Let’s talk about Air Arabia flight 111
On September 18th 2018 an Air Arabia Airbus A320 was on a scheduled flight from Sharja UAE OMSJ to Salalah Oman OOSA.
The flight was also a training flight for the second officer – that is the EASA equivalent of the FAA IOE.
The runway in use was 30. Intersection Takeoff from link 14 about 1/3 of the runway.
Amazingly the crew taxied to the runway but instead of turning to the left and taking off on 3000-meter-long runway turned by mistake to the right and took off in the wrong direction on a 1000-meter-long runway.
Below is a link to the report in the description if you want to read its not that long. a 45-page long report.
There are three outstanding points worth discussing in this report.
1 The FO on that flight had 159 total flight hours.
2 There was a total loss of SWA of both pilots.
3 The FO realized at about 50 knots that something was wrong and called her bad feeling aloud Once the training captain realized what had happened, he still chose to continue the takeoff and not abort.
So let’s start with the 159 total hours. To make a long story short it is perfectly normal. When you consider what is required to become a pilot or any other profession for that sake you rely on a few parameters.
Basic aptitude
Instruction
Training
On the Job Training
Experience – the hardest to quantify of them all.
FAA vs ICAO/EASA
The main difference comes down to OJT vs Competencies, MPL vs 1500-hour rule.
While ICAO and EASA chose competencies as the leading theme of pilot qualification the FAA chose experience. It is a historical choice based amongst other things on geography and the accessibility and low prices of GA in the USA.
The FAA is in huge violation of ICAO standards. Not for the 1500-hour rule but for the absence of the MPL
Here is a link to the FAA page on differences from ICAO standards and recommended practices. Starting at item 2.5.1.1 there is a whole lot of “The United States has no 14 CFR provisions for MPL”
https://www.faa.gov/air_traffic/publications/atpubs/aip_html/part1_gen_section_1.7.html
I have posted a long comprehensive post in Hebrew regarding this point.
Moving on to the takeoff in the wrong direction.
If you read the report the circumstances are that this is the Second officer’s second rostering, A four-day trip with the training captain. On the previous two takeoffs they used runway 12 and that is a right turn from the taxiway
The Taxi was a short one during which the captain was busy starting the second engine and then performing the before takeoff procedure and checklist – the report fails to separate the two.
The report correctly analyzes that even though the company identified taxi and takeoff as critical stages of flight the captain was “head down” and thus missed the wrong turn. This resulted in a total collapse of both pilot’s SWA. The GCAA also contributes some complacency to the fact that Sharja is the Domicile of Arabia Air, and the captain was very familiar with the airport.
But the report stops there. It states that the loss of SWA was due to poor workload management (WLM). But does not try to explore the question: how can this happen?. And to me that falls short of the real reason for the loss of SWA.
Obviously poor WLM can lead to loss of SWA, But the training captain with 22000 hours of experience knows that. He knows that better than all the investigators. He knows that taxi is vulnerable he knows that lining-up on the runway is vulnerable. He knows that he is there to mitigate the risks associated with a pilot of very little experience.
Yet he still chose to go “head down “for an extensive period for the engine start procedure and CL and the lineup Procedure and CL.
Well most of the time this lies with the company and the tendency to prioritize Application of knowledge (APK)-SOP over all other competencies.
Philosophically at a company level this is highly connected to a concept of aiming and manifesting a zero-mistake target as a mean of achieving zero accidents.
If this is the case – not only this target unachievable but this target is not conducive to safety.
Setting zero mistake target throws crews to always look for SOP deviations. This increases workload on one hand and makes the signal to noise ratio between small lapses and errors to Big Gross errors smaller than desired, when everything is important than nothing is more important than other. And switching on taillights becomes as important as taking off in the correct direction.
This also leads to the pilots monitoring each other rather than monitoring the airplanes flight path.
A company should have a good philosophy of priorities, but sometimes they don’t. and sometimes that is not enough if you write one thing and exercise something else – like teaching training and debriefing everything in terms of SOP compliance and nothing in terms of priorities, SWA or WLM.
The report anyway does not go into this issue but– the Training captain was a highly qualified training captain with 22000 hours, flying with a second officer on her first rostering and still adhered to all the written Normal SOP and prioritized it over his SWA.
The report might even worsen this practice of – everything is in the SOP by recomanding changing SOP rather than philosophy of flight and training.
3 Regarding the decision to continue the takeoff in the wrong direction.
Here the investigation is even more reluctant to take a stand as to the why the takeoff was not aborted. , This is clearly a less than optimal decision and the report states that there was no problem rejecting the takeoff.
The report is correctly attributing a lot of weight to startle effect. This is something on the agenda of the aviation community for a long time with no obvious solution. Ill get back to that later.
As a policy all airplanes and companies have a distinction between low energy RTO and high energy RTO. Below 80 knots for Boeing and below 100 for Airbus. But in this case this was not a normal Takeoff. The captain at about 60 knots realized there was something wrong and after a few seconds more realized what was wrong.
He still chose to continue the takeoff in a spectacular fashion by applying full thrust and lowering flaps from position 1 to position 2.
Usually, decision making is divided based on time available into three processes.
Long term – where a structured decision making can be applied such as PAVE DECIDE or FORDEC.
The midrange will rely highly on checklist use.
And the short term will rely mostly on instruction, training, experience, and pre-decisions. A set of ready-mades what ifs.
All are affected by startle, and thus was a big one. Realizing you are taking off in the opposite direction you are supposed to is a serious blow to self-confidence self-esteem and God only knows what else.
It goes all the way to this captain realizing his reality perception was completely wrong deciding that he should save the day by violating almost everything he was trained to do because he knows better.
So. Don’t do that. Think about what constitutes “unsafe flight conditions” is a telephone call from the cabin? how about ten calls from the cabin during takeoff.?
And don’t try to fix a mistake by making a much worse decision.
And regarding training for “startle effect” well that is one spot the industry has not come up with a good solution yet.
But we should we have to, As the planes and engines got better and better we became the weakest link in the safety chain percentage-wise by a lot.
You can watch this analysis on my YouTube channel Practical-Aviation
Thank you
