airlines – John Vincent

Why Timely Aviation Safety Reporting Matters

Waiting for accident reports can be frustrating. I’ve found this to be the case in past experiences. When a major fatal aviation accident happens the demand for information is exceptionally high. That means that every credible source of information will be drawn upon.

I don’t think anyone expects professional aviation accident investigators to come up with instant answers. Extensive and meticulous work is required to arrive at detailed findings. When it’s possible accident investigators publish interim reports to ensure that relevant information becomes generally available.

Countering this reality is the need to ensure that the aviation system is not operating at elevated risk during the period that investigation is being conducted. Information needs to flow to those who are empowered to take corrective action.

Given the nature of international civil aviation, accidents can occur anywhere at any time. There’s no rule, statistical or otherwise, that can stop these extremely rare events occurring. Much as it’s fine to promote an ambition for zero accidents, it’s not going to happen.

The frustration I’ve pointed to is shared by industry and authorities. As time goes by the level of speculation and misinformation always increases where there is an absence of verifiable facts. There’s always a need for industry, authorities and investigators to cooperate. As often each one will have a part of the jigsaw that when put together describes what happened.

For all sorts of reasons, this necessary cooperation does not always exist or exist as a smooth pathway to resolving a situation and initiating corrective action. Where barriers exist and delays accumulate the collective aim of assuring aviation safety is harmed.

The International Air Transport Association (IATA), at their recent conference, highlighted this as being a significant issue[1]. There are international standards, but these standards are not always applied in the manner with which they were intended. It seems obvious to say. It’s essential to learn safety lessons and take corrective action as soon as it’s humanly possible.

Where sufficient resources are an issue then there must be cooperative arrangement to allow others to help. It’s by sharing expertise and equipment that the time between occurrence of an event and the implementation of risk reduction measures can be reduced.

Risk reduction measures do not always need to be the final measure. There are the conventional strategies for addressing aviation safety risk – reduce, eliminate or mitigate. Even if publication of a final accident report is a year or more away, there’s often much that can be done in the interim.

Bureaucratic protocols, political sensitivities and commercial interests are real. However, most governments have signed up to obligations within the ICAO convention and its standards. It’s recognised that timeliness is vital.

[1] https://www.iata.org/en/pressroom/2025-releases/2025-10-14-02/

Impact of Speculation

The sadness of the loss of live and the suffering of air crash victims’ families, must be respected. On 12^th June, Air India’s London Gatwick bound flight AI171 crashed after take-off from Ahmedabad airport. Only one passenger walked away from this catastrophe. Additionally, there were fatalities on the ground as the Boeing 787 aircraft came down in a built-up area.

My heartfelt condolences to those connected with this tragic fatal accident.

The technical accident investigation is well underway. In time, a probable cause for this accident will be determined. This will be published and available to all. As per the international arrangements of ICAO Annex 13 a report will be published. Organisations, with appropriate expertise, will carefully sift through the evidence to establish a sequence of events. This is not a matter of establishing blame. It’s a process of determining what happened with the aim of preventing it from happening again.

Meanwhile, the widespread reporting of the accident can only offer speculation as to the details of who, what, where, when and how and why. There are facts. The time, place and the people involved. Media interviews, with whatever pictures and video recording there are dominate the public domain. However, this is far from the volume of information the accident investigators will handle. They will have access to every nut and bolt, every document, every recording.

After another aircraft accident, back in August last year I wrote: Speculation is a natural human response. When faced with a paucity of information we often put together what we know and then make a best guess as to what happened or what might happen. However, wise or unwise it’s not possible to stop speculation.

In the case of flight AI171 the global media speculation has been, and is, of a new order of magnitude. Normally, the authorities caution against giving too much weight to early conjecture. This is prudent in that the obvious is often not as obvious as it might first seem. Accident investigation can be like putting the pieces of a complex jigsaw together. Deliberately and with great care.

What has been surprising in this case is the intensity of the speculation related to this accident both through traditional and social media. The proliferation of experts offering opinions has reached a new high. Until conflict and war grabbed the headlines everyday a novel theory, or a variation of a theory has been offered. Each one chasing credibility and expanding on limited sources.

Let’s not be pious. I’m not immune from this need to fill a void. My own reasonably well-informed theories float around in my head, but I question my senses in sharing them with others. It’s not a fear of being wrong, as I might be, no, more a fear of cluttering up a confusing mass of information to an even greater extent. Piling theories on top of theories.

Can we have too much of “experts” offering their opinions? Some will be trustworthy and considered, and others will not. How far is it reasonable to stretch what little is known into detailed stories of possible cause and effect?

How is the average person going to tell the difference between sound reasoning and imaginative nonsense? This problem was brought home to me in a recent conversation. When a newspaper revelation is told to me as a “fact” when I know it isn’t, then I see the dangers in excessive speculation.

This may not matter so much to me. In so far as it affects me. However, to an air crash victims’ family this not considerate. To be led to thinking that the cause of an accident is generally known, when it isn’t, that’s disrespectful. It’s the downside of speculation. Not something that is ever going to stop, it’s true. What some keyboard warriors need to think about is the impact of their wild guesses or prejudices.

POST 1: Even reputable publishers latch on to theories that are at best well intentioned and at worse just flying a kite. Air India crash: Early speculation points to possible dual-engine failure | Engineering and Technology Magazine

POST 2: To be fair this YouTube commentator does a good job at making it clear what is fact and what is not https://youtu.be/dIgnR0zw3FU

Safety Analysis

In discussions about safety one model is often called up. Its simplicity has given it longevity. It also nicely relates to common human experience. The model is not one of those abstract ideas that take a while to understand. If you have been on a safety training course, a lecturer will give it couple of minutes and then use it to draw conclusions as to why we collect and value safety data.

On illustration, and it’s a good one for sticking in the memory, is a picture of a big iceberg. Most of an iceberg is underwater. One the surface we only see a fraction of what is there. This is the Heinrich pyramid. Or Heinrich’s Law[1] but it’s not really a law in the sense of a complete mathematical law.

The logic goes like this. In discissions about industrial major accidents, there are generally a lot more minor accidents that precede the major ones. Although this was drawn up in the 1930s the model has been used ever since. And we extend its useful applicability to transport operations as much as workplace accidents.

Intuitively the model seems to fit everyday events. Just imagine an electrical cable carelessly extended over the floor of a hanger. It’s a trip hazard. Most of the time the trips that occur will be minor, annoying events, but every so often someone will trip and incur a major injury.

What we can argue about is the number of precursor events that may occur and their severity. It wouldn’t be a simple universal ratio, either. Heinrich said there were generally about 30 accidents that cause minor injuries but 300 accidents with no injuries. A ten to one ratio.

Forget the numbers. The general idea is that of the iceberg illustration. Underlying that example of the pyramid is the notion that there are a lot more low severity events that occur before the big event happens. Also, that those low severity events may not be seen or counted.

It’s by attempting to see and count those lesser events that we may have the opportunity to learn. By learning it then becomes possible to put measures in place to avoid the occurrence of the most destructive events.

In British aviation I will reference the 1972 Staines air accident[2]. A Brussels-bound aircraft took off from London Heathrow. It crashed moments later killing those onboard. One of the findings from this fatal aircraft accident was that opportunities to learn from previous lesser events were not taken. Events not seen or counted.

Thus, Mandatory Occurrence Reporting[3] was born. Collecting data on lesser events became a way of, at least having a chance of, anticipating what could happen next. Looking at the parts of the iceberg sitting under the water.

How many fatal accidents have been prevented because of the safety analysis of data collected under MOR schemes? If only it was possible to say.

[1] https://skybrary.aero/articles/heinrich-pyramid

[2] https://www.bbc.co.uk/news/uk-england-surrey-61822837

[3] https://www.caa.co.uk/our-work/make-a-report-or-complaint/report-something/mor/occurrence-reporting/

1985 to 2025 Trends

On reading J. C. Chaplin’s paper on the first 100-years of aviation safety regulation in the UK[1], it struck me that the journey from the 1910s to the 2010s was one of constant change. That change has not slowed down. In fact, the last 40-years of my aviation career have seen dramatic technological changes that have demanded ever new regulatory methods and practices.

Overwhelmingly aviation history writings obsess about the early days of flying or the start of the jet age. It’s as if those periods were so dominated by great pioneers that nothing worthy has happened since. I exaggerate for effect, but I think you get the meaning of my comment.

So, what of the race from the 1985 to the 2025? I think that is useful period to look at. One of the reasons is that those years are mark the transition from an analogue era to a digital one.

The early 1980s saw experimentation with the potential for digital technologies, most particularly fly-by-wire systems. Quickly the military understood the increase in aircraft performance that could be gained by use of such technologies. Groundbreaking was Concorde in that it demonstrated that critical electronic control systems could safely go into everyday operation. That project drove the development of new regulatory methods and practices.

A turning point occurred in the mid-1980s. That silicon revolution that impacted so much of life was dramatically put to use in civil aviation. Computing power had so miniaturised and become affordable so that past theoretical possibilities could now be practically realised.

The Airbus A320 aircraft first flew in 1987. It was a shaky start. Not everyone was convinced that safety critical systems were indeed safe. The not so obvious discovery that the human factor was even more important for a computerised aircraft. Learning to adapt and adjust ways of operating didn’t happen overnight.

The lesson is that learning lessons must be part of the process. Through applying continuous improvement, the Airbus A320 family has grown ever since.

Maybe there needs to be a short paper to cover civil aviation safety regulation from 1985 to 2025. It’s needed now. It’s needed because the next 40-years are going to see equally dramatic changes. In the time to come the main driver will be the environment.

[1] https://www.aerosociety.com/media/4858/safety-regulation-the-first-100-years.pdf

Understanding Aviation Safety

The recent dramatic events in Toronto brought to mind the equally dramatic event of Air France Flight 358 back at the latter half of 2005. Then a large aircraft was destroyed but the crew and passengers got away without fatalities. The combination of bad weather and poor decision-making led to a catastrophic runway excursion.

I remember that the year 2005 shook the aviation community. There was a whole succession of fatal aircraft accidents across the globe. In Europe, Helios Airways Flight 522 was particularly tragic. Errors led to the crew suffering hypoxia and as a result the aircraft and everyone onboard was lost. In Italy, lives were lost as an ATR72 aircraft ran out of fuel and plunged into the Mediterranean Sea near Palermo.

West Caribbean Airways Flight 708 fell from the sky killing all on-board. Kam Air Flight 904 hit a mountain killing all on-board. In Indonesian, Mandala Airlines Flight 091 crashed. A few passengers survived but many people were killed on the ground.

I sincerely hope that 2025 is not going to turn into another 2005. However, I do take the view that there is a cyclic element to the occurrence of fatal accidents. We are often proud to be able to say that the time (number of years) between one cluster of aviation accidents and another grows as overall safety improves but we are a long way from zero-accidents.

The global aviation industry is an incredibly safe industry when considering how many passengers are carried every year. However, zero-accidents remain an illusion however it might be touted as the ultimate goal.

As safety practitioners try to be ever more pro-active in our safety regimes there’s inevitably a reactive element to aviation safety. The aftermath of the 2005 experiences led to ICAO holding its first high-level safety conference in 2010 in Montréal. There have been two more such conferences since. One in 2015 and one in 2011.

The results have been to push the aviation industry towards a more pro-active management of safety. It’s not just the industry. In cases, the regulatory weaknesses that exist in individual States has needed to be given attention.

Add all this up over the last 20-years and you would expect everyone to be pro-actively managing aviation safety. Sadly, that’s not the case as some States and organisations are still managing the transition to a more pro-active approach. Some are so resource constrained that they are more inclined to talk about aviation safety than to act upon it.

Regulatory weaknesses exist in some unlikely places. Additionally, with the fashion of the time being to cut “red tape” at every opportunity, more troubles might be just over the horizon.

I’d like to see a break between the association of what is regulatory and what is considered bureaucracy. The two are not necessarily the same. Regulation and standards are synonymous. And what we know is that there is no successful complex industry without standards.

Please let’s not wait for the next accident report to tell us what to do.

Toronto Regional Jet

The bubbling cauldron of social media is overflowing with comments on the regional jet crash in Toronto. So, far 2025 is starting as 2005. After a period when aviation safety results were admirably good, we now enter a period when events conspire to show us that we should never take aviation safety for granted. Obviously, the question gets asked – is this a statistical blip or is something more concerning happening?

As would be expected the Canadian air accident investigators are gathering data. No doubt there will be preliminary reports. Much evidence is available to help the air accident investigators determine probable cause. This evidence available includes a plethora of video footage. The ubiquity of the mobile phone has led to a situation where videos circulate on social media before they get into the hands of professional investigators.

Speculation on this major accident ranges from the Trumpian – I saw a video therefore I know what happened to the more considered comments about how well the cabin crew did in evacuating the broken aircraft under horrendous conditions.

Certainly, the landing appears to have been a hard one. The weather condition, as seen on the pictures doing the rounds, was windy but not stormy in the sense of poor visibility. Snow cleared from the runway. Surrounded by a landscape of white.

Luckly the aircraft slid down the main runway. That dissipated energy to an extent that most passengers were not badly hurt and therefore able to escape the wreckage. Another fortuitous part of the sequence of events was the absence of a fire at the time of evacuation.

I need to be careful in using the word – fortuitous. The investigators will put together the exact sequence of events but there’s no doubt in my mind that credit should be given to the good design of the aircraft. Generally, accidents and serious incidents are more survivable that people might initially think. This is NOT simple luck. Although, for individuals’ luck may play a part in their fate.

Structures and Cabin safety experts spend their working lives thinking about the – what ifs. The objectives set for aircraft designs maximise the opportunities for survival. Cabin crew can fly for a lifetime and never experience a catastrophic event. When they do their training kicks in, and lives are saved. My thanks are to all those who work tirelessly behind the scenes to ensure that aviation safety isn’t taken for granted. Those who do the serious business.

POST: Agreed. https://edition.cnn.com/2025/02/20/us/flight-attendants-safety-plane-crash/index.html

Investigating the Black Hawk and American Eagle Collision

What’s mysterious about the recent tragic collision between a US Army Sikorsky UH-60 Black Hawk helicopter and the American Eagle Flight 5342, was the failure of the normal procedure of “see and avoid” and the lack of an avoiding manoeuvre from the helicopter[1].

Taking the timings from reports of the investigators’ work so far, the air traffic controller’s instruction to the military helicopter to pass behind the commercial jet was seventeen seconds before the catastrophic collision impact. Given the trajectory of the commercial jet, as the pilots were focused on a landing, they had little possibility for an evasive manoeuvre other than a go-around. I imagine the commercial pilots and the tower controller reasonably assumed that the military helicopter would comply. In fact, why would they have any reason to question that assumption?

A question has arisen about night-vision goggles. Were the crew of the military helicopter using these devices? Night Vision Imaging System (NVIS) are not new[2]. They are used in both in military and commercial flying. There are a series of technical requirements that address their safe use. For commercial flying helicopters, that use such visual systems, they must additionally be equipped with a Terrain Avoidance and Warning System (TAWS).

One of the down sides of night-vision systems are that the greatly enhanced capability can lead to overconfidence and potential misjudgements by pilots. When used by pilots these systems amplify ambient light and thus help pilots maintain visual references. That’s good for night flying over difficult terrain at low altitude. It’s not so good when there are multiple bright light sources all around, as there are in a big city.

I’m sure that the accident investigators will be giving the above subject a great deal of consideration. Afterall, the evening of this tragic accident was one of fine weather and fair visibility. The investigators have a significant task ahead analysing data and verifying the performance of both humans and machines in the accident situation.

NOTE 1: Worth a watch https://youtu.be/hlMTpIAlpw0

NOTE 2: Key safety system off in Army helicopter that collided with American Airlines jet, senator says | Reuters

NOTE 3: Night Flying “there are factors that can make it more challenging, like the lack of visual references and encountering visual illusions”. Flying into the Dark. What You Need to Fly at Night | by FAA Safety Briefing Magazine | Cleared for Takeoff | Jan, 2025 | Medium

[1] Evidence of a last-minute manoeuvre may still come to light. Sadly, the outcome remains the same.

[2] https://skybrary.aero/articles/night-vision-imaging-system-nvis

Understanding Aircraft Accident Recorders

There’s quite a bit of chatter on social media about accident flight recorders.

One of the skills required by an aircraft accident investigator, and not often mentioned, is the ability to grapple with rules, regulations, and technical requirements. This is given that civil aviation is one of the most highly regulated industries in the world.

The story of the development of the accident flight recorder is a long one. No way can a few words here do justice to all the efforts that has been made over decades to ensure that this vital tool for accident and incident investigation does what it’s intended to do.

In fact, that’s the first technical requirement to mention for accident recorders. Namely, FAR and CS Subpart F, 25.1301: Each item of installed equipment must be of a kind and design appropriate to its intended function. That basic intended function being to preserve a record of aircraft operational data post-accident.

Aircraft accident recorders are unusual. They are mentioned in the airworthiness requirements, however they play no part in the day-to-day airworthiness of an aircraft. The reality is more nuanced than that, but an aircraft can fly safely without working flight recorders.

FAR and CS 25.1457 refers to Cockpit Voice Recorders (CVR)[1] and 25.1459 refers to Flight Data Recorders[2]. Both CVR and FDR receive electrical power from the aircraft electrical bus that provides the maximum reliability for operation of the recorder without jeopardising service to essential or emergency electrical loads. Both CVR and FDR should remain powered for as long as possible without jeopardising aircraft emergency operations.

Before drawing too many conclusions, it’s important to look at the above certification requirements in relation to their amendment state at the time of type certification of an aircraft.

If the aircraft of interest is the Boeing 737-800 then the FAA Type Certification date is 13 March 1998 and the EASA / JAA Type Certification date is 9 April 1998. Without wading through all the detailed condition, the certification basis for the above aircraft type was FAR Part 25 Amendment 25-77 and JAR 25 Change 13 [Note: EASA did not exist at the time].

FAR and CS 25.1457 and 25.1459 were in an earlier state than that which is written above. That said, the objective of powering the recorders in a reliable way was still applicable. There was no requirement for the CVR or FDR to be powered by a battery. What hasn’t changed is the requirement for a means to stop a recorder and prevent erasure, within 10 minutes after a crash impact. That’s assuming that aircraft electrical power was still provided.

So, when it’s reported that the South Korea Boeing 737 accident recorders[3] are missing the final 4 minutes of recoding, the cause is likely to be the loss of the aircraft electrical buses or termination by automatic means or the removal of power via circuit breakers. We will need to wait to hear what is found as the on-going accident investigation progresses.

[1] https://www.ecfr.gov/current/title-14/section-25.1457

[2] https://www.ecfr.gov/current/title-14/section-25.1459

[3] https://www.bbc.co.uk/news/articles/cjr8dwd1rdno

MH370 and MH17: A Decade On

The unthinkable happened in 2014. One major international airline suffered two catastrophic accidents. These tragic events ran contrary to all the trends in historic aircraft accident data.

In March, flight MH370 disappeared. In July, flight MH17 was shot down. In both cases there were no survivors from these international flights. This remains an unprecedented situation. It is a sobering consideration that such dreadful events were possible in a mature international framework of civil aircraft operations and regulation.

A decade on the pain of those who lost friends, family and colleagues in these tragedies is not diminished. Aviation should not lessen its attention to discovering more about what happened and putting measure in place to prevent reoccurrence of these events.

These two aviation catastrophes are different in respect of causal factors. One remains a mystery but, from what is known, has the hallmarks of an operational accident. The other is undoubtably an aggressive malicious act. Failings in the two elements of aviation safety and security, often viewed separately, are both capable of catastrophic outcomes.

Malaysia Airlines was a State-owned airline in the traditional model. There’s no reason to suppose that the airline harboured deficiencies that led directly to the two fatal accidents. In hindsight, the question is often asked: could both accidents have been avoided?

The extensive underwater search for MH370, in the southern Indian Ocean, resulted in no findings. However, floating debris from the fateful Boeing 777-200ER was discovered. Unlike what happened with Air France Flight 447 were the installed accident flight recorders were recovered from the deep ocean, there has been no such good fortune in respect of MH370.

Accident flight recorders are one of the primary tools for accident investigators. Installed recorders are built and tested to withstand extreme conditions. The reasonable assumption being that they will be found with any aircraft wreckage. The accident of MH370, is one where a deployable recorder may have been beneficial. That is one that ejects from an aircraft when it is subject to the high impact of the sea surface and then floats, possibly away from an accident site. There is a good case to be made for installing both deployable and installed recorders[1]. Particularly a case for long-range international overwater aircraft operations.

The facts surrounding the criminal act of shooting down of flight MH17 are well established. Sadly, in a troubled world it is impossible to say that such malicious acts will never occur again. What is to be done? Avoidance is by far the optimal approach. Commercial flying over warzones, where heavy weapons are known to be used, is extremely foolish. Now, it is good that much more flight planning attention is paid to understanding where conflict zones exist[2].

NOTE 1: On 07 March 2014 at 1642 UTC1 [0042 MYT, 08 March 2014], a Malaysia Airlines (MAS) Flight MH370, a Beijing-bound international scheduled passenger flight, departed from KL International Airport [KLIA] with a total of 239 persons on board (227 passengers and 12 crew). The aircraft was a Boeing 777-200ER, registered as 9M-MRO.

NOTE 2: On 17 July 2014, at 13:20 (15:20 CET) a Boeing 777-200 with the Malaysia Airlines nationality and registration mark 9M-MRD disappeared to the west of the TAMAK air navigation waypoint in Ukraine. All 298 persons on-bard lost their lives.

[1] https://flightsafety.org/files/DFRS_0.pdf

[2] https://www.easa.europa.eu/en/domains/air-operations/czibs

Turbulence

Turbulence is the result of atmospheric or environmental effects. Afterall, aircraft are craft that fly in the air. This is a hazard that is inherent in flying. Clear air turbulence (CAT) is common. However, extreme examples experienced in commercial aviation are rare. For one, aircraft operators and their crews do their best to avoid known potential atmospheric or environmental upsets, namely bad weather.

En-route turbulence accounts for a substantial number of cabin crew members injuries, and can occur at any time and at any altitude[1]. As far as I know, the UK Civil Aviation Authority (CAA) does not hold detailed data on turbulence injuries occurring on foreign registered aircraft. Numbers of injuries to passengers and flight crew on UK registered aircraft resulting from turbulence are recorded. However, it is not always known whether those injured in turbulence encounters were wearing seat belts.

Nevertheless, I can confidently say that the more passengers that are wearing seat belts during turbulence encounters the less the number of injuries. Deaths in these circumstances are rare. As might be expected fatalities are more likely to results from a combination of multiple causes and factors.

This subject is not immune from airline economics and competition. International flight routes can often be highly competitive. Fought over. So, the route taken, and associated fuel costs, can have an impact on the likelihood of a hazardous weather encounter. In fact, choosing to take routes for the benefit of picking-up specific winds is a common practice.

A high percentage of cases of turbulence events come about by flying too close to active storms[2]. Here there is often visual cues, reports, forecasts and feedback from turbulence encountered by other flights. This all helps crews avoid the worst weather encounters.

With very few exceptions, flight turbulence does not result in fatalities, permanent injure, or structurally damage commercial aircraft. However, turbulence is recognised as both an aviation safety and an economic issue, and it has been steadily increasing. Speculation and some research cites climate change as a reason for this increase. Also, there is the international growth in air traffic and development of new long-range routes.

One thing to say is that until recently, with INTERNET connections now in both in the cockpit and cabin, it could be the case that a passenger could access better real-time weather information than a flight crew. Now, SATCOM connections providing up-to-date weather information are more common on modern civil aircraft types.

There is still more that can be done to reduce crew and passenger injuries during turbulence encounters. There will inevitably happen despite any policy to avoid hazardous weather. The greatest threat to life exists to cabin crew. The cabin is their place of work.

There is potential to develop and employ better airborne detection systems to assist crews. That maybe by enhancing existing weather radar systems. It maybe by new means of turbulence detection using LIDAR, and possibly AI/ML. There is research and innovation that could be done to develop algorithms to better predict turbulence hazards.

Avoidance remains the best strategy.

[1] NASDAC Turbulence Study, August 2004

[2] US CAST briefing in 2004.