Two inspectors and I conducted surveillance on a Florida-based operator. My fellow inspectors had found issues with the operator’s weight and balance (W&B) forms. I later walked past the ramp manager’s office, where the two inspectors were talking with the manager (who spoke not-so-good English) about the W&B forms. The inspectors spoke s-l-o-w-l-y, VOCIFEROUSLY, as if the non-English fluent manager would better understand what they were telling him, but it did not help.
Since I began writing articles, I am one of a few authorities writing about mistakes made in aircraft accident reports, specifically aircraft maintenance mistakes. I am reading a book by the authors Eric Friginal, Elizabeth Mathews and Jennifer Roberts called, English in Global Aviation (Bloomsbury Academic, 2020). It is a brilliant book focusing on misuses of the English language – the language of international aviation – in aviation and how these misuses affected aviation safety.
The book is encouraging for its honesty. The authors know their topic; their expertise speaks to safety issues never raised before in accident investigations. The book is timely; it analyzes how accident investigations have been affected (negatively?) by, e.g. conversations between English-speaking pilots and foreign air traffic control (ATC); foreign pilots, whose native language is not English, with United States’ ATC; foreign pilots slipping between English and their native language in the cockpit.
Listening to the cockpit voice recorder (CVR) of an accident flight is difficult for many reasons. CVR transcripts can be frustrated by sounds that are hard to hear around, such as rushing air, audible alerts, pilots speaking over each other or pilots alternating between English and their native language. It is discouraging that an accident investigation agency (AIA) like the National Transportation Safety Board (NTSB), continues to misinterpret CVR data of an accident flight’s last minutes.
The authors first example is to discuss American Airlines flight 965 (AA965); the Boeing 757-223 struck the summit of El Deluvio mountain on December 20, 1995, near Cali, Colombia. The authors discovered important language errors in phraseology in the radiotelephony communications between Colombia’s ATC and the AA965 pilots. These misunderstandings eventually led to the airliner impacting terrain.
It was unfortunate that the Colombian AIA, Aeronautica Civil of the Republic of Colombia (ACRC), led the investigation. I was a liaison to the ACRC in 2003 for a DC-9 accident in Mitu, eight years after AA965. The ACRC missed basic air cargo modification issues while the NTSB bungled the flight data recorder readings. As with the Mitu accident, the ACRC’s inexperience on the AA965 investigation meant that important issues had been missed.
The authors spell out how, in AA965, radiotelephony communications, phraseology and plain English mistakes, led to the accident because of simple misunderstandings. The book lays out a more informative sequence of events, but the Root Cause was that the Colombian controller’s grasp of English phraseology caused confusion between the controller and the AA965 pilots.
The authors stated, “Accident investigation is not about blame; it is about a fearless and comprehensive uncovering of any and all information that may be applied to prevent future accidents.” In part, I disagree with the authors’ view. AIAs, e.g. the NTSB, obsess about Blame and they take it out of context. Clearly, investigation reports must determine Root Cause(s), not be used as lawsuit fodder. Responsibility should replace Blame. Responsibility for safety failures must be established and addressed. If not, Probable (aka Probably) Causes become – indeed, have been – nothing but politically-correct whitewashes; they have become absurd and useless. Nothing gets solved; safety is not improved; aircraft continue to crash.
Consider the NTSB’s AA965 recommendation: “… the Federal Aviation Administration (FAA) should develop with air traffic authorities of member states of the International Civil Aviation Organization (ICAO), a program to enhance controllers’ fluency in common English-language phrases and interaction skills sufficient to assist pilots in obtaining situational awareness about critical features of the airspace, particularly in non-radar environments.” This NTSB word salad missed the point entirely. Nothing about responsibility. No urgency. No plan. No direction. A safe recommendation that solved … nothing.
On page 23, the authors said, “Accident investigators are committed to a thorough and unbiased review of all the evidence available.” This statement is true but gives AIAs too much credit. Consider Lion Air 610 (LA610) and Ethiopian Airlines 302 (EA302) (Aviation Lessons Unlearned articles XXXI, 11/2/2019, and XXXVII, 4/30/2020), two accidents alluded to in the authors’ Preface. In both LA610 and EA302 obvious investigatory mistakes were made and there was insufficient evidence to base the Findings on (like AA965?). Government agencies investigated government airlines with extreme bias (ACRC looking into the Colombian ATC?). And why did the NTSB and ICAO assign blame to Boeing? Was it convenient? All at once, Blame became acceptable, almost a noble act. An international pile-on with little-to-no proof. Then investigatory agencies, including the NTSB, guaranteed future disasters by repeating what was easy, the mantra: “It’s Boeing’s Fault.” They did this while ignoring obvious problems with the airlines’ cultures, English translations, pilot training and understanding fundamental maintenance practices.
The authors spoke of Avianca flight 52 (AV52) in 1989 (Aviation Lessons Unlearned XXXIV). In this case roles were reversed: a Colombian flight crew with a limited grasp of the English language trying to land in Kennedy airport. The root cause: the crew failed to divert to Boston, their alternate. The authors had found that AV52’s First Officer did not have a command of the English language; the captain relied on him for communicating their desperate fuel situation and emergency. In AV52’s accident, the NTSB had investigatory authority and the best Probably Cause was … AV52’s ‘fuel management’ problems(?). AV52 preceded AA965 by six years. If someone on the NTSB’s AV52 investigation team understood basic English phraseology issues, would AA965 have been prevented? We will never know.
What of the cultural problems? Before AA965, what importance did Colombia place on quality English being spoken by their ATC controllers? Six years earlier, if the international AV52 PILOTS had poor English skills, how much less would Colombia have invested in their in-country controllers? Colombian ATC standards appeared to be much lower than US ATC standards. With AV52, ICAO overhauled language requirements for international carriers. What did ICAO do about controllers after AA965?
The authors make a critical point at the end of Part One of the book: “… language issues played a role, which accident investigators recognized at some level, but which did not rise to the level of being recognized as a causal or contributing factor …” This echoes the main point of the Lesson Unlearned articles, that important information has repeatedly been missed, information that could have directed investigators to contributing factors and then the accident’s specific root cause(s). For instance, why was the Colombian controller in AA965 interviewed twice before the ACRC learned about his phraseology doubts? How was that missed the first time? Did anyone connect AA965 to the AV52 accident? What have been the consequences of these mistakes?
In chapters 4 and 7, the authors talk specifically to Aircraft Maintenance. “Accident investigators are pilots, engineers, and other technical experts.” The authors highlighted the obvious: no mechanics – and that is the point. Have English-speaking mechanics caused accidents through communication mistakes? In the Colgan 9446 accident, during an Operational Test of the elevator trim system, the mechanic in the cockpit running the pitch trim switch thought ‘leading edge (LE) UP’ meant the Elevator Panel’s LE; the mechanic observing on the tail thought ‘LE UP’ referred to the Trim Tab panel’s LE; these panels move contrary to each other. A simple communication mistake led to a reverse trim and then the accident.
Even airframe and engine maintenance manuals are, what mechanics would consider, ambiguous, in some cases, confusing. Major airliners have manuals that are difficult to understand from a mechanic’s point of view, which is why using engineers to investigate accidents is pointless; the engineers’ contributions to maintenance manuals are from an engineer’s point of view. Employing engineer investigators continually ignores ambiguous maintenance instructions used for continued airworthiness.
It is encouraging that the authors give high importance to Maintenance as a causal factor in accidents because AIAs have ignored Maintenance for decades. In the two accidents, LA610 and EA302, involving the B737-MAX, each accident’s root cause involved either the operator’s inexperience with routine Return-to-Service procedures or the operator’s pilots did not recognize (maybe ignored?) the deteriorating maintenance situation. Language barriers played a large part in these accidents; perhaps the translation of maintenance instructions from English to the native language was not the best quality.
Mechanics, unlike pilots, have the benefit of time. If instructions are confusing, call the manufacturer; if a return-to-service test does not clear the problem, call the manufacturer. In both the LA610 and EA302 reports, calls to Boeing were not mentioned. How could investigatory agencies ignore the obvious?
On page 23, “Investigators examine the corporate culture of the company for which the pilots work.” Oh, if only. For instance, AIAs, such as the NTSB, employ pilot investigators without airline experience while qualified FAA-certificated maintenance-experienced investigators are non-existent. These investigators have no experience with culture; they cannot recognize cultural issues; they cannot understand basic operator culture. Culture, in Operations or Maintenance, has rarely been properly examined as a causal factor, indeed looked into at all. The use of these investigators, unqualified in the specialties they investigate, damages investigation quality and postpones safety improvements.
I have worked accidents where English was a point of contention, where even those who live in an English-rich environment got it wrong. I have also worked international accidents where primary languages played heavily into misunderstood instructions. English in Global Aviation demonstrates that another set of causal factors are being ignored by accident investigating authorities around the world and the consequences are being felt by the flying public.