Black Boxes Reveal The Cause Of TransAsia Crash

Preliminary assessment reveals a classic screw up.

Posted Feb 06, 2015

When a crash takes place, investigators determine the cause. They then make recommendations to prevent such an accident from happening again.

Based on a preliminary assessment of black box data, this crash was a classic screw up. In a hurry to shut down the failed engine, the pilots shut down the engine that was operating properly. On a two-engine airplane, when power has been lost on one engine due to its failure, if the properly operating engine is mistakenly shut down, the plane is left with no power. Unless the good engine can be quickly restarted, a crash is inevitable.

Procedures exist to prevent this kind of crash from taking place. In an emergency, brain function may be reduced. See https://www.psychologytoday.com/blog/the-brain-and-emotional-intelligence/201203/the-sweet-spot-achievement 

When under great stress, a pilot, policeman, soldier, doctor, or nurse - instead of “rising” to the occasion - "descends" to the level of their rote training. Hopefully, the procedure they need to carry out has been carved into their psyche by repetition.

Pilots receive emergency procedure training in a flight simultor. In training, when an engine fails, the rule is to do nothing until the plane has climbed to a safe altitude. Then, the pilots carry out the engine shutdown procedure.

  • The pilot flying the plane continues to fly the plane.
  • The other pilot - the pilot not flying - carries out the procedure.
  • The first step is to identify which engine has failed.
  • Before anything further is done, both pilots must agree on which engine is the problem.
  • The pilot who is not flying places a hand on the fuel shutoff lever of the failed engine, but does not move the lever.
  • The pilot flying must then determine that the hand is on the fuel shutoff lever of the problematic engine.
  • Only then does the pilot who is not flying shut off the fuel supply to the failed engine.

In this case, one of the pilots shut down – not the problematic engine – but the engine that had been operating properly. Thus, with no power, the plane had to descend to maintain its speed. The plane ran out of altitude and crashed before they are able to restart the good engine.

What is the take away message? In the interest of safety, pilots must be receive enough emergency procedure training to be able to carry out every emergency procedure by habit under stress.

Some observers say that as aviation has grown rapidly in Asia, pilots may not be receiving the training needed. Consider the San Francisco crash of Asiana 214. The pilots were unable – even with a supervisory pilot on board – to safely conduct a visual landing on a sunny day, something any amateur pilot can do. See http://en.wikipedia.org/wiki/Asiana_Airlines_Flight_214

In the U.S., as regional carriers have grown rapidly, training has not always been adequate for the needs of relatively inexperienced pilots. Look back at the crash of Colgan Air flight 3407 caused by an inept and insufficiently trained pilot. Fatigue may also have been a factor. See http://en.wikipedia.org/wiki/Colgan_Air_Flight_3407

A sustained public outcry in the Buffalo area resulted in new FAA regulations. Airline pilots are now required to have a minimum of 1500 hour of flight experience. Also, new rules have been put into place to reduce pilot fatigue. A pilot new to airline flying may need extra training to be able to perform emergency procedures flawlessly under stress. The new fatigue rules, though a step in the right direction, still include significant compromise. The future will tell us whether or not they are adequate.

Currently, since no major airline has had a fatal accident since 2001. Statistics, being intellectual, do little if anything to reduce anxiety when facing a flight. On the ground, we may turn to control or escape to regulate anxiety. In the air, neither is available and passengers may develop high anxiety, claustrophobia, or panic. For emotional help with fear of flying, please see my other blogs on this subject.