GUJARAT NATIONAL LAW UNIVERSITY

Recent Air Disaster

Rashi Srivastava
15B114
 Index

S. No. Particulars Page Number

2. Failure to follow mandates by the aircraft 3

3. Failure to follow mandates by the aircraft 5

4. Conclusion 10

1
Introduction

International Civil Aviation is a nothing short of a miracle happening all across the world. In
the words of Freeman Dyson, “Aviation is the branch of engineering that is least forgiving of
mistakes”. From the time an aircraft takes off to the time it lands, everyone has to take care of
themselves, everyone is solo. Although technology and lessons from the past have together
made air travel far safer and more reliable over the past few decades, there are still many
emerging problems out there which involve climatic changes, software failures, etc. Dramatic
steps taken by the United States and Europe for conducting surveillance over implementation
of ICAO minimum standards have focused on sustainable growth of the whole international
aviation community altogether whereby the numbers of accidents have decreased
considerably over the years. Before every takeoff everyone in aviation industry should keep
in mind that they owe it to the passengers to keep learning how to do it better. This paper
focuses on some recent air disasters around the world and the issues which caused them. The
project is divided into two broad categories of issues in air disaster, the first one deals with
technical faults in the aircraft itself while the second one deals with the situations wherein the
crash was caused by a failure to follow mandate by the aircraft personnel or the ATC or the
Aircraft Carriers.

2
Crash due to Technical Faults in the aircraft

A defect in an aircraft just like any other product attracts a liability on the part of the
manufacturer rather in case of an aircraft the responsibility placed on the manufacturer is
much more than that placed on any other manufacturer because of the number of lives
dependent on it. An airplane or helicopter can be made without a single aircraft design defect,
but one of its component parts might still have a manufacturing defect. For instance, a critical
part might not be machined exactly to design specifications and be installed on the aircraft. If
the part is not a perfect fit, as required by the plans and specifications, and it fails and causes
a crash, the manufacturer is responsible even if it did everything it was required to do to try to
make the part correctly. This concept of “strict liability” is applicable. 1 Recently a new trend
in aircraft manufacturing has surfaced which is known as Zero Defect Movement, it
represents a move away from the World War II approach of tolerating certain defects in order
to increase production and get planes into service more quickly. The main factor influencing
this trend is strict safety requirements that the manufacturers are strict safety requirements
which the manufacturers and the air carriers are required to meet.2 Two very prominent air
crashes involving such a defect includes American airlines flight 587 crash wherein Flight
587 took off from JFK International Airport on November 12, 2001. Shortly after takeoff, the
plane crashed into a neighbourhood in Belle Harbour, New York, killing all aboard plus five
people on the ground. The NTSB determined the probable cause of the crash was pilot
error and an aircraft design defect. Due to excessive operation of the rudder flaps by the first
officer, the vertical stabilizer separated and broke away from the plane. Our firm represented
the families of nearly a dozen passengers killed in this crash. 3 The other such crash is China
Eastern Airline Flight 583 crash in a flight from Shanghai to Los Angeles wherein the crash
was a result of a defectively designed handle. The latest plane crashes involving such a defect
include Ethiopian Airlines Boeing 737 Max crash on 10 March 2019, six minutes after
take-off and Boeing 737 Max, operated by Lion Air, crashed into the Java Sea on 29
October 2018. Both the aircrafts involved the same model of aircraft and some

1
‘Aircraft Design and Manufacturing Defect’ (Baum Hedlund Aristei Goldman)
https://www.baumhedlundlaw.com/aviation-accident/aircraft-design-and-manufacturing-defect/ accessed on
16 April 2019
2
Kriendler & Kriendler LLP, ‘Will Zero Defect trend in aircraft manufacturing make defects obsolete?’
(Kreindler, 9 February 2017) https://www.nationwideaviationaccidentlawfirm.com/2017/02/will-zero-defect-
trend-in-aircraft-manufacturing-make-defects-obsolete.shtml accessed on 16 April 2019
3
‘Aircraft Design and Manufacturing Defect’ (Baum Hedlund Aristei Goldman, )
https://www.baumhedlundlaw.com/aviation-accident/aircraft-design-and-manufacturing-defect/ accessed on
14 April 2019

3
circumstances of the crash were also similar and killed 246 people. After the second crash,
airliners all across the world grounded the best selling model of airplanes in history. More
than 300 Boeing 737 Max planes are in operation and more than 5,000 have been ordered
worldwide since 2017.The investigation although is still going on, focuses mainly on Max 8’s
stall-prevention system, apparent maintenance lapse, and potential pilot error. Boeing has in
return updated Max 8’s flight control systems especially Maneuvering Characteristics
Augmentation System (MCAS) which automatically tries to stabilizes the aircraft by pushing
the nose of the plane down, pilot displays, operation manuals, and crew training.4

Provisional flight data from the tracking website FlightRadar24 suggested ET302 climbed
erratically in the short time it was in the air. The pilot of the plane, as in the Lion Air case,
reported difficulties to air traffic controllers quickly after takeoff and requested permission to
turn back, Ethiopian Airlines said.5

US regulators and safety experts are now asking how thoroughly the FAA and Boeing vetted
the anti-stall system and how well pilots around the world were trained for it when their
airlines bought new planes. The report alleges that the analysis produced by Boeing understated the
power of the control system and that it could reset itself every time the pilot responded. This meant
that the system could repeatedly push the nose of the plane down.6 It was found that many
pilots did not know that the system of MCAS even existed and in Lion Air crash the pilots
repeatedly used procedures outlined by Boeing to disengage the MCAS system but the plane
still went into an unrecoverable nose-dive. Further, Boeing will mandatorily install a warning
light that alerts the pilot when the angle of attack sensors disagree.

4
Verge Staff, ‘Boeing 737 Max airplane crashes: all of the news, updates, and analyses’ (The Verge )
https://www.theverge.com/2019/3/21/18274868/boeing-737-max-airplane-crash-updates-highlights accessed
on 16 April 2019
5
Gwyn Topham, ‘Ethiopian Airlines crash: Boeing faces safety questions over 737 Max 8 jets’ (The Guardian, 11
March 2019) https://www.theguardian.com/world/2019/mar/11/ethiopia-airline-crash-china-grounds-
boeing-737-max-8-jets-in-wake-of-disaster accessed on 16 April 2019
6
BBC desk, ‘Boeing expects 737 Max software fix by end of March’ (19 March 2019)
https://www.bbc.com/news/business-47622721 accessed on 17 April 2019

4
Failure to follow mandates by the aircraft personnel, ATC and aircraft
carriers

Air travel requires a lot of cooperation and effective communication between the ground
facilities including the ATC and the aircraft personnel. This helps them to maintain safe
distance with other aircrafts in air, informs the pilots about the accurate flight paths, weather
conditions on the path and other critical and valuable information.

Apart from this the air carrier is liable to undertake timely servicing of the aircraft and to
make sure that the aircraft is airworthy at all times. It has been noticed that although the
technology has gained great heights when it comes to air navigation but it has not been
implemented at the same pace and a lag is created between the research and development and
the implementation of the same. Today, automobile drivers with smart phones and mapping,
traffic, and weather apps have access to more accurate real-time information than aircraft
pilots receive from our ATC system. Flight times today on high-volume, intermediate-range
routes are scarcely better, and in some cases they are worse, than they were in the 1960s,
when commercial flights used either propeller planes or early jetliners. Our ability to provide
a vastly improved system is not in question. Over the past two decades, aviation experts have
developed a new air traffic paradigm—often called air traffic management, or ATM, to
emphasize its use of much richer information than a single locus of “control.” Under this
framework, technologies such as digital communications and GPS could facilitate automating
much of the routine separation of aircraft, permitting far greater use of the entire airspace
than the limited “airways” defined by ground-based navigation aids. New technologies and
procedures would also increase the effective capacity of airport runways, improve landing
protocols, transform staffed ATC facilities on the ground, and provide pilots with more
accurate and timely information on weather and other variables.7 Human factors affect
everything that one does, the international Ergonomics Association defines human factors as,
“the scientific discipline concerned with the understanding of interactions among humans and
other elements of a system, and the profession that applies theory, principles, data and
methods to design to optimize human well-being and overall system performance.”8 Even a

7
Robert W. Poole, Jr., ‘Organisation and Innovation in Air Traffic Control’ (Hudson Institute Initiative on Future
Innovation, 2013)
<https://www.hudson.org/content/researchattachments/attachment/1199/poole_hi_res.pdf> accessed on 15
April 2019
8
Stephen Hunt, ‘The Flight 703 Tragedy’ (Navigatus Consulting, 11 March 2018)
http://www.navigatusconsulting.com/human-factors-saratov-airlines-flight-703/ accessed on 14 April 2019

5
small decision, miscommunication or discrepancy can lead to the most vicious of the crashes
in the history of air navigation. Some of the recent air crashes due to such failure to follow
mandate as prescribed include:

1. Cubana de Aviacion Boeing 737 airliner crash near Cuba's main airport in
Havana on 18th May 2018- The flight took off from Havana airport and was headed
for Holguin and crashed in a yuca field near the airport itself. The crash caused 112
deaths. Back then Cubana de Aviacion, Cuba’s national airline had been plagued with
safety issues and one third of its fleet was grounded a day before the crash due to
serious technical and safety issues including cracks and mechanical issues.9 The plane
was almost 40 years old and was leased from a Mexican charter company named
Damojh Airlines which was not even a member of International air transport
Association (IATA). According to the reports, the airline company was already under
the scanner for safety issues due to lack of maintenance of the planes and the
company had received safety complaints in the past as well. The head of Guyana's
civil aviation body, Cpt Egbert Field, told that the same plane had been barred from
using Guyanese airspace in 2017 after authorities found its crew were overloading
luggage on flights in Cuba. Guyanese authorities had discovered suitcases stored in
the plane's toilets.10 Between 2008 and 2009 Engineer Ernesto Rodríguez Martín, an
inspector of Operational Safety for Cubana de Aviación, conducted nine audits of
flights leased to said airline, which revealed a fire in the cockpit, worn rubber, a tire
that exploded on landing, missing life jackets, hydraulic leaks in the brakes, inactive
meteorological radar, and the poor preparation of crews, among other problems.
The expert recommended "not contracting under any circumstances" the services of
Damojh-Global Air.11 But the warning was blatantly ignored by the authorities and
the scarcity of funds compounded with Marxist-Leninist ideology led to this deadly
aircrash. In July 2018, Global Air came out with a statement blaming the pilots for the
crash, Damojh, which leased the Boeing 737 to Cubana, Cuba’s national airline, said
in a statement on its website on Monday that black boxes retrieved from the wreckage

9
Hannah Parry, ‘More than 100 dead after Cuban Boeing 737 carrying 113 passengers and crew explodes in a
ball of flames and crashes moments after taking off from Havana airport’ (DailyMail Online, 18 May 2018 )
https://www.dailymail.co.uk/news/article-5745945/Plane-crashes-near-high-school-campus-moments-taking-
Havana-airport.html accessed on 14 April 2019
10
BBC News, ‘Cuba plane crash: Damojh company 'had safety complaints'’ (BBC News, 20 May 2018)
<https://www.bbc.com/news/world-latin-america-44188469> accessed on 14 April 2019
11
Roberto Alverez Quinones, ‘The Causes of the Plane Crash Are Political’ (Diario De Cuba, 31 May 2018)
<http://www.diariodecuba.com/cuba/1527768110_39711.html> accessed on 15 April 2019

6
 showed the crew had piloted it at a “very steep angle.” This, it said, led to a lack of lift
that made the plane plunge after take-off.12 But the statement was condemned by the
Cuban led commission investigating the crash because the company had no access to
the black boxes and further, the investigation back then was at a premature stage and
the causes of the crash are still not in public domain.
2. Saratov Airlines Flight 703 crashed on 11 February 2018 - the flight took off from
Moscow’s Domodedovo airport and was heading to Orsk near Russia’s border with
Kazakhastan and crashed near the town of Argunovo. The plane was carrying 65
passengers and 6 crew members and there were no survivors. The seven-year-old
passenger jet had gone into a steep descent five minutes after take-off, after which it
had vanished from radars.13 The Interstate Aviation Committee stated that, prior to
departure, the heating of the three pitot tubes had not been turned on. The plane
losing altitude just six minutes after takeoff. It reached 6,400 feet before dropping to
5,800 feet, rising again briefly and falling sharply — all within one minute.14 The
faulty instruments were blamed in the pre-investigation stage. A preliminary analysis of
the on-board flight recorder indicated the plane had problems two-and-a-half minutes after it
took off, at an altitude of around 1,300m (4,265ft). The flight commander had declined de-
icing of the aircraft before takeoff. The instruments began displaying different speed
readings, probably because of iced speed sensors while their heating systems were
shut off, the committee said.15

12
Sarah Marsh, Daina Beth Solomon, ‘Commission probing Cuba plane crash rejects speculation about cause’
(Thomson Reuters, 17 July 2018) < https://www.reuters.com/article/us-cuba-crash/commission-probing-cuba-
plane-crash-rejects-speculation-about-cause-idUSKBN1K72DE> accessed on 15 April 2019
13
Mark Bennets, ‘Russian passenger plane crashes outside Moscow, killing 71’ (The Guardian, 11 February
2018) https://www.theguardian.com/world/2018/feb/11/russian-passenger-plane-saratov-airlines-flight-
6w703-crashes-outside-moscow-reports accessed on 15 April 2019
14
Neil MacFarquhar & Ivan Nechepurenko, ‘Russian Plane Crash Kills All 71 Aboard’ (New York Times, 12
February 2018) https://www.nytimes.com/2018/02/11/world/europe/russia-plane-crash-saratov-airlines.html
accessed on 16 April 2019
15
BBC News, ‘Russia Saratov crash: Ice on sensors 'may be cause'’ (BBC News, 13 February 2018)
https://www.bbc.com/news/world-europe-43048921 accessed on 16 April 2019

7
 In 2015 the regional airline was banned from operating international flights, after inspectors
found someone other than the flight crew in a cockpit. The airline appealed and changed
its policy before resuming international charter flights in 2016. In 2011, one broke up
mid-flight during a training flight in the Belgorod region in southern Russia, killing
all six crew members on board.16
Investigation revealed that the deadly crash was a consequence of Human error
because the pilots did not switch on the heat detection censors on the plane due to
which the critical air censors were covered with ice and the plane finally became
uncontrollable and leapt into its death dive.
In May 2018, the regional Russian Airline was forced to cease operations due to
safety concerns after the crash, Russia’s Transport Ministry annulled the license of the
airline and the airline was later shut down.17
3. Nepal air crash US-Bangla Airlines Flight 211 crashed on 12 march 2018 - US-Bangla
Airlines Flight 211, was landing at Tribhuvan International Airport in Kathmandu on a flight
from Dhaka, the capital of Bangladesh, when it crashed. It was carrying 67 passengers and
four crew members and 51 people died. The flight had overshot the runway by about 150 feet,
nose-diving into the deserted field just beyond the airport fence. A few minutes later, while
the first batch of rescuers was pulling panicked passengers out of the front of the plane, an
intense fire burst out at the back.18 During landing the Air Traffic Control tower of the
Tribhuvan International Airport initially gave clearance to the flight crew to land on the
runway 02 but the flight crew proceeded to land on the runway 20 which is the opposite

16
ibid
17
‘Russian Airline Shuts Down After Deadly Crash near Moscow’ (The Moscow Times, 31 May 2018)
<https://www.themoscowtimes.com/2018/05/31/russian-airline-shuts-down-after-deadly-crash-near-
moscow-a61633> accessed on 19 April 2019
18
Jeffrey Gettleman, ‘‘Save Me, Save Me’: Scores Dead in Plane Crash in Nepal’ (The New York Times, 12
March 2018) https://www.nytimes.com/2018/03/12/world/asia/kathmandu-plane-crash.html> Accessed on
19 April 2019

8
 direction of the runway. Before landing, upon asking the intention of the crew by the Air
Traffic Control, the crew replied that they wanted to land on the runway 02.19
The crash has been blamed on the erratic behavior of the pilot, Capt. Abid Sultan
throughout the course of the flight. Sultan was an experienced pilot with more than
5000 hours of flight experience. Due to the vast terrain and its location in a bowl
shaped valley with the Himalayas to the north of the Kathmandu Airport, pilots are
given special simulator training and Sultan had himself landed more than 100 times in
Kathmandu. According to the The Accident Investigation Commission of Nepal the
probable cause of the accident was disorientation and a complete loss of situational
awareness on the part of crew member. During the flight the captain was irritable,
tensed, moody, and aggressive at various times. He was smoking during the flight,
contrary to company regulations. He also used foul language and abusive words in
conversation with the junior female first officer. He was engaged in unnecessary
conversation during the approach, at a time when sterile cockpit rules were in force.
The captain had a history of Depression and he seemed very unsecure about his future
as he had submitted resignation from this company, though only verbally. He said he
did not have any job and did not know what he was going to do for living.20
Both Nepal and Bangladesh conducted investigation. An official probe panel,
constituted after the Nepal’s worst aviation disaster in 26 years, has put much of the
blame on the “emotional” situation of captain of the ill-fated US-Bangla flight 211
while the sole Bangladeshi investigator on the panel, Capt. Ramatullah accused air
traffic control (ATC) of Kathmandu airport of failing to “perform their duties
properly”.21 Echoing Captain Rahmatullah’s observation, Investigating agency’s
Chairman Air vice Marshal M Naim Hassan said: “The case of pilots losing directions
is not unnatural … It happens. And Nepal airport is risky due to the hills around it.
The pilot missed the approach, but it was the ATC’s responsibility to help him, which
the Nepal ATC failed to provide,” he said22

19
Wreckrox, ‘US-Bangla Airlines Flight BS-211 fatal crash’ (Medium Corp, 12 March 2018) <
https://medium.com/@wreckrox/us-bangla-airlines-flight-bs-211-fatal-crash-12-03-2018-e5442e6bace0>
accessed on 19 April 2019
20
Aviation Safety network database (Flight Safety Foundation, 27 January 2019) <https://aviation-
safety.net/database/record.php?id=20180312-0> accessed on 20 April 2019
21
Tribune desk, ‘US-Bangla flight 211 probe report: Nepal, Bangladesh investigators differ on crash cause
’ (Dhaka Tribune, 28 January 2019) <https://www.dhakatribune.com/world/south-asia/2019/01/28/us-bangla-
flight-211-probe-report-nepal-bangladesh-investigators-differ-on-crash-cause> accessed on 18 April 2019
22
ibid

9
Conclusion

The purpose of these Air crash investigations is not to impute liability; rather it is to
find out the cause of the crash and making sure that nothing like this ever happens
again. ICAO specifies multiple standards and recommended practice under the
Chicago convention in order to avoid such circumstances, organisations like FAA
have also started to undertake audits in other countries in order to enforce the
minimum safety standards recommended by ICAO. Montreal convention, 1999 on the
other hand focuses on imputing liability and awarding damages to the victims of any
mis-happening on board of the aircrafts. But there have been cases where the causes
of the crash could not be figured out at all; the most famous one of them being MH
370 Malaysian Airline. It has been 5 years since the Malaysian aircraft on its way
from Kuala Lumpur to Beijing disappeared on 8 March 2014 with 239 people on
board and till date no one knows for sure what happened on board of the flight. In
2018 a 495 page report was published which says that the controls of the aircraft were
likely deliberately manipulated to take it off course but it could not determine who is
responsible. Such crashes pose a bigger threat to the aviation industry of the unknown
causes which might not be avoided in the future as well.

10