Pilot error?

On the morning of 21 March, 2025, a Chinese-built K-8 jet trainer aircraft of the Sri Lanka Air Force (SLAF) crashed at Wariyapola. Fortunately, the two pilots ejected from the aircraft and parachuted down to safety.

A team of seven has been appointed to investigate the accident. Their task is to find the ‘cause behind the cause’, or the root cause. Ejecting from an aircraft usually has physical and psychological repercussions. The crew involved in the crash are the best witnesses, and they must be well rested and ready for the accident inquiry. It is vital that a non-punitive atmosphere must prevail. If the pilots believe that they are under threat of punishment, they will try to withhold vital information and not reveal the truth behind what happened, prompting their decision to abandon the stricken aircraft. In the interest of fairness, the crew must have a professional colleague to represent them at the Inquiry.

2000 years ago, the Roman philosopher Cicero said that “To err is human.” Alexander Pope said, “To err is human. To forgive, divine.” Yet in a Royal Air Force (RAF) hangar in the UK Force (RAF) hangs a sign declaring: “To err is human. To forgive is not RAF policy” These are the two extremes.

Over the years, behavioural scientists have observed that errors and intelligence are two sides of the same coin. In other words, an intelligent human being is liable to make errors. They went on to label these acts of omission and commission as ‘Slips, Lapses, Mistakes and Violations’.

To illustrate the point in a motoring context, if one was restricted to driving at a speed limit of 100 kph along an expressway and the speed crept up to 120 kph, then it is a ‘Slip’ on one’s part. If you forgot to fasten the seatbelt, it is a ‘Lapse’. While driving along a two-lane road, if a driver thinks in his/her judgement that the way is clear and tries to overtake slower traffic on the road, using the opposite lane, then encounters unanticipated opposite traffic and is forced to get back to the correct lane, that is a ‘Mistake’. Finally, if a double line is crossed while overtaking, while aware that the law is being broken, that is labelled as a ‘Violation’. In theory, all of the above could be applied to flying as well.

In the mid-Seventies, Elwyn Edwards and Frank Hawkins proposed that good interaction between Software (paperwork), Hardware (the aircraft and other machines), Liveware (human element) and the (working) environment are the essentials in safe flight operations. Labelled the ‘SHELL’ concept, it was adopted by the International Civil Aviation Organisation. (ICAO). (See Diagram 01)

In diagram 01, two ‘L’s depict the ‘Liveware’, inside and outside an aircraft flightdeck. The ‘L’ at the centre is the pilot in command (PIC), who should know his/her strengths and weaknesses, know the same of his/her crew, aircraft, and their mission, and, above all, be continuously evaluating the risks.

Finally, Prof. James Reason proposed the Swiss Cheese Theory of Accident Causation. (See Diagram 02)

From this diagram we see that built in defences in a system are like slices of Swiss cheese. There are pre-existing holes at random which, unfortunately, may align and allow the crew at the ‘sharp end’ to carry out a procedure unchecked.

Although it is easy and self-satisfying to blame a crew, or an individual, at an official accident investigation, what should be asked, instead, is why or how the system failed them? Furthermore, a ‘just culture’ must prevail.

The PIC and crew are the last line of defence in air safety and accident prevention. (See Diagram 3)

A daily newspaper reported that it is now left to be seen whether the crash on 21 March was due to mechanical failure or pilot error. Why is it that when a judge makes a wrong judgement it is termed ‘Miscarriage of Justice’ or when a Surgeon loses a patient on the operating table it is ‘Surgical Misadventure’, but when a pilot makes an honest error, it is called ‘Pilot Error’? I believe it should be termed ‘Human Condition’.

Even before the accident investigation had started, on 23 March, 2025, Minister of Civil Aviation, Bimal Ratnayake, went on record saying that the Ministry of Defence had told him the accident was due to an ‘athweradda’ (error). This kind of premature declaration is a definite ‘no-no’ and breach of protocol. The Minister should not be pre-empting the accident enquiry’s findings and commenting on a subject not under his purview. Everyone concerned should wait for the accident report from the SLAF expert panel before commenting.

God bless the PIC and crew!

– Ad Astrian