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Report on Ethiopian Airlines Flight 409 Lebanon crash finds pilot error

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On Tuesday, January 17, 2012, the Minister of Public Works & Transportation for Lebanon, Mr. Ghazi El-Aridi, released the final report of the investigation into the crash of Ethiopian Airlines Flight ET-409, which plunged into the Mediterranean Sea nearly two years ago, shortly after taking off from Rafik Hariri International Airport (BEY) in Beirut on Monday, January 25, 2010 at 2:41 a.m. local time.

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The 191-page document identifies causes of the accident, which took the lives of 82 passengers and 8 crew members, mostly Ethiopian and Lebanese citizens, as well as foreign nationals from 7 other countries, and contains numerous pages of technical data of special interest to commercial pilots and aviation professionals, as reported on Tuesday, January 17, 2012 by Nazret.com, Ya Libnan, Ethiopia Forums, The Daily Star, ABC News, Tadius Magazine, and multiple other media sources.

It places responsibility on the flight crew of the Boeing 737-800, registration ET-ANB, Captain Habtamu Benti Negasa and First Officer Alula Tamerrat, saying that the pilot flying the aircraft (PF) had lost situational awareness and failed to follow air traffic control (ATC) instructions; that the monitoring pilot (PM) did not adequately intervene; and that the aircraft went into an uncontrolled spiral dive caused by inconsistent inputs on the aircraft flight controls, flying under great G-force into the sea.

These charges were individually rejected in detailed online documents by Ethiopian Airlines, and the Ethiopian Civil Aviation Authority (ECAA), and in Appendix Z of the findings.

An attached slide show with images from the official accident report and video clip also accompany this report.

The French independent agency BEA, Bureau d'Enquêtes et d'Analyses pour la sécurité de l'aviation civile, based at Le Bourget Airport (LBG) near Paris was appointed by both Lebanon and Ethiopia to conduct a scientific analysis and determination into the causes of the accident, assisted by the NTSB and The Boeing Company in the United States, along with representatives from Lebanon and Ethiopia.

According to the agency's official website, "The safety investigation, whose sole objective is to prevent future accidents and incidents, includes the gathering and analysis of information, the drawing of conclusions, including the determination of cause(s) and/or contributing factors and, when appropriate, the making of safety recommendations."

BEA continues to define its responsibility by saying that "The identification of causes does not imply the assignment of fault or the determination of administrative, civil or criminal liability."

We have been following this tragic accident for almost two years, and have already published at least 18 factual articles, including detailed photographs, slide shows and video clips from international news agencies.

This dispatch provides an overview of both the official report and the Ethiopian objections, with links to the original source documents, to allow those interested to review them in detail.

The final report was privately circulated to all parties on September 10, 2011, to allow for input, disagreement, and corrections.

It found two basic causes for the accident, shown below in bold type:

1 - The flight crew's mismanagement of the aircraft's speed, altitude, headings and attitude through inconsistent flight control inputs resulting in a loss of control.

2 - The flight crew's failure to abide by Cockpit Resource Management (CRM) principles of mutual support and calling deviations hindered any timely intervention and correction.

It also identified nine contributing factors, also shown below in bold type:

1 - The manipulation of the flight controls by the flight crew in an ineffective manner resulted in the aircraft undesired behavior and increased the level of stress of the pilots.

2 - The aircraft being out of trim for most of the flight directly increased the workload on the pilot and made his control of the aircraft more demanding.

3 - The prevailing weather conditions at night most probably resulted in spatial disorientation to the flight crew and lead to loss of situational awareness.

4 - The relative inexperience of the flight crew on (aircraft) type combined with their unfamiliarity with the airport contributed, most likely, to increase the flight crew workload and stress.

5 - The consecutive flying (188 hours in 51 days) on a new type (of aircraft) with the absolute minimum rest could have likely resulted in a chronic fatigue affecting the captain's performance.

6 - The heavy meal discussed by the crew prior to take-off has affected their quality of sleep prior to that flight.

7 - The aircraft 11 bank angle aural warnings, 2 stalls and final spiral dive contributed in the increase of the crew workload and stress level.

8 - Symptoms similar to those of a subtle incapacitation have been identified and could have resulted from and/or explain most of the causes mentioned above. However, there is no factual evidence to confirm without any doubt such a cause.

9 - The First Officer (F/O) reluctance to intervene did not help in confirming a case of the captain's subtle incapacitation and/or to take over control of the aircraft as stipulated in the operator's Standard Operating Procedure (SOP).

The report also included an extensive series of safety recommendations directed at the Operator, Ethiopian Airlines, the Ethiopian Civil Aviation Authority (ECAA), and the Government of Lebanon, aimed at preventing other accidents from similar causes.

Ethiopian Airlines was told to revise its CRM program (Cockpit Resource Management) and stress First Officer assertiveness and leadership especially in periods of abnormal performance.

It was told to adjust crew pairing and scheduling policies in order to ensure a less stressful cockpit environment, along with other recommendations to assess and detect improved crew performance.

The Ethiopian Civil Aviation Authority was tasked to ensure that the recommendations to the airline have been implemented, and told to re-examine the regulations concerning crew pairing policies.

The International Civil Aviation Organization (IACO) was advised to re-examines international requirements for the identification, training and reporting of subtle incapacitation symptoms and cases.

The accident investigation recommended that the Lebanese Government establishes requirements to ensure that responses to such accidents are made systematically without reliance on foreign assistance.

The Lebanese Director General of Civil Aviation (DGCA) should also re-evaluate the working conditions of the ATC personnel, along with establishing administrative and logistic support for any future investigations.

Ethiopian Airlines (ET) reported a series of exceptions and disagreements with the findings of the report. These can be found in Appendix Z.

In that document, the carrier takes the position that the findings are biased, and heavily influenced by the original position of the Lebanese government which immediately blamed the ET pilots, even before any facts were investigated or evidence recovered.

Such alleged prejudicial reasoning is also called "confirmation bias", meaning that the person or agency holding such a view tends to exclude any evidence which conflicts with its pre-established position, and only focuses on facts and evidence that help to confirm its original position.

The operator has also repeatedly complained that it was excluded from fully participating in the investigation by not being permitted to examine retrieved aircraft parts; to view all of the victim's bodies, of which only a small number were subjected to an autopsy; and pointed out that 92 percent of the aircraft wreckage remained underwater and unrecovered, possibly concealing evidence of a midair fire or explosion.

The airline also objected that investigators ignored critical evidence and eye-witness accounts of an orange ball or fire, which happened before the plane impacted the water.

They point out that the Captain was an experienced pilot with 20 year service and total flying time of 10,233 hours, even though he only had 188 hours as pilot in command (PIC) of a Boeing 737-800, and the First Officer had 350 hours flying this type of aircraft.

Mr. Tewolde Gebremariam, Chief Executive Officer of Ethiopian Airlines, called the report "lacking evidence, incomplete and not presenting the full account of the accident."

He also noted that the report contained "numerous factual inaccuracies, internal contradictions and hypothetical statements that are not supported by evidence," adding that the investigative authority "denied the recovery of the wreckage and ignored crucial information such as security footage, autopsy and toxicology records, baggage screening X-ray records, terminal CCTV records, full Cockpit Voice Recorder (CVR) recovery and read out, allowing victims' bodies to be buried without medical examination and also declining to provide a detailed profile of passengers."

The very fact that Ethiopian Airlines has disputed so many findings, and raised multiple objections, along with the numerous leaks, charges, and counter charges in this incident seems to diminish the credibility of the findings, and more importantly, obscures the truth and raises further controversy.

While we are not in a position to question or criticise the BEA, or the manner in which they exerted their authority in this inquiry, in looking at past investigations in which the NTSB served as the lead agency, it appears in those cases that all potential evidence was investigated, examined, and reviewed in detail without complaints about missing critical facts.

In high profile cases, the independent NTSB has also held frequent conferences with the media, in which members of the public and other concerned parties have been invited to attend. Such events are always open, transparent, video documented, and conducted with full disclosure.

The happenings in Lebanon, by contrast, appear to be heavily influenced by political concerns and national interests, which may have been unavoidable in order for the process to proceed.

We can only hope that such findings are truthful, fair, and accurate, helping to being closure for all of the parties.

Tell us your thoughts. Please leave comments below or by email and subscribe to get future updates. There is also expanded coverage of other recent news articles. You may also wish to follow our dispatches as the News Analysis Examiner.

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