An in-depth accident investigation report, issued by the French Investigative Authority BEA, is a ‘catalogue’ of almost everything that could – and is going – wrong in part of today’s airline industry. Fatigue, issues with training and qualification of pilots, shortcomings in CRM, lack of safety culture in the company, questionable company set-ups, commercial pressure on pilot decision-making, inadequate oversight by authorities, etc.… The list of factors that contributed to the Hermes Airlines' Airbus A321 SX-BHS accident in 2013 is long and telling.
The 212-page report contains a noteworthy confession that must wake up the whole industry:“Although complying with the regulations in force, the management choices that limited to minimum conformity with regulations exposed the airline to an increased risk of accident.”
Such a management choice was e.g. to “accept, or indeed even favour” applying a quasi-systematic waiver for unforeseen circumstances that allows an extension of the flight duty period, in order to avoid resorting to augmented crews – a more expensive solution. The flight crew’s flight duty period was close to 15 hours at the time of the event. Observation of the crew’s performance showed alterations which were symptomatic of fatigue. The day before the event flight, the Operations department of French Air Méditerranée, whose low cost subsidiary Hermes Airlines is, had advised them to provide for an augmented crew because of possible extension of the flight time due to a possible technical stop. However, this advice was not followed.
Similar traces of commercial pressure are found also in the decision-making by the pilot. Interviews with Hermes Airlines personnel indicated that they were concerned with limiting costs to a minimum. Some even “feared losing their jobs in the event of an error incurring substantial additional costs. […] The Captain’s decisions were made in a context of adverse economic pressure.”
Another choice was the cost-driven approach to crew selection and training. Hermes management’s justification for selecting inexperienced crew “because of the low cost profile of the operator” is one aspect. When combined with inadequate in-house training, conversion course and the pairing on an inexperienced F/O with a captain equally lacking experience, it’s a recipe for disaster.
Last but not least, the report depicts a failing safety management by the airline and inadequate oversight by the responsible authority. The number of safety reports, filed by crews in 2012 and 2013 revealed that the latter were reluctant to report negative facts. The geographical spread of the crews did not enable them to share a common platform to receive and exchange safety information or to discuss in-flight experiences. The overseeing authority – the Hellenic CAA – on its turn did not manage to establish appropriate oversight – a fact, which EASA was also aware of.
The real message of this report is not that the management of one small, charter airline had made a series of wrong choices. It is that the airline industry must open its eyes for the hard and bitter truth: what is legal, is not always what is safe.
