Cuba atribuye a errores humanos el grave accidente aéreo de mayo de 2018

HAVANA, Oct. 1st (El Toque) Friday May 18th, 2018 was a fine day for flying. After a night of rest in Havana, the crew of flight DMJ972 was in a good mood:

“You disappeared on me yesterday,” the co-pilot said to another person, in the cabin already.

“Everybody was ready yesterday. I had to leave the room to liven up and…

The pilot leaves his sentence hanging. There is laughter in the plane’s cabin.

It’s mid-morning at the Havana airport in Rancho Boyeros. Everything seems to be fine. In less than half an hour, they’ll be up in the air heading for Holguin. It’s a well-known route.

“Authorized departure KAVUL2A towards Holguin, transition AVEPI altitude 150 at the start, transponder 1673,” came incoming from the air traffic control tower.

“Roger, we are… we are authorized to leave for the airport of… Holguin via KAVUL2A transition AVEPI, code 1673 initial ascent 150, DMJ972 and RNAV negative,” came the response from the plane.

“Correct, safe flying.”

While the BOEING 737-210 ADV rolled down the runway and picked up speed, some noises could be heard coming from the landing gear. The crew didn’t worry too much, it could just be uneven ground on the runway. Nothing serious.

The odyssey began as soon as the plane started taking off. The crew and passengers would experience 30 seconds of a nightmare which, from the transcriptions of the plane’s black box recordings, seemed to last an eternity.

As soon as the plane started taking off, it began to lean towards the right and go off course. The co-pilot, who had the controls in his hands, gave them to his superior.

“What did this guy do?!” the captain asks while trying to deal with the banking (side inclination) and trying to control the plane. He yanked the steering wheel to the left and pushed down on the right pedal. He managed to correct the first banking and level the wings out, although only for a few short moments.

However, the plane began to incline again, five times more, more violently and he couldn’t straighten out the wings. Meanwhile, it rocked upwards, sharply. The plane was completely out of control.

“Go back by the…!” the co-pilot didn’t finish his sentence. At that moment, it was just instinct. The crew was dreaming about landing a plane that was barely responding to its controls.

Four seconds later, there was a loud bang. The captain’s voice reflected the terror of the moment:

“What happened?! What happened?! What happened?!… May Day!! May Day!!…”

“Delta Mike Julier 972, May Day, May Day, May Day!!” the co-pilot transmits to the Jose Marti traffic control tower to declare the emergency.

In the recordings, you can hear one of the crew members shout “Turn back, turn back!!”, but there was no way back. “It’s going down!! Go back!!”. There wasn’t a way out.

Two seconds later, voices and sounds were indistinguishable. A crew member, hanging onto the last thread of hope said: “Go up, go up, go up!!”, but they had no chance. You can hear desperate cries and then, three seconds later, a devastating silence.

From the airport’s observation towers, they watched the whole thing in horror:

“Hey, a plane just crashed right now! It crashed and exploded (…) Please, help me tell everyone that it’s up in flames!” they shouted.

The BOEING 737-201 ADV has crashed to bits, it’s up in flames, under the sun and clouds of a Friday in May.

The Final Report

The final report of the airplane crash, that took place on May 18, 2018, confirms that the most likely cause of the disaster was the loss of the plane’s controls which were the result of a series of errors, most of which were human. The document was published on the official Civil Aviation Institute of Cuba website, earlier in September.

According to the Civil Aviation Accident and Incident Investigations Committee, the unusual positions of the plane immediately after take-off (which led to the crash) were mostly due to inconsistencies in the crew’s training, errors in weight and balance calculations and the low operational standards that were revealed during the flight.

A hundred-or-so pages long, the report describes how the analysis of information and voice recorders (black boxes), as well as other lab evidence and evidence from the scene of the accident, allowed them to determine that errors in weight and balance calculations affected the speed of the shift change, as well as the pilot’s ability to understand why the plane was acting in this way.

For that matter, the report revealed that the crew didn’t introduce last-minute changes relating to baggage, passengers and fuel supply, onto the load and trim sheet.

According to the investigative committee, the weight of the actual take-off was much greater than the one used in their calculations and the aircraft’s center of gravity was 10% behind what they had calculated, near the rear end (29%).

“The abovementioned is a contributing factor, even when it doesn’t exceed the technical possibilities of an aircraft,” the report highlights.

While no “evidence proving the defects or poor functioning of the aircraft” that could have contributed to the accident, was found, some breaches that prove lapses in good maintenance practices were pointed out.

DAMOJH LLC. (GLOBAL AIR) PLANE

On May 18th, 2018, BOEING 737-201 (belonging to Mexican airline Damojh LLC.  – Global Air – recently rented and operated by Cubana de Aviacion), crashed a few seconds after taking off at Havana’s Jose Marti International Airport.

The accident resulted in 112 deaths, six of which were crew members. The only survivor was young 19-year-old Cuban Mailen Diaz Almaguer, who underwent several surgical operations, including the amputation of a leg.

After the accident, several media outlets and Internet users cast doubt on the reputation of Damojh airlines belonging to Global Air, and Cubana de Aviacion’s lack of rigorous investigation before signing contracts. Complaints made to the company because of its lack of aircraft maintenance for example, came to light.

According to an investigation by El Universal.mx, Global Air only had three BOEING 737 planes running in Celaya, Guanajuato. A 737 needs a runway that is between 2000-2500 m long at least for a safe landing. However, in Mexico, where Damojh had its headquarters, there was only an aerodrome that had a runway 920 meters long.

In 2010, the airline’s operations were suspended after a forced landing at Puerto Vallarta, Mexico. In 2013, former pilot Marco Aurelio Hernandez sued the company before Mexico’s Civil Aviation Board because of the lack of maintenance of its aircraft.

Hernandez, who had flown the plane that crashed in Cuba on several occasions, said that he flew planes with flat tires more than once, he flew over South America without radar and engines failed on him on more than one flight.

He told Milenio that while he was working for this airline (2005-2013), he informed Manuel Rodriguez Campo, the company’s owner, of these irregularities.

“In 2010, Cubana de Aviacion was also advised to stop chartering Global Airplanes because of defects and irregularities. Hiring pilots without the necessary experience was one of these. The recommendation came when one of its flights began its descent off the radar while flying over Santa Clara,” the Mexican newspaper stated.

In spite of these warnings, Damojh airlines began its operations in Cuba on May 14, 2018, to fly “full charter” flights.

Just four days after the crash in Havana, after which the Mexican government suspended the airline’s operations and several former employees came forward to report serious breaches of revision and maintenance protocols of the rented planes.

During the investigation of the causes of the accident, the company was asked to complete the relevant technical documents, so an analysis of the information could be made, but it was sent back incomplete, “so this analysis couldn’t be carried out with the meticulousness it required,” the Accident Investigation Committee stated.

Moments after the accident in Havana. Taken from AFP

THE PLANE: BOEING 737-201

The BOEING 737-201 ADV (license plate XA-UHZ) was built on August 7, 1979.

Under a wet-lease contract, the Damojh company rented out the plane, the crew, and maintenance staff to Cubana Airlines.

“There are different ways to rent; in this case, Global Air was responsible for its planes’ maintenance. We’d rented out this plane for less than a month. We still have all of the documents where it states that the crew was qualified and fit for work,” explained Adel Yzquierdo Rodriguez, who was the Cuban Minister of Transport at the time of the accident.

Almost 40 years old, this BOEING had flown for the low-cost Honduran company EasySky, covering the Havana-Georgetown (Guyana) route, according to BBC Mundo.

However, Egbert Field, general director of Guyana’s Civil Aviation Authority (AACG), told the BBC that in 2017, his agency suspended its license to fly, because “the plane’s performance wasn’t very good.”

Field explained that during a “superficial inspection”, a Guyanese inspector discovered faults on the plane and excessive baggage. After an inspection of the black box, it was determined that the plane “didn’t work properly” or “optimally”, he said.

No longer able to fly to the US because it failed to meet that country’s Federal Aviation Administration requirements, Global Air couldn’t do maintenance works on any of its BOEINGS at any of the three plants that the US plane manufacturing company has there.

Even though the final report of the accident in Cuba doesn’t attribute likely causes of the crash to technical problems, there were “flaws in good maintenance practices.”

Out-of-date checks of the plane were one of the main irregularities; anomalies in the General Maintenance Manual and Workshop Procedure, the absence of an inspector to control traffic and overnight services, to name a few.

THE CREW

A year after the accident, the Civil Aviation Institute of Cuba (IACC) revealed the possible causes of the accident in a brief official statement.

“The investigation committee determined, according to the information taken from the flight’s recording device (black box) and the result taken from the depiction of the aviation standards of this flight, that the most likely cause of this accident were the actions of crew members and errors in calculating weight and balance, which led to a loss of control and the airplane crashing during take-off,” Armando Daniel Lopez, the president of this state agency, said.

The flight’s crew was made up of a captain (53 years old), a co-pilot (40 years old), a maintenance engineer (mechanic) and three air stewardesses. They were all Mexican.

The Report by the Civil Aviation Accident and Incident Investigations (CIAIA), published on September 11th, stresses that no psychological or physiological traits were found that could have affected the personnel; yet the crew’s actions revealed poor compliance with operational standards.

In regard to the Captain, it emphasizes the fact that while he carried out training every year in a simulator, there was no proof that he had carried out exercises to prevent a crash in unusual positions and taking back control of a plane.

It also revealed that the Captain’s medical check, in which he was determined FIT FOR WORK on May 2, 2018, didn’t have the signature of the corresponding authority.

“However, Mexican authorities were able to access information in their medical institutions, which informed them that this pilot would have passed the medical check and been considered “fit for work”, but the medical evaluator didn’t sign it due to an error in the procedure,” the report explains.

In the case of the co-pilot (who began the take-off and then passed the controls over to the Captain), he stopped flying for 5 years and 10 months and had 416 hours of flight time experience before the accident with Global Air.

He had flown two planes at night on the 16th and 17th, with only 4 hours and 40 minutes between them on average.

“In spite of having guidelines in his General Operations Manual (MGO) for certain tense operations, due to concepts used of “flight time”, the pilot didn’t rest enough and, even though it doesn’t directly relate to this investigation, this continuous practice could lead to future accidents,” the report highlighted.

Other investigations proved that the co-pilot had been given pointers on his piloting technique on several occasions.

With insufficient documentation, the CIAIA couldn’t verify that the operator (Damojh) was to be held responsible for the training and checking the competence of its pilots.

THOSE RESPONSIBLE

A few days after the BOEING 737-201 ADV crashed in Havana, the CIAIA had already stressed that the only objective of this analysis was to prevent future accidents or events of any kind linked to this one.

According to Cuba’s Aviation Law (RAC 13) and Annex 13 of the Chicago Convention on International Civil Aviation, the investigation of airplane accidents isn’t to find those responsible or guilty.

However, given the irregularities and complaints made about Damojh airlines, and testimonies from some of its former employees, some Cubans questioned the efficacy of Cubana de Aviacion when contracting this company.

The Cuban airline’s captain Ovidio Martinez expressed his disapproval in the comments section on Cubadebate and emphasized how he felt ashamed of the aviation board’s leaders and their procedures.

“Why didn’t they dig into this company’s shaky background?” Martinez asked. “If they had, they would have known about the great maintenance problems they had and the problems they had training their crews, a long time ago.

Who needs to be overseeing this company’s operation to assure us that our passengers are being carried safely?” he concluded.

In this regard, the final report only states the following: it is recommended that the Civil Aviation Institute of Cuba (IAAC) belonging to the Cuban State, establish more effective means to decide its lease, charter and plane exchange contracts, as well as establishing greater and more consistent monitoring practices accordingly.

It remains to be seen whether anyone will be taken to trial to be held accountable for this accident.