Pathogens At The State Level: Look Out Below

Bob Baron, Ph.D

On May 22, 2020, a Pakistan International Airlines A-320 (Flight PK8303) crashed into a crowded residential area after both engines failed as it approached Karachi airport for a second landing attempt. Ninety-seven of the 99 people onboard were killed. Four people were injured on the ground, with one of them expiring later at a hospital.

The preliminary accident report, which was released at the time of this writing, revealed a multitude of errors by the flightcrew. The Flight Data Recorder (FDR), Cockpit Voice Recorder (CVR), and Air Traffic Control (ATC) radar data have provided enough evidence so far to indicate that this particular crew committed a series of violations and procedural deviations that resulted in a totally preventable accident. Data so far indicate that the crew did not follow standard callouts and did not observe Crew Resource Management (CRM) aspects during most of the flight. According to the Pakistani Aviation Minister, the crew was engaged in conversations related to the Coronavirus. This caused self-induced distractions, during critical phases of flight, where the crew should have been focusing solely on the safe operation of the aircraft. It is also a violation of the Sterile Cockpit Rule (SCR); a rule that was put in place decades ago to prevent these very types of distractions. These “soft skills” errors were in addition to myriad technical errors that were contributory to this accident.


Improprieties At The State Regulator Level

As if all of this weren’t bad enough, at the same time as the release of the preliminary accident report, Pakistan’s Civil Aviation Authority (PCAA) announced that it has grounded 262 airline pilots (about a third of the active pilots in the country) who may have had fake or falsified pilot licenses obtained through cheating and having others take exams for them. According to Aviation Minister Ghulam Sarwar Khan, the pilots, as well as five senior officials at PCAA, were terminated and may face prosecution, pending the outcome of the investigation. He also said there has been an investigation into collusion between pilots and civil aviation officials since late 2018.       

State-level corruption and scandals occur in other countries as well. In 2011, more than 12 commercial pilots in India had their licenses revoked and a top airline safety official was suspended after a government investigation revealed widespread fraud and corruption in the aviation industry. The State airline, Air India, fired pilots as a result of the inquiry, which found that pilots were falsifying records, cheating on flight exams, and paying bribes to testing officials. In addition, nepotism was found to run rampant in the industry.


Solution Or Part Of The Problem?

The Regulator’s role is, among others, to promulgate and enforce the rules and regulations to ensure the safety of the traveling public. Unfortunately, in a number of cases, rather than being the solution, the Regulator becomes part of the problem.  

On June 3, 2012, Dana Airlines Flight 0992, a Boeing MD-83, crashed into a densely populated area. Engine No. 1 lost power seventeen minutes into the flight with a further loss of power on No. 2 engine on final approach to runway 18R at Murtala Muhammed Airport, Lagos, Nigeria (LOS). All 153 persons onboard the airplane, including six crew, were fatally injured. There were also six ground fatalities. (view my full presentation here).

Though the accident was caused by multiple deficiencies at Dana Airlines, the investigation also revealed that the Nigerian Civil Aviation Authority (NCAA) contributed to the accident by being negligent in carrying out its oversight duties. The accident pilot (a U.S. expatriate) should not have been flying that aircraft on that day. He had many issues related to his background that should have been a red flag to the NCAA. Yet, inexplicably, the NCAA did not validate the Captain’s foreign license. And although the Captain’s license was stamped, it was not signed by an NCAA officer. A proper background check would have revealed that:

  • The Captain had a license suspension in 2009 by the U.S. Federal Aviation Administration (FAA) for misdemeanors related to a heavy landing and fixing of panels that were neither entered in the aircraft logbook nor reported.
  • The Captain had unresolved issues with the FAA.
  • The Captain conducted flying duties in violation of rules and regulations.
  • The Captain’s recommendation letters were not signed.
  • There were numerous adverse remarks noted about the Captain in Dana Airline’s training, particularly relating to Standard Operating Procedures (SOPs) and checklist usage. Additionally, there was-
  • No record of ground school training.
  • No record of indoctrination course.

Proper oversight would have prevented this Captain from becoming employed by Dana Airlines. And while Dana Airlines itself carried much of the responsibility for this accident, it also shows us how the Regulator can become part of the problem, rather than the solution.




Unfortunately, it took a catastrophic accident such as this to initiate change. A classic example of reactive safety. Even then, a sweeping change (for the better) in a government agency can be a daunting task. Change won’t happen if people don’t want to buy into and support culture change. Some Regulators believe, mistakenly, that just because they have a State Safety Program (SSP) and meet most of the International Civil Aviation Organization (ICAO) Standards and Recommended Practices (SARPS), or even have Category 1 status in the U.S. FAA International Aviation Safety Assessment (IASA) program, they are operating as a safe organization. This can be a total misconception. And this mindset can breed complacency as well as lead to a false sense of security.

In the case of the NCAA, there were philosophical challenges at the highest level of the aviation system. Nigeria’s former Aviation Minister, Stella Oduah, was quoted as saying, “We do not pray for accidents but it is inevitable...We do everything to ensure that we do not have accidents, but it is an act of God,” she said. “We do not speculate on the cause of accidents.” Clearly, this line of thinking has no place in aviation. But you can see how the confluence of these types of beliefs and philosophies can confound the ability of an aviation Regulator to work objectively and rationally to improve aviation safety. You cannot blame God for your aviation accidents. That’s the easy way out. You need to own it, fix it, and regain the trust of the flying public. Otherwise, what did they die for?


Contain The Pathogens

As an aviation safety consultant with more than three decades of experience, I have traveled the world and worked with many organizations and cultures. I have seen the good, the bad, and the questionable. I’m also an Industrial/Organizational Psychologist. I know how organizations behave in the practical world and how/why some of them become dysfunctional. It usually starts with a poor safety culture, leading to practical drift.

The temptation to drift between right and wrong can be a big problem, especially in countries where corruption, bribes, and favoritism are the modus operandi. Appointments to positions at the Regulator (and Operator) levels based on who they know, or how they are related, is not going to cut it. Favoritism, in place of properly qualified personnel, will set the stage for more accidents and incidents. This all needs to stop. I realize this admonition is going to fall on deaf ears and this will continue to be a serious problem at the top of some organizations for a very long time. Please, prove me wrong.

Other issues that I have observed at the Regulator level may not be as egregious as corruption and scandals, but nonetheless they are worthy of mention, because these issues can, and will, filter down to the Operators and cause operational safety issues. Remember, the Regulator should be part of the solution rather than part of the problem. Here are a few of the Regulator issues I have observed.

Let’s start with transparency—or lack of. Most Regulators have a website. That’s the good news. The bad news is that the quality and content of the websites I’ve seen vary considerably in terms of content and usefulness. For example, some Regulators do not post the results of accident and incident investigations. In some cases, yes, the State also has an independent accident investigation agency that might post that information on their own website. In either case, I have seen a lack of transparency regarding accident and incident information. The reports are hidden and/or inaccessible. This defeats the whole purpose of the accident investigation process. Investigations and their subsequent reports are used to prevent the same types of accidents and incidents from occurring again, which is the purpose of accident investigations. They aren’t doing much good for that purpose if they are being hidden. If you’re lucky, you might be able to request, and receive, a copy of the report. But I wouldn’t count on it. I’m sure by now you can figure out why some of these reports might remain buried.  

The lack of transparency can also affect the ability to disseminate critical safety information pertaining to how Operators should, for instance, comply with the implementation of their Safety Management System (SMS). I have reviewed some CAA websites only to find little to no guidance for the Operators’ SMS implementation. In fact, many of the CAA websites I reviewed didn’t even mention the status of their own SSP. Additionally, I have seen situations where a CAA barely had an SSP, but yet they were enforcing SMS Phase 2 and even Phase 3 standards for their Operators. I call it “the blind leading the blind.”

Another issue that has always concerned me is when a State has a CAA but lacks an autonomous accident investigation agency. This isn’t common, but when it does happen, it is a cause for concern. A CAA conducting its own accident investigations for Operators in its jurisdiction is a really bad idea. Objectivity is lost. Do you think that a CAA is going to apportion part of the accident’s contributing factors to itself? The final accident report reading, “Contributing factors included a lack of oversight by the XXXX Civil Aviation Authority.” Doubtful. There will be bias, falsifications, lost evidence, etc. And speaking of lack of transparency, I can pretty much guarantee you that the final accident report will not be posted on the CAA’s website. I’m not being theoretical. I see this in the real world.


Not For A Million Dollars

Recently, my company was invited to bid on a lucrative contract to assist a CAA with its SSP. I immediately responded and told the CAA we had no interest in bidding on their project. Why? Because I knew it was the type of government agency that, despite how much we would try to help them, we would be wasting our time. They first need to do a major overhaul of their culture and be deeply committed to running a safe, efficient, and respected Regulatory Authority. Until then, look out below.


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