The tragic PIA Flight PK 8303 incident brought great pain and sorrow for the nation. While such accidents bring about great tragedy, it is important that we stress on what we learn from them so that we prevent any further loss. These accidents necessitate an honest review of changes we have made – or rather failed to make – in order to avoid such occurrences.

PIA must move swiftly and adopt safety as its core organisational culture. When aviation accidents happen, they are more likely to be embedded in the system for a long time. In PIA’s case, the prevalent safety culture just aims to tick regulatory compliance whereas it should be the governing culture – embedded in the organisation’s DNA – of any aviation body. There are various safety checks in place with an aim to identify potential hazards. No matter how well the work is organised, how good the procedures are, how well the equipment is designed, people within an organisation will never perform better than what the organisation will allow. Such events are not so much the result of error prone worker as they are the result of error prone work environment.

Modern-day air travel is considered to be a relatively safe means of transport. There has been a great reduction in the accident rate since 1960 and this has mainly been due to enhancements in technology, operational procedures, and training. The problem is not as much with the equipment as much as the way the equipment is used. Human error continues to be considered as a major cause in over 70 percent of aviation accidents. To this end, the global aviation industry has evolved and adopted human performance principles and practices to consciously reduce human errors. Development and implementation of Crew Resource Management (CRM), Line Oriented Flight Training (LOFT) to improve crew coordination in a realistic environment, Flight Data Monitoring (FDM) to improve performance standards, and Safety Management System (SMS) to put all the responsibility of any accident or incident where it belongs; that is the management that PIA requires in its true letter and spirit.

There is also a need to change the traditional training philosophy which is based only on knowledge, skills, and experience, and is generally employed in Pakistan’s aviation industry. Global aviation safety standards have introduced a new stream of key focus areas that are an inherent part of training programs across the world. Therefore, Pakistan needs a serious and honest review of whether its aviation industry gives proper attention to key focus areas such as attitude development, stress management, risk management, psycho-motor skills, flight deck management, and crew coordination.

The investigation into the PK 8303 crash should be objective and must be made public and if Pakistan fails to conduct an independent investigation into this accident, then another opportunity to set our course right will be lost. The International Civil Aviation Organisation (ICAO) provides a complete framework of how investigations into aviation accidents should be conducted. According to ICAO’s recommended practices, investigators should enjoy complete independence, unrestricted authority, and should have the ability to withstand political pressure. In cultures like ours, such investigations can often be derailed and findings can be hushed up. Different stakeholders including individuals, government figures, airlines, regulator etc. can look to safeguard their own interests and reputations rather than looking into all the causal factors.

Paul Stephen Dempsey wrote in the Independence of Aviation Safety Investigation Authorities Journal 2011 about the importance of avoiding conflict of interest in such investigations. Dempsey wrote that the safety investigator and regulator need to be separated. While the investigator looks at the causes of safety accidents and makes recommendations, the regulator should enforce regulations. Therefore, instances where these lines are blurred and where this difference between the investigator and regulator is not maintained are inherently flawed. As Dempsey puts it in his paper, the fox should never be allowed to guard the hen house.

Involving Subject Matter Experts (SMEs) from operators, regulators, industry, and pilots in the PK 8303 investigation is critical. The involvement of these experts will make the investigation objective and will not offer symptomatic treatment but will take a deep dive into structural flaws that need to be addressed by Pakistan’s aviation industry at large and by PIA in particular. Involving the Pakistan Airline Pilots Association (PALPA), for instance, will only add more credibility to the investigation.

Off late, the higher management in our aviation organisations, both regulators as well as PIA, have been brought in from the outside. As a result, professionals who know the working environment across all levels of mid to lower-tier management never make it to the top. Those brought in from the outside often lack training and experience in civil aviation organisations which, in turn, hampers the institution’s growth and also leads to arbitrary policies and procedures.

Similarly, an independent audit by an internationally reputed aviation entity, such as ICAO’s Universal Safety Oversight Audit Program (USOAP), should be commissioned. This audit should look at aviation systems in Pakistan and focus on regulatory framework and its implementation in airlines. The investigation must look at whether Pakistan’s aviation industry implements and monitors all that is written on paper in terms of safety standards. It must also look to address broader organisational safety culture. For instance, does the industry accept the concept of Crew Resource Management and how effectively is the Safety Reporting System implemented? How effective is our Flight Data Monitoring in improving our performance and standards? Is aviation safety a core business value for the airlines?

Our system has often failed to put in place corrective measures after aviation accidents in the past. This time, with more blood on our hands, we have another opportunity to learn and evolve through our mistakes. If we need another accident to prove that we have a problem, then maybe we are part of the problem.

Muhammad Aziz uddin

The writer is a former PIA captain with over 40 years of airline flying experience, including training and work on accident prevention programs. He can be reached at azizuddin60

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