 1997. Perhaps Korean was the only airline to read the report. If anyone at PAL did read it, they seem not to have passed the lessons on to the airline's operations department and its flight crews. Or if they did, the lessons have already been forgotten.
The NTSB's report said that almost everyone involved in the Nimitz Hill crash could have performed better. The crew and the airline that trained them; the air traffic controllers and the system they worked with; the Federal Aviation Administration for allowing the minimum safe altitude warning system on the approach/en route radar system to be suspended. Both in 1997 and last December the airport navigation aids were only partially serviceable, but the flights left for Guam in the full knowledge that this was the situation.
There is no real recognition in the world airline industry that particular safety lessons learned by others apply to everyone in the same business. When an accident report comes out, who reads it? The only certain readers appear to be lawyers representing the bereaved families, and the airline's and the aircraft manufacturer's legal teams. Other readers would include senior pilots and operations people at the airline that had the accident. The press may take a temporary interest, but more often than not the media shows greater interest in the questions at the time of the accident than the answers when they become known a couple of years later. There are a few others: engineers like Don Bateman, originally of Sundstrand, now Honeywell, who develop and improve equipment - like the GPWS and now Enhanced GPWS - that provides the chance of saving an aircraft from a similar fate in future.
There is no industry system for persuading airlines to take each other's accidents seriously. The International Civil Aviation Organisation is supposed to be the repository for all reports but often is not even sent copies. ICAO has been promoting the idea of GAIN, a global aviation information network, but this has been going nowhere for a long time. About 120 airlines have acquired BASIS, the British Airways Safety Information System, but this system for spotting incident trends is a series of in-house units. The International Air Transport Association has pledged to use the BASIS model to build up something wider, but today gives the impression that current financial disciplines have forced the issue well down its priority list. The Flight Safety Foundation perhaps comes nearest to enabling airlines to learn from others' experiences by summarising significant major reports in digest form and disseminating them to members. But information is simply not used by people who consider it irrelevant to them.
In a worldwide industry there needs to be a global culture. There are some things, like safety, that the whole industry should hold in common. They transcend considerations like competition or corporate confidentiality - competing commercially on safety is something that even safer airlines do not dare because it implies that industry standards are suspect. At present, however, global safety cohesion is missing, and no single organisation is charged with creating the awareness that it is essential. Leadership, data, and effective propaganda is needed, and IATA, having started, is the best organisation to take responsibility for it.
Source: Flight International
