Rushing to Judgment

There's no sense sugar coating the reality: Airline flying is essentially an unnatural act that requires blind trust and a complete surrender of control. That's why whenever something goes wrong, there's a collective shudder in the public consciousness and a very real need for rapid reassurance that whatever just happened will not happen to us when we fly!

Interestingly enough, long periods of perfectly safe operation in the airline industry just make this reaction worse, as we saw last week with the Toronto crash of an Air France Airbus A-340, or on Sunday with the crash of Helios Airways flight ZU522, an Boeing 737, north of Athens.

The basic facts of the Helios crash are still being worked out today. But we do know something about the Air France accident. By the time Flight 358 rocketed off the end of the runway and caught fire, nearly four years had elapsed since the last major airline accident in North America. The immediate aftermath of news reports and conflicting eyewitness accounts obscured not only the significance of 309 people surviving largely as a result of 30 years of cabin safety improvements, but it obscured the fact that tens of millions of passengers have flown unscathed since American 587 went down in New York City in 2001.

Of course we need to know what happened in Toronto, as well as in New York, and as rare as airline accidents are these days, we still need reassurance. The problem is, we're never going to get either reality or reassurance from oversimplification or premature conclusions.

Research and industry analysis long ago proved that there is never -- EVER -- a single cause to any major accident, whether aviation, rail, medical, nuclear or even corporate. Every accident, incident or near miss has a long chain of contributing causes that all came together -- we might say line up -- to reach from the beginning of a sequence to the end result.

And this reality is one of the most difficult things to convey in the first hours after an airline mishap, and Toronto is a classic example.

Initial Response and Search for Details

In the first few minutes after the Toronto accident last week, those of us in the media had only a few basic facts, including the information that an Airbus A-340 had exited the far end of the runway, broken into three pieces, been evacuated and caught fire.

It became quickly apparent that there had been a severe thunderstorm in progress over the field at the time, and further, that the Air France crew had already made one "missed approach" to the airport. We also discovered within minutes that the flight was inbound from Paris, and that there were reports of lightning striking near or around the aircraft as it made its approach to the runway.

Driving all these facts toward some sort of conclusion about cause was the usual combination of public pressure and curiosity combined with the natural media inertia toward getting the story out first. Even for aviation professionals, the almost vortex-like temptation was to say: Aha! The weather must be responsible. Maybe they were hit by lightning or they hydroplaned off the runway (the wheels were floating on a film of water rendering the brakes ineffective for too long) or shifting wind currents unique to thunderstorms somehow affected the flight path. In other words, if we just looked hard enough, the cause had to be apparent, and it had to center around weather.

But when you realize that there is always a chain of contributing problems, mistakes, misinformation, bad conditions and/or bad judgment combining to produce a bad result, the need to warn everyone off an immediate conclusion becomes compelling, and the best way is usually to talk about the fact that safety investigators will approach the job by assiduously avoiding any conclusions for months or even years until literally all the facts that can be known are laid out on the table.

In Toronto, for example, why did the flight crew elect to continue to land into a thunderstorm when the margins of safety were obviously going to be reduced?

To answer that, we have to know what information the crew had about the wild weather and when they received it. What kind of training did the crew have that led it to make those decisions? Was there pressure on the crew because of schedule, or some reason not to proceed to an alternate airport such as Montreal? How did radio communications from air traffic control or Air France operations personnel contribute to the decision, if at all? What was the condition of the airfield in terms of standing water, which might create hydroplaning, and was the crew made aware of it? What were the wind conditions and did they change without notice? Why did the pilots permit the big jet to touch down so far down the runway, rather than landing toward the first segment of the concrete ribbon? And what exchanges were there between the pilots that might have contributed to their actions and decisions, and did those exchanges contribute to the judgment to continue, or block a potential decision to go around a second time? What role did lightning play, if any, in physically striking the aircraft or startling the pilots, and despite reports from the survivors, did the cabin lights go out in the air, or only after the aircraft had left the far end of the runway (there's a well-known tendency of humans in severe situations to back-impute occurrences to an earlier time than they actually occurred).

These are all very important questions, and they highlight the fact that there could easily have been a dozen contributing elements to the crew's actions and the aircraft's response -- even before we approach the question of mechanical soundness.

Was the weather involved? Clearly it had to be, but how did it contribute to the chain of occurrences that led to the accident is the question, and we're never, ever going to be able to answer such things rapidly in the hours after an incident, let alone hold up one isolated, speculative element and pronounce it the cause.

So, if there is a next time -- and we all pray there won't be -- don't let any of the piecemeal reports and facts stampede your thinking. As always, there will be a complex chain, and we need to know and correct each link to improve safety.