A recent conviction in Italy brings a long-simmering issue to the forefront.
For a long time, policy in dealing with aviation accidents has been to not treat them as criminal investigations, in order to obtain full and complete cooperation in the investigation, on the premise that finding and fixing the root cause of an incident is more important to aviation safety than prosecution. There have been a few exceptions, in cases of deliberate action, and civil liability has been found a number of times. But generally, world governments agree to keep their criminal investigative forces out of the accident investigation, unless called in.
But that’s been changing in the last couple of years, and the recent conviction of 7 airline executives, pilots and maintenance workers in Italy has spurred some real concerns in the aviation industry:
Seven Tuninter crewmembers and managers, including two pilots, have been convicted by an Italian tribunal for a crash in which 23 passengers survived and 16 were killed in August 2005.
The crash involved an ATR-72 that took off from Bari, Italy, and was headed to Djerba, Tunisia, and was forced to ditch in the sea close to the Sicilian coast.
The incident was caused because the aircraft fuel gauges and indicators had been incorrectly replaced by the maintenance personnel with those of the ATR-42. The instruments indicated there was enough fuel on board when the aircraft took off, while there was not actually enough fuel to carry out the intended flight.
The two pilots have been charged with multiple counts of manslaughter and air disaster, and sentenced to a term of 10 years because, in theory, they had the opportunity to reach the Palermo Airport for an emergency landing if they had followed proper procedure. Another five technicians and managers have been found guilty, with the chief operating officer and the maintenance chief sentenced to nine years each, while three technicians have been sentenced to eight years each. Two others defendants were not found guilty. None of those indicted were present at the tribunal, and Tuninter lawyers have announced they will appeal the verdict.
(that’s the entire Aviation Week Online article; the print edition has much more)
Wikipedia describes the incident better. The conviction was based on the a simulator study that shows that had the pilots followed the correct fuel-out procedures (feathering the propellers, setting optimal glide path), the plane could have made it to Palermo. But that ignores a key issue - the fuel gauge was wrong. The pilots didn’t know they were out of fuel, so they tried restarting the engines (by the correct procedure). And when that didn’t work, they found a place to ditch very near a ship so that rescue was possible for at least some of the passengers.
If you look at Google News results for this incident, you will find a distressing focus on the fact that the pilots prayed during the incident. Apparently some witnesses claimed that the pilots prayed instead of acting. And this seems to have played into the conviction. But the cockpit voice and flight recorders don’t seem to back this up. Yes, there were interjections like “God help us!” on the voice recorder, but there doesn’t appear to be any indication that these interfered with their actions, which were correct for engine-out situations (but not out of fuel). The real question is whether they should have detected the out-of-fuel condition even though their gauges said they weren’t. I’m no expert.
But it wasn’t just the pilots who were convicted. It was also the maintenance crew, and airline executives, in a form of top-to-bottom criminal negligence procedure.
There’s no doubt that there’s negligence here. The maintenance crew screwed up inexcusably. There may have been systemic maintenance procedural issues that would implicate management. The pilots seems to me to be the least culpable. There’s certainly plenty of civil liability, and the airline has already made some payments to the victims.
But to criminalize this? This seems utterly counter-productive - especially when the pilots appear to have done the right thing with the information they had. Here’s a press release from the Internation Federation of Airline Pilots’ Association (PDF file):
The technical investigation into the circumstances leading to the crash revealed that it happened because an incorrect fuel gauge sensor was fitted to the aircraft which, in turn, lead to a double engine failure due to fuel exhaustion. The flight crew reacted to the loss of power in a textbook fashion and completed a successful ditching at sea. Under the internationally accepted approach to accident investigation such circumstances would not be grounds for a criminal prosecution.
IFALPA strongly believes that this prosecution was totally unwarranted given the facts of the accident and furthermore once again calls into question its commitment to the improvement of air safety. Italy has been criticized in the past for its stance on accident related prosecutions and this case provides another example of this policy.
Italy seems to think that criminalization is a better deterrent to future negligence than full and free disclosure. I disagree. What do you guys think?
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