Avoidable fatalities – Ignored lessons

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By Francis Mungai

In the face of risk, managers must stay teachable; a review of ignored lessons that tragically resulted in 349 avoidable deaths. On November 12, 1996 Saudi Air 763 collided with Kazak Air 1907 over Charkhi Dadri, New Delhi. 349 people were obliterated from the Indian skies making it the most fatal mid-air Collison accident of all times. VK Dutta was the ground controller managing the radar equipment on the fateful day. Dutta, then a young agile soul, a bit wet behind the ears, clearly competent but seemingly overwhelmed; while addressing the accident’s investigation team told them “evenings are always busy”

The investigative report determined the cause of the accident to be pilot error and placed the fault on the Kazak crew, but how did this happen? The Kazaks were flying a modified Russian military plane an Ilyushin Il-76 which in addition to the two main pilots had a third seat in the cockpit for a radio controller who was responsible for all communications with the ground controller. This added role bred a communication mishap and misinterpretation of instructions. The Kazaks ended descending too quickly on their approach to Delhi, putting them directly in the path of the off taking Saudi plane.

Whereas it’s easy to point a finger to the Kazak pilots, it’s also worthwhile to note that there was a wider systemic failure on other parties outside of the Kazak cockpit. Earlier in 1978, the US had suffered its worst air disaster yet, when a Boeing 727 operated by Pacific Southwest collided mid-air with a Cesna resulting in 144 fatalities. This accident resulted in improvements on radar systems altitude monitoring as well as introduction of traffic alert and collision avoidance technology on commercial airliners.

Part of the reason why ground controller Dutta felt overwhelmed on the fateful day was not just the evening traffic; he was also operating a piece of outdated radar equipment with inability to monitor flight altitude. Equally worrying is that both planes did not have collision avoidance technology; this was clearly an avoidable disaster. After the accident, Indian authorities decreed that all commercial airlines be fitted with updated technology as well as improvement on radar equipment, but the horse had bolted

What lessons can business leaders draw from this tragedy? Principally, It is that you cannot run a business long enough to learn all the mistakes; you are gambling with a blow up! Human beings evolved to be the race that they are today because of collaborative effort; connecting and learning from others is wisdom. Secondly, mishaps reflect rather nosily on where the business priorities are. For the management Chakri and the airlines involved, keeping a lid on costs at the expense of safety is a common theme, tragedies show us where the priorities ought to be at, to obsess with the important elements and cast out frills. Finally, heeding sound professional advice is a requisite to risk management.

mungai@algorithm-consult.com

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