“Control-check ‘routine’ led E190 upset crew to miss reversed ailerons”

Remember 11 November 2008, when an Air Astana plane was experiencing flight control problems after departure out of Lissabon (Portugal)? People were watching while a potential catastrophe unfolded live. Luckily, the pilots managed to get the aircraft back under control and landed the crippled machine at the 3rd attempt. The flight was a transfer flight (without passengers) after extensive maintenance.

On 31 May 2020 the Portuguese investigation agency published a preliminary report. The next week FlightGlobal published an article with the above title. Take a look at the judgemental language. Based on the title alone, the conclusion is simple: ‘Human Error’. While in this story, the pilots are the actual heroes since they successfully avoided disaster.

Some will claim that if they would have done their checks as they have should, there would have been no need for any ‘heroism’ anyway. Flight control check seems wrong? Return to the hangar. Period. But imagine you pick up your car from the garage after maintenance? Would you check the oil level and tire pressure?

These guys didn’t get up in the morning and think “Hey, let’s try flying a plane with reversed ailerons!” So let’s look at the (systemic) context:

  • What was the experience of the flight crew with flight-checks?
  • Were they properly trained/prepared for their task? (Airbus has published test-flight guidance after a number of incidents. Indeed, not every flight check was/is carried out by test-pilots…)
  • Was the crew aware of the flight control issues?
  • What was the guidance provided to the maintenance organisation and the mechanics/engineers?
  • Could the Embraer engineers have foreseen the twisted connection?
  • How was it possible that a wrong cable combination could be physically connected?

Make it easy to do the right thing.
Difficult to do the wrong thing.
And extremely difficult to do something catastrophic!

Systemic thinking

Source: FlightGlobal, Kazinform