For many people today, air travel is a normal part of everyday life; a hassle at times, perhaps, uncomfortable, maybe, but something we do without much thought. And that’s because the chances of dying or being severely injured in an aircraft accident are remote.
When they do happen, however, aircraft accidents make headline news across the world. Out of these tragedies emerge lessons; not only about what happened, but also about how to improve standards and procedures, so that air travel might be as safe and as comfortable as possible.
Following on from our previous post about five aircraft accidents that transformed aviation in the 20th century, we will look at five noteworthy examples from the 21st century, which have also had a significant impact on the industry.
1. Royal Air Force Nimrod crash
When: 2 September, 2006
Where: Chalaghor in the Panjwaye District of Kandahar, Afghanistan
Royal Air Force Nimrod was a Nimrod MR2, XV230, that caught fire during a reconnaissance flight and crashed in Kandahar, Afghanistan, killing everyone on board. The disaster marked the biggest single loss of life in the British military since the Falklands War.
The aircraft experienced a fuel leak while refuelling mid-air; at the time, it was monitoring a NATO offensive against Taliban insurgents. The fuel is believed to have seeped into the bomb bay and caught fire after coming into contact with an uninsulated hot air duct. The pilot was aware of the fire and attempted to redirect to Kandahar air base, descending from 23,000 feet to 3,000 feet in just 90 seconds. However, the crew had no chance of containing the fire.
An RAF Harrier aircraft observed the Nimrod in descent and witnessed one of the wings explode, before the rest of the aircraft imploded. The victims included 12 RAF personnel, a Royal Marine and a British Army soldier.
An independent review of the tragedy, led by Charles Haddon-Cave QC, concluded that the aircraft was not airworthy; in fact, the Nimrod fleet had been plagued by errors since its introduction in 1979. Following a seven-month inquiry, the report stated:
"The shortcomings in the current airworthiness system in the MOD are manifold and include:
- a failure to adhere to basic principles;
- a military airworthiness system that is not fit for purpose;
- a safety case regime which is ineffective and wasteful;
- an inadequate appreciation of the needs of aged aircraft;
- a series of weaknesses in the area of personnel;
- an unsatisfactory relationship between the MOD and industry;
- an unacceptable procurement process leading to serial delays and cost-overruns;
- and a safety culture that has allowed “business” to eclipse airworthiness."
In the report, Charles Haddon-Cave QC detailed the chain of catastrophic errors that led to the huge loss of life, naming those he considered culpable and criticising the Ministry of Defence.
The disaster led to many changes, including the formation of the UK Military Aviation Authority (MAA), an independent organisation responsible for the regulation, surveillance, inspection and assurance of the defence air operating and technical domains. It ensures the safe design and use of military air systems. An independent accident investigation agency, now called the Defence Accident Investigation Branch, was also formed.
2. Air France Flight 447
When: 1 June, 2009
Where: Atlantic Ocean
Air France Flight 447 was an Airbus A330 that was travelling from Rio de Janeiro, Brazil, to Paris, France, when it crashed into the Atlantic Ocean after stalling mid-air. The flight data recorders were not recovered until May 2011. They showed that the crash was ultimately the result of the crew’s failure to respond correctly after icing of the pitot tubes caused the autopilot to disconnect - with catastrophic consequences.
Having departed Rio de Janeiro-Galeão International Airport on 31 May, 2009, at 19:29 local time, the aircraft last made contact at 01:35 UTC, which was three hours and six minutes after departure. At this point, it passed into a so-called “dead zone” – that is, an area where an aircraft falls outside of the communication range of either air traffic control or other aircraft.
Due to the length of the flight, each of the pilots were allocated a rest break; the captain had arranged to take the second slot and left the cockpit at 02:01 UTC, leaving the two first officers at the controls. Shortly after this, the aircraft entered an area of turbulence (which wasn’t unusual for this part of the world) and, soon after, ice crystals began to form on the pitot tubes.
As a result, the pitot tubes stopped recording accurate information about the airspeed and the autopilot and then the engine’s auto-thrust systems disengaged, transitioning the aircraft from “normal law” to “alternate law”. The aircraft started to roll right amid the turbulence; in response, one of the first officers put his side-stick to the left. Over the next thirty seconds the aircraft rolled from left to right and he also pulled up on his side-stick, raising the nose – an action both not required and extreme in the circumstances. Consequently, the aircraft’s angle of attack increased and the stall warning sounded twice.
By 02:11 UTC, the aircraft had reached its maximum altitude of 38,000 feet and its angle of attack was 16 degrees, increasing to 30 degrees as the aircraft began to descend. Again, the aircraft stalled. In response, the relief first officer took over the controls and pushed his control stick forward to lower the nose and recover from the stall; simultaneously, the other first officer pulled his stick back – the two actions effectively cancelled each other out.
At this point, the relief first officer summoned the captain back to the cockpit. He eventually realised that the other first officer was causing the stall by putting the aircraft into climb mode but by then it was too late – the aircraft was too low to recover and crashing was inevitable. The aircraft crashed belly-first into the ocean at 175mph, breaking up on impact and killing all passengers and crew instantly.
"The accident resulted from the following succession of events:
- Temporary inconsistency between the airspeed measurements, likely following the obstruction of the pitot probes by ice crystals that, in particular, caused the autopilot disconnection and the reconfiguration to alternate law;
- Inappropriate control inputs that destabilised the flight path;
- The lack of any link by the crew between the loss of indicated speeds called out and the appropriate procedure;
- The late identification by the PNF of the deviation from the flight path and the insufficient correction applied by the PF;
- The crew not identifying the approach to stall, their lack of immediate response and the exit from the flight envelope;
- The crew’s failure to diagnose the stall situation and consequently a lack of inputs that would have made it possible to recover from it."
This tragedy was a powerful example of how both technical and human factors can combine to cause a fatal outcome. Reliance on automation meant that the flight crew were left bewildered when faced with an emergency situation that required manual flight skills. Additionally, the Air France culture meant that the captain saw it fit to leave the cockpit even as the aircraft was moving into an area of bad weather, leaving an anxious first officer at the controls. Poor communication and a lack of comprehension ultimately ended in disaster.
Following the accident, the pitot tubes were replaced on several Airbus models and reforms were implemented to bring about a shift in the company’s culture and training procedures, with particular emphasis on manual handling of an aircraft and the importance of collaborative communication between pilots and co-pilots.
3. Malaysia Airlines Flight 370
When: 8 March, 2014
Where: Southern Indian Ocean (presumed)
Fatalities: 239 (declared dead in absentia)
Survivors: 0 (presumed)
The disappearance of Malaysia Airlines Flight 370 remains the biggest and most enduring mystery in the history of commercial aviation. The aircraft was travelling from Kuala Lumpur International Airport, Malaysia, to Beijing Capital International Airport in China when it disappeared without a trace. The aircraft has never been found and the official search was suspended on 17 January, 2017, after 1,046 days, following a tripartite decision of government officials from Malaysia, Australia and China.
The Boeing 777-200 was being flown by 53-year-old Captain Zaharie Ahmad Shah, alongside 27-year-old first officer Fariq Abdul Hamid. However, just 38 minutes after takeoff, all contact with the plane was lost over the South China Sea – systems designed to automatically transmit the aircraft’s position, including the transponder and the aircraft communications addressing and reporting system, all failed. And yet, data shows that the aircraft continued to fly for a further seven hours, ending its flight in the southern Indian Ocean. No distress signals were sent, the weather conditions were normal and the aircraft had not been experiencing any technical issues.
The search for the lost aircraft was the most extensive in aviation history, encompassing the Gulf of Thailand, the South China Sea, the Strait of Malacca and Andaman Sea, and the Indian Ocean. Several pieces of wreckage belonging to the aircraft have been found, but the location of the bulk remains unknown.
The disappearance of MH370 highlighted the limitation of aircraft tracking and flight recorders and many people have noted that it is inconceivable that an aircraft could have seemingly vanished from the face of the earth. In their final report, published in October 2017, the Australian Transport Safety Bureau (ATSB) noted that the aviation industry had been slow to implement changes that might have resulted in a different outcome following the loss of AF447: "Depending on the nature of the, as yet, undetermined reasons for the loss of MH370, it is possible that timely fulfilment of the BEA’s 2009 and 2011 recommendations on transmission of flight data might have assisted in the search for MH370."
The ATSB made a number of recommendations about aircraft tracking: "While there has been significant enhancements in the tracking of commercial aircraft in recent years there are some limitations to the improvements. The ICAO mandated 15-minute position tracking interval for existing aircraft may not reduce a potential search area enough to ensure that survivors and wreckage are located within a reasonable timeframe. Therefore the ATSB recommends that:
- States ensure that sufficient mechanisms are in place to ensure a rapid detection of, and appropriate response to, the loss of aircraft position or contact throughout all areas of operation.
- Aircraft operators, aircraft manufacturers, and aircraft equipment manufacturers investigate ways to provide high-rate and/or automatically triggered global position tracking in existing and future fleets."
The report also made recommendations around search and rescue information, with the view to making the process more effective and efficient.
4. Qantas Flight 32
When: 4 November, 2010
Where: Batam Island, Indonesia
Unlike the other events listed in this post, Qantas Flight 32 did not end in tragedy – nevertheless, it had a profound impact on aviation safety. The aircraft was travelling from London Heathrow airport to Sydney, Australia, via Singapore Changi airport, when it suffered an uncontained engine rotor failure after departing from the latter. Fortunately, the flight crew were able to manage the situation, eventually safely returning to and landing at Singapore Changi airport.
The aircraft was an Airbus A380 – and this was the first time there had been a serious incident on this model. At the controls were Captain Richard Champion de Crespigny, alongside a first and second officer, and two additional check captains. As the aircraft flew 7,000 feet over Batam Island, Indonesia, about four minutes after take-off, the flight crew heard two bangs, followed by several warnings and cautions displaying on the electronic centralised aircraft monitor (ECAM).
It was later discovered that the intermediate pressure turbine disc in the No. 2 Rolls-Royce Trent 900 engine had separated from its shaft due to an internal oil fire, causing debris to impact the aircraft and resulting in significant structural and systems damage. The fire occurred when oil was released from a crack in the pipe that supplied oil to the high pressure/intermediate pressure (HP/IP) turbine bearing chamber.
Firstly, the ECAM showed a message warning of turbine overheat in the No.2 engine; this was followed by a multitude of warning messages detailing several aircraft system problems. The flight crew completed a number of initial response actions and were cleared by air traffic control (ATC) to enter a holding pattern to the east of Singapore Changi airport. In this pattern, the flight crew worked through the messages displayed by the ECAM. Having followed these procedures and performed aircraft controllability checks, the flight crew were able to land the aircraft safely.
Upon landing, the aircraft was doused with water and foam while the engines were shut down, to prevent a fire breaking out. However, engine No.1 continued to run, so passengers disembarked on the right side of the aircraft – two hours after landing.
In their report the Australian Transport Safety Bureau (ATSB) found that "the flight crew and cabin crew managed the event as a competent team with standard operating procedures and practices".
Nevertheless, there were a number of key outcomes from the report. The ATSB identified several factors that led to the manufacture and sale of non-conforming oil-feed pipes and worked with key organisations to ensure that these were addressed and actioned. The ATSB also issued recommendations to the European Aviation Safety Agency and the United States Federal Aviation Administration, recommending that both organisations review the damage caused to Qantas Flight 32 and incorporate any key lessons learned into airframe certification advisory material.
The incident also highlighted the importance of clear communication and excellent leadership on the flight deck. With Captain de Crespigny at the helm, every single person knew their role and what was required of them and calm was maintained, despite the potential severity of the situation. The training procedures for which Qantas are famous were put effectively into practice – this was a true example of the importance of culture within an airline (so many more tragic incidents can be traced back to poor practices and taking shortcuts).
5. Germanwings Flight 9525
When: 24 March, 2015
Where: French Alps
The crash of Germanwings Flight 9525 was one that shocked and horrified the world; for this disaster could not be attributed to human error or technical failures, but rather the deliberate actions of a suicidal co-pilot.
The Airbus A320-211 departed Barcelona El-Prat Airport in Spain, bound for Düsseldorf Airport in Germany – however, its journey ended in the French Alps, 100 kilometres north-west of Nice. At the controls were 34-year-old Captain Patrick Sondenheimer and 27-year-old co-pilot Andreas Lubitz. The pair had flown the plane from Düsseldorf that morning. Not long into the return flight, Sondenheimer remarked that he had forgotten to go to the bathroom before boarding. "Go anytime" was Lubitz’s response.
The scheduled flight was short so after the aircraft reached its cruising altitude of 38,000 feet, Sondenheimer told his co-pilot to prepare for landing. In hindsight, Lubitz’s strange response was a forewarning of what was to come. "Hopefully," he said. "We’ll see." A minute later, Sondenheimer exited the cockpit to use the bathroom.
Immediately, Lubitz locked the cockpit door, deactivating Sondenheimer’s emergency access code, and instructed the aircraft to descend to 100 feet, directly into the mountains below. The aircraft began dropping at a rate of 3,500 feet per minute. Air traffic control picked up on this unauthorised change but were unable to make contact with the aircraft – Lubitz was ignoring them and his steady breathing could be heard on the cockpit voice recorder right up until impact.
When Sondenheimer left the bathroom, he found himself unable to access the cockpit. It didn’t take long for panic to take hold among the passengers as Sondenheimer shouted and banged on the cockpit door. Once he realised that Lubitz wouldn’t let him in, Sondenheimer tried to use a crowbar to open the door; still the plane continued to descend. As the plane reached 7,000 feet an alarm went off: "Terrain, terrain! Pull up. Pull up!" A minute later, the aircraft’s right wing clipped the mountainside at 5,000 feet, before smashing into the mountain at 403 mph.
After the tragedy, it emerged that Lubitz had been deemed “unfit to work” by his doctor, but had failed to disclose this information to his employer – nor had any medical professional passed the information on. Lubitz had suffered from depression and "suicidal tendencies".
"The process for medical certification of pilots, in particular self-reporting in case of decrease in medical fitness between two periodic medical evaluations, did not succeed in preventing the co-pilot, who was experiencing mental disorder with psychotic symptoms, from exercising the privilege of his licence.
"The following factors may have contributed to the failure of this principle:
- the co-pilot’s probable fear of losing his ability to fly as a professional pilot if he had reported his decrease in medical fitness to an AME;
- the potential financial consequences generated by the lack of specific insurance covering the risks of loss of income in case of unfitness to fly;
- the lack of clear guidelines in German regulations on when a threat to public safety outweighs the requirements of medical confidentiality.
"Security requirements led to cockpit doors designed to resist forcible intrusion by unauthorised persons. This made it impossible to enter the flight compartment before the aircraft impacted the terrain in the French Alps."
The BEA made a number of recommendations about the medical evaluation of pilots with mental health issues, noting the need to strike a balance between medical confidentiality and public safety. It was recommended that, in some cases, patient records should be disclosed without permission, if there is deemed to be a significant risk to others.
The European Aviation Safety Agency (EASEA) also published a temporary recommendation that at least two authorised people should be in the cockpit at all times during flight. This recommendation has since been lifted after many people criticised it as a "knee-jerk response". Far more important, they argue, is the commitment to ensuring that pilots who pose a danger to both themselves and their passengers are never allowed to enter the cockpit in the first place.
Safety continues to be the primary focus of the commercial aviation industry and, as a result, our world is more connected and more accessible than ever. But we can never truly safeguard against every potential disaster. What we can do is learn important lessons when things go wrong and do our best to ensure that those same things never happen again.