A “disappointing” German report on SAA flight incident let down the industry and flying public by not making safety recommendations, an investigator claims.
The report by the German Federal Bureau of Aircraft Accident Investigation (BFU) on a SAA Airbus plane, which came close to stalling during adverse wind conditions over Switzerland in 2018, has been criticised for not making any recommendations for future aviation safety.
This is the view of David Doull, a former SAA pilot, who was appointed by the airline at the time as the lead investigator for the internal investigation of the incident. He is an accredited independent aviation human factors specialist and produced a 75-page report on the incident.
His report made several recommendations, which he says were shared with the German authorities and the manufacturer. During his investigation, Doull says he assisted the BFU with its investigation and consulted extensively with representatives of Airbus and the European Aviation Safety Association (EASA).
While he sees large parts of his investigation findings reflected in the German report, there are aspects with which he does not agree. “I understand this incident at a level of technical detail that qualifies me to comment,” Doull says.
He and Riaan Beekman, a former SAA pilot, flight instructor, and former head of SAA’s Airbus A320 training with more than 30 years of aviation experience, say they have decided to come forward, “in the interest of the flying public”.
The BFU released its investigation report on July 17 — more than four years after the incident took place. The report describes a serious incident in Clariden, Switzerland, on November 6 2018. The report does not name SAA and speaks only of “the operator”. However, it is common knowledge that SAA was the airline involved.
The German report states that, due to the erroneous application of recovery procedures, the Airbus A340-600 aircraft with 259 people on-board was close to stalling at a high altitude during a flight from Johannesburg to Frankfurt.
The flight crew reported to have temporarily lost control of the aircraft, caused by a rare and unpredictable weather phenomenon, so there was a high probability of an accident, according to the BFU report.
“The SAA internal safety investigation report came up with 12 safety recommendations, while an independent analysis using CAST (Causal Analysis based on System Theory) came up with 14 safety recommendations — six for SAA, four for Airbus and four for EASA. Yet, the BFU’s final public report produced zero safety recommendations,” says Doull. “This begs the question: what was the point? The flying public deserves better. They deserve an aviation safety system that learns and adapts away from vulnerabilities.”
Beekman agrees that in this incident, major lessons could have been turned into safety recommendations that could protect the flying public from accidents in future.
The BFU, EASA, and the SA and French civil aviation authorities had not responded to Business Day's request for comment at the time of going to print. Airbus declined to comment.
The German investigation found that the pilot in charge deactivated the autopilot and steered the aircraft manually into a climb. The maximum angle was reached several times and the aircraft system’s stall warning was activated for a few seconds each time. The Airbus 340 is equipped with high-speed protection to prevent in-flight speeds which could cause structural overload or loss of control.
“The control inputs by the pilot in charge during the active stall warning were insufficient and not energetic enough to stabilise the flight attitude in time,” states the German report. “Crew co-operation during the overspeed condition and the stall recovery was erroneous in regard to the analysis of the situation and the implementation of procedures.”
However, for Doull and Beekman an effective aviation safety culture is one where learning and adaptation happen, not a mere blame game.
“The BFU states that the crew did not perform an effective stall recovery when they actually did. That’s how the crew saved the aircraft, landed safely and with no damage nor injuries. The BFU report made a lot of statements pointing out what the crew didn’t do, without explaining why they did what they did do,” says Doull.
He points out that in its report the BFU made the assumption that certain crew call-outs were not made during the stall recovery, yet, the BFU was not able to verify this on the cockpit voice recording. Furthermore, he says the BFU’s finding is in contradiction to data from interviews with all three crew members.
“The BFU report missed the big picture about how the crew avoided an accident through their recovery. The BFU report made statements about crew actions or inactions without providing realistic context,” says Beekman. “It was practically impossible to predict all these circumstances coming together, in other words, no-one could have seen this coming.”
In the view of both Doull and Beekman, it was excellent proactive training initiated by SAA in 2008 that saved the day.
The confusing and extreme conditions the aircraft suddenly faced, caused the pilots to respond in line with a temporary directive Airbus had issued for undue stall protection system activation. In these conditions, however, Doull agrees with the BFU that it was not the appropriate response.
In the course of the investigation, Airbus found five other incidents globally where pilots of other airlines faced situations and reacted in a similar manner as the SAA pilots did by applying the temporary Airbus directive.
Would you like to comment on this article?
Sign up (it's quick and free) or sign in now.
Please read our Comment Policy before commenting.