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Unusual — 2010 Ethiopian Crash Answers Still Elusive

Posted by addisethiopia / አዲስ ኢትዮጵያ on January 25, 2011

“Unusual for an investigative authority to not issue any information in the wake of a crash.”

When Ethiopian Airlines flight ET409 plunged into the sea moments after taking off from Rafik Hariri International Airport on Jan. 25 last year, there was no shortage of theories on why the plane had crashed.

The Boeing 737-800’s fate was sealed, as was claimed variously at the time, by lightning strike, poor weather, mechanical failure, loss of power, pilot error or even an onboard explosion.

The doomed flight left Beirut’s Rafik Hariri International Airport shortly after 2:20 a.m. local time, bound for the Ethiopian capital Addis Ababa, following a raging thunderstorm. Eyewitnesses interviewed on the morning of the crash suggested the plane had entered the sea in flames following a bright flash of light.

What followed was confusion.

Lebanese authorities were quick to rule out terrorism as a possible factor, although this has not silenced conspiracy theorists suggesting a bomb had been placed aboard the jet before take-off. Two days after the crash, Transportation and Public Works Minister Ghazi Aridi suggested that the pilot had performed “a fast and strange turn” after take-off.

Media reports in the immediate aftermath claimed that the Boeing 737-800 had suffered a double lightning hit or had fallen from the sky after both engines stalled.

One report, by Reuters, quoted a source within the investigation as saying that the crash had occurred due to pilot error after the co-pilot had failed to successfully engage the plane’s autopilot in the minutes after takeoff.

In the days following the disaster, teams of aeronautical technicians, forensic specialists and transport accident experts flew to Beirut to begin assessing information retrieved from the crash site in the eastern Mediterranean, some 4 kilometers from the town of Naameh.

Delegations from carrier Ethiopian Airlines, manufacturer Boeing, the United States’ National Transportation Safety Board and France’s Bureau d’Enquêtes et d’Analyses pour la Sécurité de l’Aviation Civile were invited to send technical support following the location of the plane’s black box and cockpit voice flight recorders, pulled from the sea bed 13 days after the disaster.

Boeing, NTSB and BEA were chosen to spearhead the official investigation, based partly on data retrieved from the crash site, under the supervision of Lebanon’s Civil Aviation Authority, which still officially heads the probe.

It is common in civil air disasters for the investigative body to deliver some initial communiqués regarding crashes, particularly if it has reason to believe mechanical malfunction played a part.

Any message can then be distributed to airlines.

Aviation expert and pilot Joel Siegfried, who has followed the ET409 investigation closely since the accident, said it was unusual for an investigative authority to not issue any information in the wake of a crash.

I have seen such authorities issue multiple statements [following a crash], particularly if they come upon any important safety alert,” Siegfried told The Daily Star from his home in San Diego, California.

It is very unusual in a case like this for there to be no preliminary investigation report. It would say it seems clandestine, but I wouldn’t say it is inappropriate,” he added.

Following the crash of Colgan Air flight 3407 near Buffalo, N.Y., in February 2009, which came down nine kilometers short of the runway in icy conditions, the NTSB issued several safety warnings instructing pilots of the Bombardier Q400 aircraft to avoid engaging the autopilot in extremely cold weather.

By contrast, 12 months after the event, the CAA has yet to issue even rudimentary findings into the potential causes of the crash.

CAA head Hamdi Chaouk said that there was no requirement for an investigative team to issue a preliminary report. “A visit will be paid to Ethiopia at the end of this month and a final report will be written,” Chaouk told The Daily Star.

There is no deadline for finishing; it may take two or three months [more]. There is nothing called a preliminary report, but the report which was first forwarded to the [Lebanese] Cabinet included only facts [about the flight].”

Chaouk added that the relatives of crash victims would be notified when the report had been finalized.

It will be published internationally,” he said.

Attempts by The Daily Star to contact BEA went unanswered, but Boeing issued the following statement:

Accredited representatives, such as we are to this accident investigation, are forbidden from providing any information about an investigation that is being led by another country’s investigation body.”

When LBC television broadcast a two-part report on the investigation into ET409 earlier this month, it was unequivocal: The pilots were inexperienced and exhausted after having flown more than 100 hours in January, 40 more than international safety recommendations. The crash, the channel reported, had been the direct and sole result of pilot error; the captain and co-pilot’s collective inexperience was “certainly behind the accident.”

Ethiopian Airlines, which had already vehemently disputed Aridi’s claim in the wake of the crash, defended their pilot, Captain Habtamu Benti Negasa, following LBC’s dispatch.

It is disheartening to see such unsubstantiated reports issued in utter disregard to the pain and suffering of the families of the deceased while the investigation is still under way,” an airline statement said. “Ethiopian [Airlines] firmly maintains its position not to comment on the causes of the accident prior to the completion and official release of the results of the investigation, and has all the confidence that the investigation team will take all the factors into account when determining the final causes of the accident.”

The Montreal Protocol treaty, signed in 1975 and last updated in 2009, stipulates that, as far as acquiring compensation, blame in any air disaster is not apportioned; investigators need only establish the cause of a crash, not who was at fault.

The sole objective of the investigation of an accident or incident shall be the prevention of accidents and incidents,” states an International Civil Aviation Authority annex. “It is not the purpose of this activity to apportion blame or liability.”

According to James Healy-Pratt, an aviation attorney with over 20 years of experience in air crash litigation, it is nevertheless common for pilots to be the first point of culpability.

I am always reluctant to blame just the pilot, because he’s not here to defend himself,” he said.

Healy-Pratt’s London-based firm, Stewarts Law, is representing 27 families of Lebanese victims. At a news conference this week in Beirut, Healy-Pratt called for the Lebanese government to hasten investigative procedures in order to help relatives gather more information about lost loved ones.

He concluded, based on known facts regarding the last few minutes of ET409’s flight path, that the crash being due to pilot error alone was “extremely improbable.”

With such a dearth of information coming from Lebanese authorities, Healy-Pratt and colleague Peter Neenan, a physicist-cum-air crash lawyer, began compiling data from flight plans, airport runway plates and information from radar readouts in an attempt to recreate ET409’s final moments.

They discovered that the Ethiopian Airlines disaster bore remarkably similar hallmarks to the crash of Kenyan Airlines flight KQ507, which killed 114 after takeoff from Douala Airport, Cameroon, in May 2007.

Both flights involved Boeing 737-800s, relatively inexperienced pilots and both took off at night in poor, but not atrocious, weather conditions.

Pilot error was indicated in the Cameroonian CAA’s subsequent report, a document which Healy-Pratt however labeled “incomplete.”

Loss of control of the aircraft is a result of spatial disorientation … after a long slow roll, during which no instrument scanning was done, and in the absence of external visual references in a dark night,” the report said.

Inadequate operational control, lack of crew coordination, coupled with the non-adherence to procedures of flight monitoring, confusion in the utilization of the [autopilot], have also contributed to cause this situation.”

Spatial disorientation, a phenomenon which can occur while flying at night or in poor weather, is a result of the angle of flight disrupting the body’s natural balance perception. In such a case, a pilot or co-pilot may be unaware that a plane is banking, as was the case with KQ507. Although pilots are trained to ignore their bodies and focus instead on a cockpit’s central flight display, spatial disorientation has been cited in a number of crashes.

In addition, the KG507 co-pilot erroneously assumed he had engaged the plane’s autopilot. While this would have been virtually impossible on a 737’s old autopilot – which was engaged via a flick-switch and would only deploy if a plane was not performing a maneuver, the new system, with which ET409 was fitted, involves pressing a button which, as Healy-Pratt pointed out, “has less of a positive confirmation.” In other words, it is easy to assume autopilot is on when it isn’t.

ET409’s flight plan should have seen the autopilot engaged at a height of some 400 feet, after which the plane would bank to the north-west before continuing its path southward to Addis Ababa.

The autopilot should have overseen the plane banking to its starboard (right) side before eventually leveling out. But at 8,000 feet, the plane continued to roll hard to its right. This prompted a loss of lift, which saw the 737 fall rapidly out of the sky, plunging into the sea at Naameh, 4 kilometers southeast of the runway.

It is likely that the autopilot failed to engage, a fact which the pilot would have worked out from instrument panel warnings only after the plane was already in dire straits.

Source: Daily Star (Lebanon)



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