As a seasoned Aircraft Accident Investigator, I have come to the conclusion that occurrences are not repeated just like! But there are reasons behind it. This conviction actually came from a substantial experience in the field but most importantly, from multiple investigations as an investigator.
The aviation environment is very diverse and complex. There are many variables, directly and indirectly, related to an aviation environment. However, this discussion will primarily be focused on the pilots and maintenance crew. Aviation is a very dynamic environment. It involves risks therefore, it also requires continuous monitoring and evaluation. The Safety Management System (SMS) is a protective layer that manages the risks in an aviation environment. Crew Resource Management (CRM), Quality Assurance, Quality Control, and many other tools are the sublayers of SMS. They augment the SMS Program to ensure effective risk management.
The Problematic Areas
Despite safety nets in aviation organizations, occurrences of a similar nature repeat after some interval of time. The question remains as to why are these occurrences repeated?
The purpose of an investigation is to find the root cause of the problem. An investigation is a thorough and structured process. It requires man-hours. In case of an accident, these man-hours go into months. Repeat occurrences are alarming. Investigations help in reaching solutions through suggested corrective and preventive measures (CPM). There could be many reasons behind an incident/accident but the most probable reason is an ineffective follow-up by the monitoring agencies.
Unfortunately, in the majority of the cases, both the organization and the monitoring agencies fail to monitor the newly implemented CPMs for a very long time. It happens due to poor management systems. Here, the role of the monitoring agencies is very critical. Many times, these agencies do not maintain a strong follow-up mechanism.
Pilots and maintenance make procedural errors and mistakes. Investigations highlight the problematic areas. Unfortunately, organizations do not follow the suggested measures in true spirit. Over and above, the monitoring agencies also do not maintain a periodic follow-up check on the problematic areas and suggested measures highlighted by the investigations. In the long run, the organizations somehow take advantage of these grey areas and tend to repeat the same mistakes in the future even after a lapse of a few months.
737 MAX: A Glaring Example
The grounding of 737 MAX for almost two years is the inefficacy of the regulatory body. The regulatory body failed to monitor and act effectively after the first crash in 2018. Failure of the monitoring agency and the OEM after the first crash showed that technical glitches were not clearly identified and followed up before the second crash in 2019. It is the most recent glaring example of the ineffective follow-up by a monitoring agency that caused the loss of so many precious lives.
The way forward is easy yet very difficult. The organization involved in an incident/accident has a lion’s share in a repeated occurrence. Then comes the monitoring agencies. The ratio of this share keeps on changing in every incident because every day is a new day in aviation. The only solution to the problem is to ensure that procedural lapses highlighted in the investigations must be kept under strong watch with regular follow-ups by the monitoring agencies to avoid recurrence in the future.