The preliminary report on the Boeing 787 crash at Ahmedabad looks like a Rube Goldbergh creation. It has inevitably created so much confusion that it is now a free for all – from blaming Boeing to Air India to the pilots, it has even given rise to conspiracy theories. 

As per the International Civil Aviation Organization’s Annex 13, the primary purpose of a preliminary report is to promptly communicate the factual information gathered during the initial stages of an aircraft accident investigation. This is crucial for quickly disseminating key findings to relevant parties, including governments and organisations involved in the investigation, to facilitate timely safety actions. However, the report released by the Aircraft Accident Investigation Bureau fails to achieve the objective as it has only raised fears among the travelling public.

There have been discussions on mainstream news channels even debating whether it was an intentional act by one of the pilots. This does not inspire any confidence among the travelling public, and the AAIB should at least come forth with some clarification to allay public apprehension.

As per Annex 13, the government conducting the investigation is expected to produce a preliminary report within 30 days of the accident. This report may be public or confidential, at the discretion of the government in charge. If the AAIB wanted to maintain secrecy for some reason, they should have exercised their right to maintain confidentiality. It would have been a better choice than releasing a report which has only raised more questions and created confusion in the minds of all.

The most glaring example is the words attributed to the pilots, without even mentioning the context or who specifically uttered those words.

It is also to be borne in mind that the sole objective of an Annex 13 investigation is to prevent accidents and incidents, and generate safety data and information to aid with the prevention of future and similar accidents or incidents. It is not concerned in any way with the apportioning of blame or liability. By selectively mentioning bits and pieces of the cockpit conversation, the AAIB is only facilitating others to apportion blame.

Annex 13 outlines that States of Registry, Operator, Design, and Manufacture are entitled to appoint accredited representatives to participate in the investigation. While pilot associations or unions are not explicitly named in Annex 13 as having a right to appoint an accredited representative, they can potentially participate as advisors to accredited representatives from governments with a special interest in the accident, or as technical advisors.

In the case of AAIB, when they do not have pilots in their team who are qualified on Boeing 787s, the most sensible option would have been to include pilot representatives in the investigation.

In the United States, the Airline Pilots’ Association (ALPA) has worked with both the US National Transportation Safety Board and Canada’s Transportation Safety Board to provide line-pilot expertise whenever an airline accident or serious incident occurs. 

To aid in investigations, ALPA makes members and staff available to work alongside the investigative agencies. Their participation ensures that ALPA is on site to encourage investigators to look at all the information, that they work diligently to find the root causes of an accident, and that they always have access to a line pilot’s perspective on what might have occurred. ALPA trains members to participate in accident investigations and also serves as an advisor to oversee their participation whenever it is given party status in an investigation. 

Participation by pilot associations or unions can help enhance the transparency and accountability of the investigation process, which can build public trust in the findings. For example, after the Colgan air crash in 2009, ALPA was a party to the NTSB under the “party system” and provided input on pilot fatigue and training in regional airlines. In the case of the First Air Flight 6560 accident investigation, in Resolute Bay, Nunavut in 2011, ALPA sent one investigator to assist on scene. In the accident involving Air Canada Flight 624 at Halifax in 2015 the Air Canada Pilots’ Association played the role of observer and technical consultant. And in the accident involving the Germanwings aircraft in 2015 the French pilots’ union was consulted during policy discussions.

A case in point

The most impressive crusade in the field of aviation safety was carried out by Captain Gordon Vette of Air New Zealand. 

In 1977, Air New Zealand introduced sightseeing trips over the Antarctica in DC-10s. On the flights commentary was provided by famous explorers such as Sir Edmund Hillary. Jim Collins served as the captain of Flight TE901, the last scheduled flight of the series, Flight TE901 took off on November 29, 1979. As the plane descended to sightseeing altitude upon reaching Antarctica, the ground proximity warning sounded. The flight did not have a chance to react and TE901 slammed into the side of Mount Erebus, killing all on board.

The initial report on the accident released on May 30, 1980, initially blamed the crash on pilot error but one pilot, Captain Gordon Vette challenged this finding. He had trained Collins himself and found it unlikely that he would exhibit that level of negligence. 

It was soon discovered that the airline changed Flight 901's route, after the flight briefing, without informing Collins, thus putting Mount Erebus directly in its path. Vette hypothesised that the crash might be due to a combination of three factors: first, that the route had been changed without the crew's knowledge; second, that the aircraft's Inertial Navigation System would have shown them to be on track at the time of the crash due to this change in route; and third, that the optical illusion of a sector whiteout could have made the blank white face of Mount Erebus appear to be the snowy plains, leading the crew to believe that they were still following the route that every other flight had taken. Unwilling to let the blame for the accident be unfairly assigned to the flight crew, Vette conducted extensive research in order to discover the truth.

Due to the campaign for re-examination by Vette, a Royal Commission of Enquiry was formed in 1980 to examine the finding of the pilot error. Vette's research, along with other evidence, was presented to Judge Peter Mahon, who was in charge of the commission. Vette served as an adviser to Mahon during the proceedings. Justice Mahon even took a helicopter ride to Mount Erebus during the course of his investigation to experience the phenomenon of sector whiteout for himself. As he later described it, "I was taken for a flight myself in whiteout conditions and saw with my own eyes the flat terrain of ice and snow stretching forth for more than forty miles when in fact right in front of us there was a snow ridge several hundred feet high". Mahon's final report was published in 1981, and it largely agreed with Vette's hypotheses. Mahon found Air New Zealand to be financially responsible, describing their attempts to shift the blame on to the late flight crew as "very clearly part of an attempt to conceal a series of disastrous administrative blunders".  

Though the truth of the Flight TE901 crash eventually won out, the cost to its defenders was high. Vette's career suffered and he was eventually driven to an early exit from the company he had worked for since 1948

In recognition of Vette's efforts, the New Zealand Airline Pilots’ Association awarded him an honorary lifetime membership in 1984 and the first Jim Collins Memorial Award for Exceptional Contribution to Flight Safety award in 1991.

To conclude, if investigation agencies really wish to find the root cause of accidents and prevent accidents in future, a sincere effort should be taken to maintain transparency and include interested stakeholders in the investigation. If not, truth will be the first victim and final victims will be innocent lives. 

Captain S. Sabu is an airline pilot and member of the Flight Safety Foundation and Royal Aeronautical Society. Views are personal.

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