Can airline safety improve from average performance in 2022?

The safety performance of airlines in 2022 reflected the stability that has been seen over the past 10 years, with steady, relatively low accident numbers. Indeed, following the industry’s previous decades of emphatic improvement, safety figures have effectively been almost flatlining since 2012.

Last year saw 12 fatal accidents globally across all airline operational categories and aircraft sizes, resulting in 229 fatalities.

These figures can be compared with an annual average of 15.4 and 302 respectively in the 10-year period from 2013, making 2022 appear rather good. However, this is statistically of little significance; in fact, fatalities climbed from a 2021 total of 134, caused by 15 deadly crashes.

Apart from the loss of a China Eastern Airlines Boeing 737-800 on 21 March – in which 123 passengers and nine crew members lost their lives – all the other fatal accidents in 2022 involved small or medium-sized turboprop aircraft. Most of the airlines involved would have been unknown outside their own regional environments.

These included the 6 November crash of a Precision Air ATR 42-500, which came down in Lake Victoria, Tanzania, while attempting to land at Bukoba airport. Nineteen of the 43 people on board were killed in the accident.

That the China Eastern event was the only big-jet accident in 2022 was not rare: the previous year also included a single such loss.

It would be easy for the world to see this status quo as acceptable, but that would be a pity, because all sectors of the industry could become almost accident-free.

REDUCING RISK

To reach the impressive standard achieved by the world’s safest aviation nations today, it took a concentrated effort by organisations such as the US Commercial Aviation Safety Team (CAST) and its EU and ICAO equivalents. This began in the 1990s, with their effort to lift their relatively poor safety performance to the levels that have now been achieved.

Success happened by assembling operational data that enabled the bodies to identify the causes of the accidents that they were still suffering in significant numbers. That knowledge allowed them to design strategies to reduce risk.

Controlled flight into terrain (CFIT) accidents – at that time the most deadly risk – were almost eliminated by the determined mandating of terrain awareness warning systems.

In addition to the efforts of CAST and its multinational partners, the IATA Operational Safety Audit (IOSA) programme – launched in 2003 – has delivered performance dividends for most of the world’s larger airlines: fatal accidents have almost been eliminated among IOSA participants. But smaller carriers could also reap the safety rewards of an adapted IOSA if the strategy were to be applied with the encouragement of their aviation authorities.

Meanwhile, the interim factual report on last year’s China Eastern 737 loss, released by the Civil Aviation Administration of China several months ago, is distinctly economical with the information it provides. It confirms – but does not attempt to explain – the steep, high-speed descent profile adopted suddenly from an apparently uneventful cruising phase of flight, with no radio communication of any kind from the crew (see accident listings download at foot of article).

Expert observers have noted the fact that the flight and its unusual descent profile was remarkably similar to that of the shocking Germanwings Airbus A320 crash in France in 2015. This has inevitably resulted in speculation that it may have had the same cause, although any apparent evidence for that so far is circumstantial. In the Germanwings case, the French inquiry found that the co-pilot, who had privately been receiving psychotherapy, had deliberately crashed the aircraft in a suicide bid. No data suggesting such a conclusion of the 2022 incident has been provided by the Chinese authorities.

To put the China Eastern event in context, China’s jet fatal accident rate had been zero for the past two decades, having improved dramatically compared with its relatively poor performance in the 1990s and earlier. The crash was the first loss of a Chinese mainline jet since an Air China 767 was lost in a CFIT event in 2002.

Among the non-fatal accidents and incidents listed for 2022, the most worrying single event involved a TAP Air Portugal A320 that carried out a late go-around from the approach to Copenhagen’s runway 30 on 8 April. Just as the aircraft was approaching the flare, it swung left, triggering the go-around decision. During the attempt to climb, the crew found they were dealing with un-commanded deployment of three of the four thrust reverser doors on the left-hand CFM International CFM56 engine, which they left at idle. The crew declared an emergency and followed air traffic control vectors to land on runway 22L. They did well to land safely.

There also were some dangerous runway incursion accidents during 2022, two of which resulted in deaths by collision. On 2 September, a TAP A320 was making a night approach to Conakry airport, Guinea. The pilots discussed a stationary light visible on the runway, questioning whether it was an exit indicator, but continued the approach. When the aircraft’s landing lights finally illuminated the darkness ahead, they saw that a motorcycle was on the runway heading for its edge, but the right engine hit it, killing its two riders.

On 18 November, a LATAM Chile A320 had been cleared for a night take-off on runway 16 at Lima’s Jorge Chavez airport, Peru, when – at a speed of about 125kt (230km/h) – it hit an airport fire and rescue truck; one of three vehicles that had been cleared to cross the runway as part of a rapid response exercise. The fire crew in the vehicle were killed, the aircraft’s right undercarriage collapsed, and the wing caught fire. It came to rest on the runway and all occupants evacuated without injury.

In a further case of runway confusion, on 22 January, at an uncontrolled airport in Colorado, USA, a JetBlue Airways A320 took off from runway 10 when a Beechcraft Super King Air was approaching to land on the same runway from the opposite end (runway 28). A manoeuvre by the JetBlue crew to avoid the King Air resulted in a tail-scrape and a consequent diversion.

Meanwhile, Indonesian accident investigators have issued a final report on the crash in January 2021 of a Sriwijaya Air 737-400. The crew lost control of the aircraft during its climb away from Jakarta bound for Pontianak on the island of Borneo.

The report is significant because loss of control in flight has caused far more passenger and crew deaths than any other accident category over the past 20 years. The Sriwijaya accident is further confirmation that parts of the commercial aviation world are still failing to take action to deal with this identified risk, for which there are known remedies.

The Indonesian report attributes the crew’s failure to control the aircraft to “automation complacency” and “confirmation bias”, which is another way of saying that they failed to monitor the autopilot and autothrottle, on the assumption that they usually do the right thing.

Meanwhile, the report says, mechanical friction in the throttle quadrant caused the starboard power lever to remain stuck while the autothrottle was trying to retard both levers. As a result, the starboard power lever remained where it was, and the port one retarded even more, until the autopilot could no longer compensate for the increasing thrust asymmetry, and it disconnected. The aircraft rolled left into a spiral dive to the sea, with the crew disorientated because it was in thick cloud.

Another important final report has also just been published: the Ethiopian Aircraft Accident Investigation Branch (EAAIB) verdict on the Ethiopian Airlines 737 Max 8 crash near Addis Ababa in March 2019.

Many of the conclusions had been made known in advance because of their importance – since this was the second Max crash within a two-year period, and problems with the single-aisle’s control software had been identified by investigators and acknowledged by Boeing.

PRESCRIBED PROCEDURES

The EAAIB report is accompanied by a separately filed objection to it by the US National Transportation Safety Board (NTSB). The latter acknowledges that the Ethiopian crash report contains the truth, but maintains that it is not the whole truth.

According to the NTSB, the EAAIB did not report on the failure of the pilots to follow prescribed procedures during the developing emergency. If they had they done so, the NTSB insists, they could have prevented the crash. Also, whereas the EAAIB report has judged that erroneous signals to the aircraft’s Maneuvering Characteristics Augmentation System (MCAS) from the angle-of-attack (AoA) sensor were caused by a “power supply quality problem”, the NTSB insists that the sensor malfunction was the result of a bird-strike directly on the relevant AoA vane at take-off.

The NTSB says it is not attempting to lessen the part played by the MCAS design flaws, but alleges that the accident as a whole has not been fully examined in the EAAIB report.

Meanwhile, as a result of the corporate soul-searching at Boeing over the Max issues, real change has taken place in the company. This matters, because when a manufacturer as influential as Boeing effectively admits it had lost focus and has now identified how and why that happened, other manufacturers have the opportunity to use the lessons learned for a reflection on their own practices.

In May 2022, Boeing held a briefing on its global safety update programme. Alongside the company’s self-examination, the US Federal Aviation Administration (FAA) has looked at its relationship with the manufacturer and distanced itself somewhat. The FAA is also becoming more demanding about the demonstration of product and systems design, which is visible in some of its ongoing interventions regarding the 777X and 787 programmes, as well as the Max.

Boeing has restructured its corporate safety management system, a process which has included the creation of a new safety oversight post: chief aerospace safety officer. Mike Delaney, who was previously vice-president of Boeing Commercial Airplanes digital transformation, has been appointed to that office.

The company also set up an office of “product and services safety” to oversee regulatory compliance and product safety worldwide. The objective, says Delaney, is to create greater transparency of process within the company, and to implement a “just culture” reporting system designed to encourage individuals to report anything that warrants attention – without fear of some form of retribution.

From the time that David Calhoun became Boeing’s chief executive in January 2020, he has made it clear that the airframer’s assumptions about pilot reactions to system faults were going to have to be completely reviewed, not least because aircraft have become so much more technically complex since existing pilot performance assumptions were drawn up, effectively in the post-war period.

Boeing also is still wrestling with certification of the Max 7 and Max 10 variants, but appears to have secured an exemption from a 31 December 2022 deadline to do so or have to equip the models with a central flightcrew alerting system. That rule was introduced in the wake of the type’s two crashes, but the airframer was unable to meet the time requirement due to disruption caused by the Covid-19 pandemic.

This apparently simple issue at Boeing is a perfect metaphor for the challenges the commercial aviation world is facing. Taken as a whole, the industry has achieved impressive advances in safety performance, but it has the means to do even better.

The question remains: what actions are still required in order to achieve that final advance toward zero serious accidents?

Our annual accident listing uses data from Flight International’s research, in association with Ascend by Cirium