Aircraft Accidents and Lessons Unlearned XXXIV: Avianca Flight 52
On July 19, 1989, at 2134 (9:34 PM) eastern standard time, an Avianca Airlines Boeing 707-321B, flight 52, which originated in Bogota, Colombia, enroute to JFK Airport, crashed almost twenty miles northeast of the airport. The aircraft, mechanically sound, crashed due to fuel starvation. The airliner ran out of fuel.
The National Transportation Safety Board (NTSB) determined in accident report AAR-91/04, “… the Probable Cause of this accident was the failure of the flight crew to adequately manage the airplane’s load, and their failure to communicate an emergency fuel situation to air traffic control before fuel exhaustion occurred. Contributing to the accident was the flight crew’s failure to use an airline operational control dispatch system to assist then during the international flight into a high-density airport in poor weather.” The other contributing factor should have come as no surprise since the NTSB uses the same “cause” in all major accidents: “… contributing to the accident … was the Federal Aviation Administration (FAA)”.
The NTSB entered unchartered waters with Avianca 52. They approached this accident with little regard for what was important in the understanding of what happened or what the consequences were for getting the investigation wrong. This was the first tragic event that challenged, indeed called attention to, decades old Annexes created in the Chicago Convention of 1944.
At this time, I would like to thank my friend Oscar, who is my guru for all things International Civil Aviation Organization (ICAO). He used this accident in class as a case study to those understanding international aviation issues. There were three take-aways from the Avianca 52 that the FAA and ICAO put into place:
1 – The FAA International Aviation Safety Assessment (IASA) Program, which determined the quality of a foreign country’s oversight of air carriers operating inside another country, e.g. AVIANCA operating in the United States, and whether, e.g. Colombia’s oversight agency followed the safety standards of ICAO. This led to the development of ICAO’s Universal Safety Oversight Audit Program (USOAP), a means to audit aviation safety oversight, with scheduled and mandatory audits of ICAO States’ (Countries) safety oversight systems.
2 – Improving English language requirements for international flights as per ICAO Annex 1. English language has always been the universal language of aviation since the Chicago Convention in 1944; the cockpit voice recorder transcript demonstrated a breakdown in communication.
3 – The pushing of ICAO Article 83 bis. This was an amendment to the 1944 Chicago Convention and finally addressed issues that, in 1944, were unexpected with international travel. It allowed for specific oversight responsibilities be transferred between two States (Countries): the State (Country) of Registry and the State (Country) the aircraft is operating inside of. This allowed, not only provided for continuous oversight in foreign countries for airlines, but it would eventually include repair stations.
In the time between the accident and the NTSB report, Congressman Jim Oberstar (D-MN), Chairman of the House Transportation Committee (HTC), called then Associate Administrator in the FAA, Anthony Broderick, before the HTC to answer questions about what the FAA did to ensure foreign operators flying within the US were safe. Broderick’s response was that each State (Country), if they are ICAO members, has a Civil Aviation Authority (CAA), which had oversight to ensure the various foreign operators flying in the US were safe. The FAA had no authority over another country’s CAA; that the FAA was not authorized to audit a foreign CAA for compliance with ICAO standards. Avianca fell under the oversight of Colombia’s CAA.
HTC Chair Oberstar did not like that reply; he told Broderick to come back with a better answer.
What resulted was that Broderick took a team to other CAA offices around the world, armed with knowledge of the Air Transport Agreements’ Language, and one-by-one talked to each of them to determine the quality of oversight each provided to its operators in country and thus a better understanding of how they conducted oversight in other countries. The results were not promising; one CAA did not even employ Operations inspectors to oversee pilots, flight training, etc.
Broderick then put in work a program to ensure foreign operators had effective CAAs with qualified Airworthiness and Operations inspectors or they could not fly into the US. Under the International Aviation Safety Assessment (IASA) Program, the FAA could now ascertain another country’s quality of air carrier oversight; the FAA could now determine if the international CAAs were complying with ICAO’s 12,000 International Standards and Recommended Practices, especially those found under Annex One (Personnel Licensing), Annex Six (Operation of Aircraft) and Annex Eight (Airworthiness of Aircraft). Airlines that were assessed were those who had filed an application with the US Department of Transportation for a foreign air carrier permit, such as Avianca.
If the foreign CAA met ICAO standards, the air carrier was granted a Category One authority by the FAA. This allowed the air carrier from the assessed State (Country) to either initiate service within the US or continue to provide service into the US.
How did the NTSB miss this; why was this not in the report? Simply put, the NTSB did not do its homework. They did not try to understand the complexity of a foreign operator conducting service inside the US. The NTSB assumed the whole time that the FAA had authority, when it did not. The NTSB assumed that foreign CAAs’ oversight of air carriers was up to the standards of the FAA, which they were not. The Chicago Convention of 1944, the origin of ICAO, had taken place over forty-five years before, in the days of post-war, propeller-driven passenger airliners. The international aviation world’s perceptions of international travel were in desperate need of change.
It was unfortunate that this opportunity was squandered, this chance to generate positive change. It was a tragic opportunity that the aviation community did not wish to repeat in order to relearn what was missed with Avianca 52.
Yet, there was one more missed opportunity that was wasted, which was the pursuit of the Root Cause. All investigatory efforts were focused on the Avianca 52 flight crew’s poor command of the English language – their conversations sounded confused. The focus was on the desperation of flying with no fuel – a truth that was undeniable. The investigation, like a poor marksman, kept missing the target: Root Cause. What happened one hour and seventeen minutes before the crash, well before the fuel tanks went dry, well before things went south as the window of opportunity continued to narrow?
The answer will never be known because the question was never asked. Why did the crew not divert to Boston a half hour earlier? As the fuel fell to a decision-point level, what person – or persons – made the decision to stay in a holding pattern over Long Island? Didn’t one of the pilots argue to fly to the diversion airport? Was the culture inside the cockpit conducive to discussion or was the captain unshakeable? Was the airline responsible for driving the crew to land at JFK at all costs?
Culture continues to overpower common sense. Accidents such as Air Florida 90, Asiana 214, Lion Air 610 and Air France 447; each a tragic event where a sound aircraft was flown into the scene of the accident by indecision and poor communication skills. Cultural influences that caused Air Florida 90 only a few years prior to Avianca 52 were, and still are, an unknown, treated by the aviation community as a myth; an old wives’ tale akin to gremlins and the Bermuda Triangle.
It is past time the NTSB takes ‘culture’ seriously. Accidents, like Avianca 52, demonstrate that fifty-three years of the NTSB’s business-as-usual investigatory practices need to enter the twenty-first century; they need to embrace the reality of cultural divides within the industries they investigate. But industry is not hopeful; with apologies to Abba Eban, the NTSB “never misses an opportunity to miss an opportunity.”