Loss of control in flight has been one of the most significant causes of fatal aircraft accidents for many years. It usually occurs because the aircraft enters a flight regime which is outside its normal envelope, introducing an element of unpredictability for the flight crew involved.*

On 28 January the Irish Air Accident Investigation Unit (AAIU) published its final report on the fatal accident at Cork Airport on 11 February 2011 identifying “Loss of control during an attempted go-around below Decision Height (DH) in Instrument Meteorological Conditions” as a probable cause for the accident. In addition, nine other factors were identified as contributing to this horrible disaster. The ones that strike me the most are:

 “Tiredness and fatigue on the part of the crew members”

“Inadequate command training and checking during command upgrade of the Commander”

“Inappropriate paring of Flight Crew members”

“Inadequate oversight of the remote Operation by the operator and the State of the Operator”

It turns out that both pilots had inadequate rest before starting their duty and thus operated the flight in breach of existing regulations. Furthermore, due to inadequate training, the Commander was ill-prepared for the unusual situation they faced that day and the Co-pilot’s training and final check were not even completed. This clearly shows to me that something along the line of regulations and oversight has failed. Whether it was lack of resources or ambiguity about who is responsible for oversight, or was it inability to keep pace with the complex aviation industry landscape, we do not know that. We do know, however, that National Aviation Authorities and EASA are often struggling due to lack of resources and the accident report clearly identifies lack of oversight as one of the issues at stake. We do know that airline operations become increasingly complex and difficult to oversee.  In that particular case not only the crew but also the regulators and oversight authorities have lost control over the situation.

Too many people have lost their lives already in avoidable accidents. This is report is clearly a wake-up call! I urge every Aviation Regulator, Authority and politician to make sure adequate safety oversight of aviation becomes a top priority.

*Source: Skybrary 

by Nico Voorbach