A simple error brought down a massive cargo jet, killing all seven crew, but the mistake was linked to deeper issues of inadequate training and crew fatigue, Canadian safety investigators concluded yesterday.
The final report by the Transportation Safety Board into the fiery crash of the MK Airlines 747 jet says the disaster likely occurred because a crew member neglected to click on the correct icon of a computer software program.
That inadvertently put the weight from the previous takeoff -- over 100,000 kilograms lighter -- into the system, which caused the plane to attempt an underpowered takeoff and crash just beyond the runway of the Halifax airport on Oct. 14, 2004.
In its sole recommendation, the board calls upon air authorities to require that cargo aircraft be equipped with a system that would alert the crew when such an error is made.
Wendy Tadros, acting chair of the safety agency, said inputting errors are a worldwide and "pervasive problem."
"We believe we need an additional line of defence -- a mechanism to catch the unexpected errors," she told a news conference.
However, the lack of further recommendations was swiftly criticized by groups representing families of cargo-plane-crash victims, who complain the report doesn't address its own findings on fatigue and inadequate training.
"The report fails to address a fatal, failed business model that has become part of the air cargo industry worldwide," said Gail Dunham, president of the National Air Disaster Alliance/Foundation in the United States.
In its conclusions on contributing factors, the report states the airline didn't provide formal training on the software, and it's likely the crew member involved "was not fully conversant with the software."
"The training was not appropriate for the result they were trying to achieve," lead investigator Bill Fowler said.
The report also concludes that "crew fatigue likely increased the probability of error" as the mechanism was set. Five of the 16 findings from the report on "risk factors" are related to fatigue.
In its "factual information" section, the report notes the airline adopted lax Ghanaian regulations on the maximum number of hours crew could be on duty -- meaning that a seven-person crew were expected to be on duty for up to 24 hours.
It goes on to state "planned duty periods for previous flights indicated that 71 per cent of flights had been planned in excess of 24 hours."
On the date of the fatal flight, the pilots had been on duty for 19 hours. The report says the crew would likely have been on duty for 30 hours before reaching their final destination of Luxembourg's Findel airport. Ms. Dunham says the board should have made industry-wide safety recommendations on fatigue, and argued its failure to do so was "a failure of imagination."
However, the board defended its report, saying its findings were particular to MK Airlines and the airline has taken steps to reduce duty times and improve training.
A news release from MK Airlines says the report's findings cannot be regarded as conclusive because there was no cockpit voice recording of the pilot's and first officer's final words. The report "would always contain a significant element of conjecture," stated the release from the firm, which is attempting to become recertified under British regulations.
Dave Wilson, a spokesman for the company, insisted the training on the takeoff software was sufficient.