Our correspondent Richard Pedicini recently attended a seminar on air safety in Brazil. Here is his report:
In Northeast Brazil, aviation workers flock to flight safety seminar
In the Brazilian Northeast, unlike the country as a whole, air taxis are the category of aviation that suffers the most accidents. The "make-do" is dangerous in airplane maintenance. And the improvement of aircraft leaves the human factor ever more prevalent in accidents.
Those are among the lessons of the seminar on flight safety that packed the Infraero auditorium at the Fortaleza airport last Friday night and Saturday morning.
"We are at an extremely delicate moment in Brazilian aviation", said Lieutenant-Colonel Aviator João Carlos Beiniek, at the opening of the event. "There has never been so much said about the safety of flight."
He sees the current moment of chaos in Brazilian civil aviation as part of a transition from one stable situation to another. He cited previous moments in the history of Brazilian aviation. In the 1950s, there were 300 cities with scheduled commercial service. "But there was no regulation. If you had courage and an airplane, you had an airline."
When president Jânio Quadros canceled the aviation fuel subsidy in 1961, only four airlines survived. In the 1970s came the era of regional air transport companies, but only one of the five, TAM, continues operating today.
Col. Beiniek sees a big future for Brazilian aviation, with the potential of reaching a passenger public four times larger than at present. "The United States has 222,000 airplanes, and there's no one between them and Brazil, with its 11,000 aircraft."
Organized by Seripa II - the Regional Service for Investigation and Prevention of Aeronautic Accidents, created this year - the seminary attracted more than 120 people from Fortaleza and cities across the Brazilian Northeast. The audience included pilots, mechanics, air traffic controllers, and students and others interested in aviation.
The Fortaleza seminar was the first undertaken by the Seripa, and had the declared purpose of spreading the SIPAER doctrine . Elements emphasized were that the investigation of an aeronautic accident has as its only and exclusive purpose the search for the contributing factors of each accident to prevent future recurrences, and also that accidents are the result not of a single cause, but of a series of factors.
The "make-do" was pointed out as one of the major causes of accidents in small airplanes, as in the case of the pilot who added a homemake radiator to the engine block. The axle froze and the plane crashed, killing the inventor.
"Airplane maintenance has nothing to do with automobile maintenance", said Seripa's Leitenant Brito. An airplane, he said, is made with a minimum safety coefficient, because it needs to be light in order to fly. "While an airplane is large, it's fragile."
In accidents caused by maintenance, as in those that happen because of errors made in the air, there is also a chain of factors that culminate in an accident. An airplane is moved during maintenance, there's a change of shifts, it's not written down that tasks were not completed, a final inspection is made from the ground rather than by climbing a ladder, and a airplane takes off lacking half the screws that hold on a vital part. And fourteen people die in the crash.
Aircraft crews were the principal contributing factor in 70% to 75% of aeronautic accidents in the decade from 1985 to 1995, and the human factor may represent 90% of accidents in this new century. However, according to ICAO statistics, three out of every four accidents involve errors by people who are qualified and healthy, said Dr. Maria da Conceição Pereira Sougey, Seripa psychologist.
Dr. Pereira Sougey spoke of the importance of identifying psychological factors in accidents, and the importance of this in flight safety. She explained that an injured bird will try to continue flying, because air is his element. "But being that man is not made to fly, when he runs into a problem, his instinct is to try to land. Then, he loses the capacity to control the machine, that needs to keep flying."
The distinction between an error and a violation was brought out by the psychologist, who noted that just in the state of Bahia, this year, three accidents have happened because landing gear wasn't lowered. A simple error.
Some failures she qualified as "active failures", committed on the work floor, by those who work directly with the system. Others, "passive failures", happen at the management level, when weak points are not identified and defenses against errors are either absent or are, with time, neglected.
Vultures on the Runway
The human factors that cause accident aren't always employed in aviation. One important cause of accidents is collisions with birds. A news clip was shown which discovered the cause of a problem with vultures, which endangered planes landing at the Recife airport. An illegal slaughterhouse operated in the neighborhood, and the owner proudly showed the news crew that he washed the slaughterhouse every week, throwing the scraps of animals right at the head of the runway, where vultures leaned to wait in expectation. His understanding of the danger he was creating was at the same level as his notions of hygiene.
The Flight of Geese
Birds were also used to illustrate by Commandante Ilha, who used the flight of geese as an example of leadership. "The flight in 'V' diminishes air resistance . A goose flying alone looses up to 71% of its performance. " People, like geese, gain by working as a team.
Ilha emphasized communication as the most basic factor in CRM, and the importance of non-verbal communication, such as a pilot signaling with two thumbs up, or twirling his fingers to signal a mechanic to make the motor turn. One danger to which he alerted is the "power distance", which leaves subordinates with fear of their bosses, and unwilling to communicate problems.
'All Paths Lead to Sao Paulo'
Cel. Beiniek, besides speaking of Brazilian aviation's potential for growth, spoke of the obstacles at this moment. "It is a long path, and investment is the key." He hopes that Brazil will soon reach a moment where more is spent on the "air" side, such as runways and navigation aids.
Many airports in Brazil have only one or two runways. "If there's only one runway, and it's closed for maintenance, the airport is closed." An airport the size of Fortaleza's would have, in the United States, from three to five runways.
Another problem is that, in the flight network, "All paths leads to São Paulo." Brazil needs to have more airports in the future, with more widely distributed flights.
He also says that in as little as one year there may be a shortage of pilots in Brazil. "Without flight clubs, there are no pilots".