Features
What makes a ‘knowledge centre’?

By Usvatte-aratchi
A translation of an essay written by Professor Sirimal Abeyratne (Colombo) appeared in the Lankadeepa of 18 August, 2021. As I have difficulties obtaining typescripts in Sinhala, I will write in English. Abeyratne dwelt on two questions. First, who benefits from ‘free education’? Second, how do you engineer a knowledge centre?
Prior to answering the first question, he forays briefly into discussing ‘what is free education’. As we have developed the usage, free education is what is free to the student or her parents. But the community as a whole, that includes you and me, pays for ‘free education’. Education is provided by the state. The state, unless you are Hegelian, is the community organised for political purposes. In order to pay for my education, the state using its agent the government, collects taxes from my parents. Instead of paying fees to a private school to educate me, my parents pay taxes to the government which pays the public schools to educate me. No matter who organises the provision of education, my parents pay for my education. However, there is a difference of critical importance of who actually pays for my schooling. When it is necessary that students or their parents pay for a child’s education, whether a child goes to school depends on whether parents can afford to pay for the child’s education. When the community pays for children’s education, the child can go to school, no matter whether his parents have the wherewithal to pay for his education. The rest of the community takes on that burden. This is fairer, far more just and far more productive for social wellbeing. Education is free in school and in university in the same sense as it is in Sri Lanka in France, Germany and Finland and may be elsewhere. In the US, primary and secondary education is free in the same sense. We are in no sense unique.
US school education
In the US, school education (K-12) is organised by School Boards, elected by voters in the School Board area. School Boards pay for education with property taxes paid by owners in the area. The Board is accountable to those that elected them, by and large, the same persons who pay property taxes: an excellent example of the principle of subsidiarity at work. Parents are commonly closely associated with the school. One of them may volunteer to substitute for a teacher absent without expectation, another may help in the library and still another may accompany a class on a day-outing. That gives a clue to the differentiating in the quality of teaching in schools. The more educated and the better informed the parents are, the better their schools. Imagine a young couple who have come out of an elite university and together earn $100,000 to $200,000 a month. They can buy an expensive house in a School Board area (e.g. Montgomery County in Virginia), where public schools are of high quality. In New York City, Brooklyn High School, Bronx High School and Manhattan Science High School, all in the public sector, have excellent reputations. The high prices of houses will keep out those with low incomes. (The State of California introduced, a few years ago, a scheme to make equalisation grants to improve the quality of education in poorer counties.) The parents will take care to provide a home environment conducive to creative activity and the growth of the children’s minds. Besides, they can buy private tuition to supplement what is done in excellent schools. Parents will take the children to see the beauty of the country, to great museums, to enjoy a play and in summer perhaps to Italy, to China, to India or to Japan. The children will learn at least one foreign language (perhaps Greek or Latin, in addition), some music, to dance, play baseball and to debate. Their teachers, counsellors and parents will be aware of what elite college admission committees look for and send the children to volunteer work in a hospital or the local library. In these and many other ways children from educated and high earning families will ‘hoard the dreams’ of children of common families. Contrast that with the experience of poorly educated and low-income families whose children may never have been out of their hometowns, never seen a museum or even seen even the ocean, if in Iowa or Idaho. That pattern, on a lower scale, is quite common in our country. I had not been to Galle till I was 15 when I was hospitalised there for three nights. (I was shocked to hear from a ward doctor in a private hospital in Colombo, who normally worked in a government hospital, that he, although owning a car, had never been to Matara or to Nuwara- Eliya. He had gone to school in Veyangoda.) Given these wide disparities in income levels, educational levels and cultural practices among families, it is utopian to imagine that there are equal opportunities for all children to do well in school and in university. We can observe these differences played out in daily lives. How many physicians or surgeons have you met in this country, whose parents were tea pluckers in the hill country? Even as early as the 5th standard scholarship examination, you can see children whose parents earn regular incomes, commonly from government, end up in the top one or two percent of high scorers. Look at sharp differences of those who score high Z scores at A’Level in Mullaitivu and in Gampaha districts. There are odd instances when an extraordinarily intelligent student may break these barriers. But they are exceptional and prove the rule. In China, the same result is achieved with the hukou system and competition at gaokao, the entrance examination to universities. The $70 billion private tuition industry, now under attack there, is stark evidence of differences in the capacity between the rich and the poor to buy ‘good education’. In Colombo, you can see the same schemes at work through property prices. Borella, Maradana, Kurunduvatta, Bambalapitiya and Kollupitiya have nests of high-quality schools which feed into the more coveted faculties in selected universities. You can observe that even those who score high at Grade V scholarship examination are from families where parents have had more education in them than others. Given even the best intentions (e.g. China), there is no way that advantages enjoyed by children from families of well-educated parents, who almost invariably earn high and stable incomes, can be denied advantages in education.
Creating knowledge centers
Let us briefly, look at the idea of creating ‘knowledge centres’ that Abeyratne wrote abut. The presence of foreign students and teachers is not always a mark of a knowledge centre. There are a large number of foreign students in both China and India, although neither is yet known as a knowledge centre. A country may have a large number of foreigners as teachers, simply because it is short of competent teachers. In Peradeniya in the 1950s, the professor of Samskrt was German, four teachers in economics (Das Gupta, Sarkar, Oliver Henry and Eiteman) were from overseas, in history two and one each in Sociology, Geography and English.) Gradually local scholars replaced them. Abeyratne, in fact, was looking for students and teachers who are attracted by leading scholars in particular disciplines, who open up new lines of inquiry that may extend the width and depth of that discipline and well-functioning labs working on frontier problems in a particular discipline. In the University of Cambridge in 1989-90, out of 10,243 undergraduates, 568 or about 5% were overseas students and of 2,975 postgraduate students 1,022 or about a third from overseas. In the History Faculty in the same year, out of 60 postgraduate students admitted, 33 or more than a half were from overseas. The reputation of good scholars matters much.
Importance of libraries
The importance of libraries, especially for undergraduates has diminished somewhat with computer technology, but not entirely. For research students a great library is an essential asset. A reputation for good research is earned with publications in high quality journals and books that explore new areas or develop new insights into existing problems. That in turn implies that there are good publishing houses. University Presses are essential ingredients for ‘knowledge centres’. The Cambridge University Press comes from 1534 CE and Oxford UP from 1536. There is not a single good publishing house in our country. Good research comes out of universities with strong leaders in certain disciplines. This was most clearly evident in German universities from about 1850 to the disaster that was Hitler. This practice of powerful professors who assembled a number of researchers started in mid-nineteenth century Germany, soon spread to Britain and the US. In US, the outstanding example is Johns Hopkins in Baltimore. The expulsion of Jewish university teachers and researchers in the 1930s from Germany by Hitler and their dispersal in Britain and the US helped greatly to promote research in many disciplines in those countries: mathematics, physics, linguistics and sociology. Amsterdam, Utrecht and London had had great publishing houses from the 17th century, when dissenters of various kinds fled their home cities in search of welcoming havens: e.g. Benedictus Spinoza from Madrid, John Locke and James Mill from London.
Instance of our failure
An instance where we failed to make use of strong leaders in anthropology to establish a centre for the study of societies in South Asia was in Peradeniya in the 1950s. The leaders were Ralph Peiris, Stanley Tambiah, Gananath Obeysekera, Kitsiri Malalgoda and H. L. Seneviratne, all distinguished anthropologists. A younger scholar Sarath Amunugama joined the Civil Service. In addition, there were Michael Roberts in History and K. N. O. Dharmadasa in Sinhala, both of whom had made contributions to anthropology. They all, except KNO, dispersed themselves to more welcome homes in the US, New Zealand and Australia. Some distinguished scientists dispersed to Britain, the US, Canada and Hong Kong. There is a centripetal force at work here, without destroying which, it is unlikely that we will develop a knowledge centre in our country.
I would rather emphasise the development of good undergraduate schools from which may grow graduate schools, as was emanant in the late 1950s in the University of Ceylon but was aborted by ill-informed judgement on the development of higher education. The present ill-founded emphasis on ‘discipline’ in universities would welcome a worse disaster. The memory of Hitler destroying German universities 1930s has not been erased from our memories.
(This is the last of three notes I wrote on university matters in August, during the worst days of the epidemic in our country. It helped me to keep my mind off impending horrors. Then, our son came home spreading sunshine for a brief two weeks.)
Features
Preventing the Preventable; Preserving healthcare services

Recent address by
Dr. Sarath Gamini De Silva
to the Galle Medical Association
It is indeed my privilege and pleasure to be given this opportunity to address the members of the Galle Medical Association (GMA). I am grateful to the President and the Council of the GMA for inviting me as the guest of honour at the inauguration ceremony of your annual academic sessions.
Coming here today is like getting back to my roots again. I was born and bred in Galle and had my entire primary and secondary education at Richmond College. Between 1982 and 1995 I was associated with the GMA in my capacity, first as a senior lecturer in medicine for two years and then for nine years as a Consultant Physician at the Teaching Hospital, Karapitiya.
I was the President of the Galle Medical Association in 1994.My colleague Prof. Ariyananda and I were the first two senior lecturers in the Dept. of Medicine, with Prof. Hettiarachchi as the head. We knew almost every student in the first few batches by name, taking a personal interest in their welfare, to make sure that they did well as doctors.
The academic and non-academic staff took it up as a personal challenge to prove that the Ruhuna Medical Faculty, though rather hastily established, was second to none in the island. Looking back, we can be happy that all did very well, most of them becoming very competent specialists in various fields, later on, and are providing an exemplary service here and abroad.
We started in the dilapidated buildings at Mahamodera and then moved into modern facilities at Karapitiya, which at that time was still a building site. The long-established Galle Clinical Society later merged with the relatively new Galle Medical Association under the presidency of the late Prof. Tommy Wickremanayake, the Dean of the Medical Faculty, at that time. This wonderful auditorium, named after him, is a tribute to the late Professor’s energy and determination to see that we had the best facilities in the Southern Province. He took me round this building site on several occasions, and I once nearly had an accidental fall trying to mount this stage, only half built at that time. Today I feel quite confident standing here on a firm foundation, a podium graced by many medical luminaries over more than 40 glorious years, in the service of medical education.
The Galle Medical Association has done justice to the ideals and aspirations of its founders. As a life member, I receive regular information of your activities. The Association is meeting amply the academic and non-academic needs of its membership. Your lecture series on beyond medicine; religious and sports activities, musical programmes, leisure trips, etc., would provide much relaxation outside the exhausting routine of medical practice. Your annual academic programme is not second to that of many professional Colleges and Associations based in Colombo or elsewhere in the country. This wide array of activities is indicative of an Association keen on providing an all-round service to its members and their families, as well as to the medical students. My congratulations to all concerned.
Your theme this year, “Preventing the Preventable,” is very timely. With the economic crisis we are experiencing, the age old saying “Prevention is better than cure” is more relevant today than ever before. Certainly, true in the case of prevention of diseases, I am concentrating today on other aspects of healthcare the doctors have overlooked and to a great extent failed to prevent their decline.
Preventing the Preventable; Preserving the Healthcare Services is my concern today.
All the remarkable achievements in the fields of communicable and non-communicable diseases, with world acclaimed health indices, are now being nullified by the economic crisis in which the healthcare services appear to be caught unawares. The shortage of drugs and other equipment, costing more and more with every passing day, has made it near impossible to give proper treatment to needy patients. I will not be surprised to hear of deaths due to lack of treatment in the near future. We already hear allegations, though authorities keep refusing to accept their responsibility, of deaths due to poor quality of drugs hastily imported to overcome shortages in a poorly planned system.
This is compounded by poor household incomes, high transport costs and other difficulties the patients experience in seeking medical care.
While most of the blame for this unfortunate situation falls on poor planning and corruption by the rulers, the medical profession, too, has failed in preventing this calamity. They have contributed by their irrational prescription habits, doing unnecessary investigations and the like, leading to a high cost in the delivery of healthcare. Irrational prescriptions contribute in a big way to multidrug resistance to antibiotics, as well. Poorly regulated private practice by doctors needs an overhaul. Exorbitant fees charged by some specialists are the talking point in the society. I need not bore you with details which should be well known to all of you by now.
We as a profession should not allow ourselves to be exploited by the profit-oriented private healthcare services and the pharmaceutical industry. The patients are compelled to pay a heavy price for our shortcomings in this regard. Thus, by our inaction in dealing with such, we have failed to prevent the gradual deterioration of the respect the society has for the profession.
Has the medical profession knowingly or unknowingly colluded with the misdeeds of the politicians? As an example, I wish the institutions, like the drug regulatory authority, NMRA, did more to prevent corruption and irregularities in the procurement of drugs. They have remained mostly silent knowing very well how their decisions regarding the registration of drugs are overruled or circumvented by politicians and administrators with ulterior motives.
Functioning of the Sri Lanka Medical Council is being looked down upon by many in the profession itself. The amendments to the Act governing the SLMC has been proposed over many years to broad base its membership to include non-medical professionals and make it more effective in its primary duties of regularizing medical practice, maintaining discipline in the profession and maintaining good standards of medical education. Politicians have so far failed to enact them. With poor standards of medical education, due to shortages in staff and other facilities in hastily established new medical schools, SLMC has been largely silent on these aspects. At present it appears that the medical trade unions and indirectly the political influence are hampering its proper functioning. As a result the SLMC remains mainly a body for holding the ERPM for foreign medical graduates and registering the medical practitioners. Our professional associations should be more involved in its affairs and add their voice for reforms.
I have been a member of the SLMC for 10 years in the past. But your chief guest as its immediate past president, who was removed from the post in a most unprofessional way by the politicians, with perhaps the connivance of our own colleagues, will be in a better position to address these issues. That action initiated by our own professional colleagues has now established a precedent for the Health Minister to have a bigger say in the SLMC affairs, seriously undermining its autonomy.
In my address to the Colombo Medical Congress a year ago, I stressed how our Professional Colleges and Associations kept a blind eye without getting involved and having their say in the administration of the health service. Even when there was an uprising asking for a system change, the medical profession remained largely silent without adding their voice. This was in stark contrast to the legal profession who stood up with the people asking for justice. By remaining ‘respectable’, confining ourselves to academic activity only, we have allowed our efforts at improving services to the public and training postgraduates to become meaningless. As a result, we are now spending tax payers’ money for training specialists for service abroad. With an unprecedented exodus of locally trained doctors and other healthcare staff, we are helping richer countries to serve their citizens better. The world-acclaimed health indices we have achieved by hard work over the years are becoming irrelevant with rampant malnutrition and other maladies affecting a significant proportion of the people.
Even the few medical men who dared to warn the authorities publicly on impending childhood malnutrition in their area had to face disciplinary action. The services of an alumnus of the Ruhuna medical faculty have been terminated as a result. Unfortunately, there is hardly any protest heard from the trade unions or other medical organizations against such action, at a time when elsewhere numerous unlawful activities and rampant corruption remain unpunished.
As much as the people are asking for all 225 in the Parliament to be thrown out, there are loud whispers in the society that the medical profession, too, is corrupt exploiting the people in various ways. There is no use in our grumbling about any shortcomings of doctors and incidents of medical negligence being highlighted in mass media regularly. Naturally, the good work done by the doctors will not be talked about with praise as that is the minimum the society expects from us.
It is high time our annual conferences and other meetings had a regular session or symposia on various aspects of the doctor in society, discussing our own faults and ways of rectifying them. All Colleges, especially those dealing with clinical disciplines coming into direct contact with the public daily, should communicate regularly with their members on these issues. They should also keep a close watch on the activities of health-related institutions like the SLMC and the NMRA already referred to, and intervene where necessary, without waiting till it is too late.
Thus, prevention in broader terms involves not only prevention of diseases but also prevention of other irregularities in the administration of health and questionable practices of our own colleagues that have a direct bearing on the health of the people. The medical profession, despite its many shortcomings, is still respected and influential. Our strong voice will be heard by the rulers, medical administrators and the general public.With these thoughts let me conclude by wishing you all a very successful and enjoyable annual sessions. I wish you all a very good evening.
Features
Ambiguity of National Evaluation Policy?

By Dr Laksiri Fernando
For the second time, Ranil Wickremesinghe has inaugurated a National Evaluation Policy (NEP) for Sri Lanka. The first one was in 2018 and also in September at the Global Parliamentarians Forum for Evaluation (GPFE) held in Colombo. As its website said, “The National Evaluation Policy (NEP) of Sri Lanka, was launched by Prime Minister Ranil Wickremesinghe at ‘EvalColombo 2018,’ the first ever global conference on evaluation organized by the Global Parliamentarians Forum for Evaluation (GPFE).”
Blocked Website?
He inaugurated the same or a different one as the President of Sri Lanka on 8 September 2023 at Temple Trees with the participation of some key Ministers, Officials and Foreign Delegates. The Presidential Secretariat’s website quite genuinely titled the posting of the speech as “Sri Lanka’s long-awaited National Evaluation Policy finally commences after seven years.” However, there was no policy document posted on the website. When I searched on the President’s website (president.gov.lk) the following was the message I got.
“Sorry, you have been blocked. You are unable to access president.gov.lk.”
It is still difficult for me to figure out why I have been blocked. Is it a technical error or a political decision? Is the website closed to everyone or only for me? My primary objective was to see the details of what they called ‘National Evaluation Policy Implementation Framework.’ That is what the President mentioned in the Speech.
However, on the website of the Ministry of Finance, Economic Stabilization and National Policies, (Ministry of Finance – Sri lanka (treasury.gov.lk) there was a pdf titled, the ‘National Evaluation Policy of Sri Lanka.’ It is only a four-page document even without page numbers or a date. Two pages were devoted to a long glossary and references. There were five references all being websites accessed in 2017. This is quite intriguing.
For Good Governance
A National Evaluation Policy (NEP) is part of good governance. In the case of Sri Lanka, such evaluations should particularly address corruption and misuse of funds. Without an NEP, governance accountability to the people and to the international community cannot be achieved. In 2009, the UNDP (United Nations Development Program) said, “There is general consensus that evaluating the performance of public policy is an important instrument for good governance. There is, however, a gap between this general agreement and the actual implementation, use and sustainability of monitoring and evaluation (M&E) systems, processes, and tools on the ground.”
This was after an international conference held on the subject in Casablanca (Morocco) in December 2009. Sri Lanka participated at the conference represented by the Director General of the Ministry of Finance and Planning, Velayuthan Sivagnanasothy. He presented a well-prepared paper, titled “Sri Lanka: National Monitoring and Evaluation System: Experiences, Challenges and the Way Forward.” As Sivagnanasothy assured, there was a national monitoring and evaluation system in Sri Lanka at that time. I also can remember its existence participating at several meetings and conferences as the Director of the National Centre for Advanced Studies (NCAS) and a Director of the Colombo Stock Exchange (CSE).
It is possible that the above situation changed when unreliable persons like Mahinda Rajapaksa and Basil Rajapaksa became controlling the country’s Ministry of Finance. A large number of projects were undertaken with foreign loans without an evaluation of the project plans and the progress of their implementation. When countries like Norway, Canada, Japan, and Australia gave aid, grants, or loans to Sri Lanka, they themselves conducted their independent evaluations. However, there were some other countries and agencies who didn’t want this requirement. This is one reason why and how Sri Lanka became heavily indebted and failed to repay loans.
Avoiding politicisation
There is no question that national evaluation policies can easily become politicised. The best way to avoid the infection is to develop these policies independently and as part of management science/studies. There can be an independent commission on national evaluation. Project planning, management, monitoring, and evaluation are already subjects taught in universities. There are a good number of Sri Lankan people who are qualified in this field at least at the graduate level. What is needed is to introduce postgraduate degrees and develop the subject to be useful to the country and others.
Various sectors in Sri Lanka should have clear national policy/policies. In 2012 the World Bank published a book titled ‘Building Better Policies’ focusing mainly on monitoring and evaluation. It is fully available online (Building Better Policies – Google Books). It says in the foreword, “This book is useful to anyone who cares about the quality of public policies and who wants to learn and understand how public policies and programs can be shaped with the objective of improving people’s welfare.”
The report in the Presidential Secretariat’s website on the so-called inauguration says, “The President acknowledged a significant void in Sri Lanka’s governance system – the absence of a national policy.” This is very true as the immediate circumstances categorically revealed the situation.
On the day of ‘inauguration of NEP,’ it was reported “Sri Lanka will be transformed into an education hub in South Asia,” an assertion made by the Minister of State for Education, Dr. Suren Raghavan. People are not unknown to various dreams of ‘hubs’ declared by different politicians from time to time. Raghavan cannot be the same type given his educational and professional background. Yet, he has also stated “the focus of the new education reforms is on creating a system that enables students studying in the arts stream to attain a bachelor’s degree in science.” This is completely intriguing and no further information was given on how it could be done.
Four days later, Dr Wijeyadasa Rajapakshe made a similar declaration about educational reforms and said, “vocational institutions to be given the same recognition as universities.” Wijeyadasa Rajapakshe primarily is the Minister of Justice, Prison Affairs and Constitutional Reforms. However, he is also the Chairman of the Parliamentary Special Committee on the Expansion of Higher Education and perhaps he made this statement in that capacity.
Conclusion
What is clear from these statements and declarations is that the present government or politicians in general in the country do not have any idea of expanding the university or higher education system. Renaming vocational institutions like Technical Colleges as universities is not a solution. Quality of higher education and integrity should be preserved. Also, giving the arts students just BSc degrees is not a solution for the problems associated with that stream. Sciences and social sciences should be promoted and developed. Immediate evaluation of the whole educational system is necessary. There can be an independent commission on the subject with capable people. Most important is the promotion of the English medium in higher education without discriminating against anyone who wants to study in the Sinhala or Tamil medium.
Features
Aviation safety and human element

By Capt. G A Fernando
gafplane@sltnet.lk
RCyAF/ SLAF, Air Ceylon, Air Lanka, SIA and SriLankan Airlines.
Former Crew Resource Management (CRM) Facilitator, Singapore Airlines Ltd.
Member, Independent Air Accident Investigation Pool
(The first part of this article appeared in The Island of 18 Sept., 2023)
In 1982, an Air Florida Boeing 737 crashed into the Potomac River, Washington D.C., after takeoff from Washington National Airport in icing conditions. Erroneous engine thrust readings (higher than actual), and the co-pilot’s lack of assertiveness in communicating his concern and comments about aircraft performance during the take-off run were among the factors cited (NTSB/AAR 82- 08).
Experts say that one needs to be ‘aggressively’ safe. All communications (verbal or written) and standard operating procedures (SOPs) should be proactive, predictive and preventive. Some of the accidents mentioned could have been prevented.
As can be seen in the diagram shown, the SHELL boundaries are not smooth but inherently full of serrations, and much effort is needed to interact efficiently and seamlessly. Some experts stress that it is Communication in the form of SOPs that ‘lubricate’ the system for smooth interaction between elements’ while the captain (team leader) sets the tone. In fact, where air safety is concerned, Capt. Tony Kern, a human factors expert, says in his book Redefining Airmanship that to maintain air safety, it is imperative that the team leader knows himself, knows his team, knows his aircraft and equipment, knows his mission and, above all, evaluates the risks involved with the task at hand.There can be problems with the interaction within the team (Liveware and Liveware). Sometimes the Captain (Leader) has to be an expert in conflict resolution! (See Figure 01)
Threats and Hazards
Almost every situation in life is full of ‘threats’. When it involves one personally, it becomes a ‘hazard’. In the aviation context, if there is a flock of birds in the vicinity of an aircraft, they constitute a ‘threat’. However, if that flock of birds starts crossing the flight path of the aircraft, it becomes a ‘hazard’ and avoidance action needs to be taken. Remember the ‘Miracle on the Hudson’? The engines failed because of bird ingestion.
Many airports, too, contain manmade threats and hazards which are usually eliminated only after an accident. In fact, pilots say that blood has to be spilt for changes for the better to occur. At many airports high-rise or security-sensitive buildings are built without planning, and no consideration given to air safety, thus violating the law.
The Ratmalana International Airport is a case in point. On the landing approach from the Attidiya side there is the Parliament and Akuregoda Military Headquarters which are prohibited over flying areas. In the vicinity of the Ratmalana International Airport, there is the Kotelawala Defence Academy and Hospital. At the Galle Road end a solid wall creates a hazard for landing and departing aircraft. Elsewhere, at the Puttalam-Palavi airbase a cement factory is in line with the runway, whilst at China Bay-Trincomalee the silos of a flour mill obstruct landing and take-off paths. These hazards at the latter two airports render them useless as ‘alternate’ (alternative) international airports. If sufficient thought had been given to air safety planning, the loss-making Mattala Rajapaksa International Airport in the Hambantota District would never have been built.
The Swiss Cheese Model
Just as one proverbial swallow doesn’t make a summer, one error alone will not create an incident or an accident. Rather, it will be caused by a chain of unsafe events not picked up by the system. The triviality of one such potentially disastrous cause or lapse is echoed in the words of a poem from the 17th century, later popularised by Benjamin Franklin in his Poor Richard’s Almanac: (See Figure 02)
Reasons for accident occurrences are similar. In fact, the Toyota Corporation asks ‘why’ at least five times when determining the ‘root cause’ of a problem.Aircrew members are regularly taught to recognise unsafe patterns highlighted in past accident investigations, so as to nip them in the bud if and when identified.
Professor James Reason postulated the ‘Swiss Cheese’ model, which states that in any organisation, the layers of safety and security controls in place should be able to block, or cover, one another, to prevent accidents. But unfortunately, there are random holes of all sizes in these layers, like slices of Swiss cheese. Hence, the possibility that with the presence of latent conditions and active failures, these holes will align and allow a potentially dangerous situation or practice to go through without being trapped, thus creating an accident or incident. (See Figure 03)
As illustrated in Reason’s ‘Swiss Cheese’ diagram, latent failures of the system are those that compromise safety, having existed and been taken for granted for short or long periods of time; active failures are immediate, unsafe human acts. In fact, the crew (human element) is the last line of defence before an accident or incident occurs.
To illustrate these points, I shall revisit the 9-foot/3-meter concrete wall that was erected several years ago at the Galle Road end of the runway at Ratmalana International Airport.
This wall could be regarded as a man-made hazard. The runway is 1,833 metres (6,014 feet) in length, not long enough by worldwide standards for a so-called ‘international airport’. By international law, at a pre calculated critical speed (known as the go/no-go speed) pilots are allowed only two seconds in which to make a critical decision whether to stop or continue the take-off. According to calculations by the Boeing Company, a decision to stop any later than two seconds (called ‘dither time’) will result in an aircraft reaching the end of the runway at a speed of 60 knots (69 mph).
On a rainy day, if pilots of a medium-sized aircraft decide to abort the take-off three seconds late, they are unable to stop within the paved runway, with deployment of maximum braking and other stopping devices such as reverse thrust, and the aircraft will ‘overrun’. Because the grass in the overrun area is wet and slippery, the brakes are rendered ineffective. Consequently, in the case of Ratmalana, the aircraft will definitely impact the wall and perhaps catch fire as fuel tanks are usually full during departure.
So, the delay in making a decision to reject the take-off rather than continue would be an ‘active’ failure by the crew. The presence of a solid wall at Ratmalana is the presence of a ‘latent’ condition caused by the Airports Authorities. Although the wall is an ‘accident waiting to happen’, the Sri Lanka Air Force (SLAF), which earns ‘welfare’ money from advertisements on the wall, stubbornly refuses to replace it with a frangible fence, that would break on impact and reduce damage to an over-running aircraft and even vehicular traffic on the Galle Road.
Returning to Reason’s ‘Swiss Cheese’ postulation, air accident investigators usually work backwards from the incident/accident, using the ‘model’ to find the root cause, unsafe acts and any failed defences. The best witnesses are, of course, the crew themselves, although they may not want to voluntarily give information if a punitive attitude is adopted by accident investigators and the authorities. It is a long-held belief that the crew involved are damned if they tell the truth and damned if they don’t. In the recent past in Sri Lanka, the Law and the Police were quick to ‘criminalise’ air accidents. Almost two years ago the accountable manager and chief engineer were arrested and remanded for failure to prevent an accident. That is another story.
The protocol should be for an independent team to do a non-punitive inquiry, and if and only if elements of negligence are highlighted in the final accident report, then the law should take its course under the direction and oversight of the Attorney-General. In short, the authorities in Sri Lanka need to get their act together and conduct themselves in a professional, impartial, fair-minded manner.
Accidents don’t only happen to “other people”, and with threats everywhere we have to learn to mitigate and manage them. While it is human to err, could we eliminate error completely? I think not. But pilots can learn to trap and minimise their ability to make errors by using their team effectively, including pre- and post-flight briefings. A common question that should continue to be asked is: “Could we have (as a team) done things better?”
Will automation of some tasks help? Instructors often repeat the adage, “Fly the aircraft and don’t allow the aircraft to fly you.” Conversely, “The aircraft flies by itself. You assist it to fly”. I believe it is the level of automation that matters, depending on circumstances.Bernard Ziegler, a French pilot and engineer who served in Airbus Industrie as senior vice president for engineering – and was the son of Airbus founder Henri Ziegler – was well known for his evangelical zeal for the application of computerised control systems in Airbus airplanes, commencing with the revolutionary A320 airliner. Bernard Ziegler attempted to design the human out of the flight deck in Airbus’s so-called ‘fly-by-wire’ airplanes, which in their early days were involved in a series of incidents and fatal accidents, due mainly to the mismatch of the man/machine interface. So much so that the A320 was called the ‘Scare-bus’ in jest. Even today many Airbus pilots are heard to ask while flying, in perplexed tones: “What is it doing now?” or “I have never seen this happen before.”
A more recent story is that of the Boeing 737 MAX. When I flew the basic Boeing 737-200 many years ago, our Irish instructor called it the ‘thinking man’s aircraft’, a perfect match between man and machine. Somehow, due to design quirks in the newly designed 737 MAX, an automatic system called MCAS (Manoeuvring Characteristics Augmentation System) was incorporated. If the aircraft got into an unusual and unsafe nose-up attitude, MCAS would be automatically activated and lower the nose to a safer angle.
Unfortunately, during the somewhat rushed introduction of the 737 MAX onto the market, many airline crews were not sufficiently trained in how to override the system – if MCAS was activated due to false indications from, say, a computer or instrument malfunction. Worse still, some airlines’ pilots were not even told that their new airplanes were fitted with such a system, and therefore unaware of what to do if and when MCAS became activated for no apparent reason. This ignorance, through no fault of the pilots, resulted in two disastrous MAX crashes, in Indonesia and Ethiopia, with a total loss of 346 lives.
As the ‘cold hard facts’ later emerged, it became apparent that although the ‘MAX’ was arguably a totally new type of aircraft, it was designated as a Boeing 737-800 to minimise legal crew-training time on the type. This extra training was seen as an undesirable burden for Boeing’s customer airlines, who would have to withdraw captains and first officers from the line for training, thus incurring loss of productivity and revenue for the airlines.
Boeing’s intent was, therefore, for the training (non-productive) period to be as short as possible. But in practice corners were dangerously cut. The US regulator, the Federal Aviation Administration (FAA) – in this case the ‘human element’ – went along with the manufacturer’s sales and training programme, which ultimately resulted in incidents, accidents, and loss of life.
In summary, statistics show that although accidents have decreased to a small percentage in terms of flights and hours flown, the number of certified air operators is also increasing, which causes the number of accidents to increase. Difficult as it is to contemplate, it wouldn’t be wrong to say that the potential exists for more human factor-based accidents to occur in future.
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