ChrisElyea.com Much analysis brings triumph, little analysis brings disaster

Nothing Good Ever Happened In A Box Canyon

The investigation into a 2004 accident raises many questions, and disturbingly, it doesn’t provide any answers.  Would your company work safely if there were no enforcement?  How safely would you work if you knew no one was watching?  Does your safety depend on people who no one is watching?

A U.S. airline was contracted by the U.S. government to provide cargo and passenger service in Afghanistan.  Legally, they were under U.S. regulations.  Practically, they were unregulated, as there were no inspectors in Afghanistan.

One morning a flight crew decided to fly into the mountains, instead of around them, just for fun.  They ended up flying into a box canyon.  ‘“At 0803:21, the first officer stated, “yeah you’re an x-wing fighter star wars man,” and the captain replied, “you’re [expletive] right. this is fun.”’^* Less than 20 minutes later, as the crew attempted a 180º turn, the plane hit the canyon wall.

Five of the six aboard were killed in the crash.  The remaining passenger survived for at least eight hours, but nobody realized the plane was missing until seven hours after the crash, and then five hours were spent searching in the wrong place.

The airline did not require its pilots to file flight plans, even though this was a legal requirement.  The pilots could have filed a flight plan anyway, but they chose not to.  Why didn’t the airline require flight plans?  Why didn’t the pilots create a flight plan?  Because it gave them the freedom to be unsafe and fly into the mountains instead of flying around them?  If they had filed a flight plan into the mountains, which was not the usual route, would anyone have questioned it?  If they had filed a flight plan, knowing that no one could monitor them, would they have followed it?

The pilots didn’t use oxygen, even though they were flying well above the altitude where oxygen deprivation (hypoxia) begins to affect the ability to think.  They were already making poor decisions, including this one, so hypoxia would only have made things worse.  The investigators interviewed other pilots working for the airline in Afghanistan.  They didn’t know the correct (and legally mandated) criteria for determining when to use oxygen.  These pilots were aware of the threat, yet they didn’t attempt to learn how to protect themselves.  Why not?  If they had known the correct thing to do, would they have chosen to do it?  Why didn’t the company provide better training?  The investigation determined that the plane was capable of climbing over the ridge, had the pilots started the climb at the time they realized they were in a box canyon.  Did hypoxia impair their judgment?

Due to the lack of infrastructure in remote areas of Afghanistan, communications were difficult.  The airline provided the pilots with satellite telephones so they could check in.  However, the airline took no action when it became apparent that these didn’t always work effectively.  This was a violation of regulations because the airline could not know if a flight had arrived safely or not.  The pilots did not seem very concerned about this, either.  Why didn’t the airline develop another solution?  Why didn’t the pilots object to this unsafe condition?

Would this accident have happened if there were inspectors to monitor the airline?  Would the pilots have behaved this way even if the airline had been more concerned about safety?

We can never really know the right answers to questions like these.  We still need to try to answer them to prevent future accidents.

*NTSB/AAB-06/07, Aircraft Accident Brief, Controlled Flight Into Terrain, CASA C-212-CC, N960BW, Bamiyan, Afghanistan, November 27, 2004