Lalu A. Damanhuri, Jakarta
Within a one-month period at the end of this year
there have been a number of serious accidents in
Indonesia in almost all forms of transport.
While it is too early to make judgments about the
exact cause of the Lion Air Boeing MD-82 aircraft crash
in Surabaya, it is quite possible the accident
was due
to the failure of Lion Air to comply with standard
operating procedures. A likely contributing factor to
the accident could also be the failure of employees to
exercise adequate operational safety oversight.
Historically, a variety of people, including
surviving pilots and cabin crew, mechanics, ground
workers, and surviving passengers, have willingly
provided key information in accident investigations. The
overriding emphasis of investigators is on understanding
the accident so that lessons learned could be used in
preventing future accidents. In the past there was
little concern with trying to punish those who might
have contributed to the accident.
However, this not the situation now and more people
are becoming reluctant to talk openly. It is also
increasingly common for people to talk to their lawyers
before talking to investigators. Although it is
difficult to determine the specific effect of this
litigious environment on the quality of investigations,
it seems clear that accident investigators are being
told less and are finding it difficult to gather
information in a timely fashion.
Actually, according to Aviation Law No. 15/1999,
there is no way a pilot in Indonesia can be charged with
causing an air accident. The current law says no one is
directly responsible for an aviation accident, and
therefore the pilot or copilot cannot be charged for
criminal recklessness or negligence as drivers on land
can.
The government, however, has established the
Transportation Safety National Committee (KNKT), the
body that conducts investigations into aviation
accidents. However, this body is not independent,
because it is under the auspices of the Ministry of
Transport. To ensure an unbiased investigation, the
existing law must be reformed in order to accommodate
air transport safety -- if necessary we should set up a
separate aviation accident law.
Automatically recorded information is becoming
ever-more critical in determining the causes of
increasingly complex accidents. Flight data recorders
(FDRs) in newly manufactured aircraft must now record 57
different measurements and soon will have to record 88.
Automation has already taken over many of the
functions previously performed by pilots, air traffic
controllers, and mechanics. For example, after takeoff,
the pilot can program the plane to fly itself. Some
aircraft are even equipped with an automatic landing
function. However, in highly automated aircraft, pilots
no longer have a direct mechanical or hydraulic link to
control aircraft components. Instead they provide input
into a computer that issues commands to the components.
In some aircraft, the computer can even alter pilot
inputs to prevent action that has been programmed as
unsafe. How can we be sure that this increasingly
complex programming will work as desired under the huge
array of circumstances that aircraft potentially face?
A key practical issue is ensuring that the pilot will
be ready to resume control of an aircraft when needed.
Take, for example, the problem of ice accumulation
during flight. Even small amounts of ice can
dramatically degrade an aircraft's performance, and with
sufficient icing the aircraft can become un-flyable.
Because the autopilot can compensate for the
accumulating ice up to a point, the pilot may not
realize that there is a problem. But by the time the
pilot resumes control from the autopilot, the plane may
have deteriorated to the point where it is no longer
controllable.
Determining the point at which adding more automation
becomes counterproductive to improving safety is a
complex issue, and we don't pretend to know where that
point is. Our concern is that the industry may not
always realize that just because we have the technical
ability to automate something doesn't
mean we always
should.
The airline industry has always been strongly
affected by business cycles. During periods of rapid
growth, budget carriers' increased demand for pilots
means that pilots often move more quickly up the career
ladder. There is always the concern that they do so with
insufficient experience and with less filtering. Less
experienced pilots are often hastily promoted to higher
position. Although there is no solid proof to back up
the statement, but from day to day we have seen a higher
rate of pilot errors in the last few years during the
period of rapid growth of this industry.
Until recently, the question of how the government
safety function should be organized haven't been given
much thought.
A second element involved in organizing governmental
institutions for safety is harmonizing international
safety regulations. A persistent theme in aviation
safety research is the disparity of safety performance
in different regions of the world. Indonesia is
dramatically less safe. The reasons are varied,
including differences in navigational and landing aids,
airports and weather. But there are also differences in
regulatory standards and enforcements in areas such as
pilot training, mandatory equipment on aircraft, and
aircraft maintenance.
These differences are aggravated by the tendency in
Indonesia for airlines to lease (buy) older aircraft
from developed countries. Although older aircraft can be
operated safely when properly maintained, adequate
maintenance is frequently lacking in Indonesia.
There have been relatively few attempts at
harmonizing international standards and enforcement on
airline operations, aircraft maintenance, pilot training
and licensing, and minimum required equipment on
aircraft. Accident investigation is also more difficult
in Indonesia, because FDRs and cockpit voice recorders
are often less sophisticated.
The traditional approach of learning from previous
accidents alone is no longer enough. Stricter penalties
from the government, including to charge and bring to
court those who are responsible for the air accident
should be taken soon.