An accident that could have been averted

Frankly, I was unsure whether to do this piece. Following Mon­day’s crash of the US-Bangla aircraft at TIA, my mind had been oscillating, perhaps like the mind of the ill-fated plane’s pilots as they struggled to decide whether to land from the north (‘20’) or from the south (‘02’). We are still not sure how this accident, which could have been easily avoided, ended up being so tragic. This crash has aroused not only deep sympathy but also immense curiosity. And not just here but the world over. This was particularly because of the availability of live communication audio between the air traffic controller (ATC) and the aircraft. One can listen to it over and over again. It is just a headphone away for anyone. For novices though, understanding the ATC jargon could be problematic.

 

Without going into the details of the accident per se, I want to approach it from a different angle. While it may be natural for someone at the US-Bangla to blame Kathmandu ATC for the accident, many on our side will disagree. But the blame game does not help anyone, nor does it enhance aviation safety. A rational and impartial analysis is vital. I have thus taken the liberty to extract comments on aviation forums following the crash. Needless to say, those comments come without any trace of regional bias. I save my dui-paise for the end.

 

As the accident was avoidable, many wondered if the ATC transcript was in fact real. They found it unbelievable, even mind-blowing. Most people on the forums wondered how the pilots got the runway number, the flight number and the wind direction all wrong. But all agreed that there was utter confusion both in the flight deck and in the tower.

 

Confirmation, Compass, confusion

 

One comment was particularly perceptive as it suggested the crash was a result of the mind processing what it expects to hear rather than what is being actually said, or what you would call confirmation bias. When you get wind from a ‘220’ direction and are flying into and with a ‘02/20’ runway, you are naturally better off landing from 02 than from 20 because of the unfavourable tailwind (a headwind is generally more preferable for take-offs and landings).

 

The fact that ‘02’ is a compass heading (of 20 degrees) raises the potential for confusion: wind from 220, a 02/20 runway—it’s a lot of 2s and 20s. The problem is compounded if you are not a native English speaker as you process the language less instinctively.

 

This commentator further said that as people find themselves in stressful situations—like landing an airline with a tailwind in an airport in a foreign country with very high terrains around—their reasoning faculties shut down and they go with their instinctive judgement. The less experienced someone is at a task, the higher this tendency is. It can even reach a point where people disregard information that clearly indicates something is wrong.

 

If both the pilots make the same cognitive error, there is nobody there to question it. The commentator rightly points out that this is the kind of cognitive stress or cockpit resource management (CRM) concern that is a nightmare for beginners.

 

Likewise, another extremely sharp comment hit the nail on the head, “Oh, my goodness just tell them to go around, this cannot be real! ATC gave them what they wanted and thought it will fix it. ATCs were aware that the pilots were confused.”

 

This, more or less, summarises everything that happened. Listening to the audio, the captain sounds very calm, and can be heard clearly reading back the ATCs’ instructions. The ATCs, on the other hand, sounded agitated and unsure. But this is not to suggest that the ATCs were primarily responsible for the crash: it was the captain’s prerogative to make a missed approach and try a stabilized approach later.

 

Domino effect

 

It was the captain who initiated the domino effect by swinging between ‘02’ and ‘20’, not just once but right up to the end. The confused ATC gave him the option to land at any end of his choosing. Disoriented as the captain was, how come he didn’t see obstructive landmarks as he passed over at a very low altitude—and still thought he could land?

 

They say a sure way for a pilot to get disoriented quickly is to attempt too late a turn at low altitudes while also trying to manage the radios and other critical flight phase items. This was what happened with the US-Bangla flight.

 

As we notice in the audio, our ATC seems to first shoot and then re-think and go for quick change, creating more confusion. This has been the hallmark of our ATCs for long. And this is not the first time I have said so. An ATC has to be a patient listener cum speaker. But most of our ATCs seem to lack this basic skill. Agreed, it is hard to do away with your native accent, but you can surely speak slowly and intelligibly to make sure the person at the other end understands what you’re saying. It saves a lot of time and unnecessary hassles.

 

This accident will go down in history as the most unfortunate accident that could have been avoided with the available tools and procedures. I am sure it will be used as an example of what pilots and ATCs should avoid. It could be instructive for airports the world over with a ‘02/20’ orientation that are otherwise operating quite normally.  

 

By HEMANT ARJYAL
[email protected]

 

30 pc pregnant women deliver in dirty sheds

Surkhet: Even though the gov­ernment has started provid­ing pregnant women monetary incentives to deliver at approved healthcare centers, 30 per­cent women of Surkhet district in western Nepal still deliver babies in unsafe cowsheds. In this part of Nepal, there many families that still consider preg­nant women ‘impure’ and rele­gate them to cowsheds for the nine months of pregnancy.

 

“These unhygienic conditions led to many still-births,” says Basanta Shrestha, the informa­tion officer of District Health Office. Even though women who do go for check-ups get Rs 400 in incentive money, around 30 percent women in the district come fewer than two times, and often deliver in the sheds. APEX BUREAU

Bheri Zonal Hospital in a shambles

When she suffered from pro­fuse menstrual bleeding, 22-year-old Ruma Tharu was brought to Bheri Zonal Hospital on January 5. She needed blood urgently, and was given O+. Medical attendants informed Tha­ru she would need another pint of blood the following morning, which her father Raju Tharu procured from a blood center run by the Nepal Red Cross Society. However, the blood that the center gave to Tharu was of B+ category. Soon after, Ruma started developing blisters all over her body. Both her kidneys stopped functioning. Ruma’s family staged a protest. The hospital suspended the nurse who had administered the blood. Ruma was brought to the capital and she survived. But she has become extremely weak.

 

Locals says the 150-bed Bheri Zon­al Hospital is marred by political interference, staff negligence and general mismanagement. Its ser­vices are increasingly brokered by middlemen. Many are compelled to seek treatment at expensive private hospitals.

 

It was only a month ago that the hospital administration caught a middleman who was sweet-talking patients into seeking private medi­cal services. But no action was taken against him. Reportedly, he was close to a senior hospital staffer.

 

The hospital is one of the few pub­lic hospitals in western Nepal with a cardiology department. But its echocardiogram machine, worth some Rs 8 million, has been broken for seven months. An echocardio­gram examination costs Rs 850 at the hospital, but private hospitals charge over Rs 2,000 for it. Similar­ly, a TMT machine bought one and a half years ago for Rs 1.3 million is also kaput. Dialysis services, which the hospital was supposed to pro­vide starting a year ago, only began two months ago.

 

Poor service quality owes to the carelessness of the Hospital Devel­opment Committee, alleges former committee chairman Bed Prasad Acharya. But Bir Bahadur Chand, medical superintendent at the hos­pital, claims that there has been steady progress. “Staff shortages have caused some problems, but specialized services have been improving. There hasn’t been any negligence.

 

What about the broken echo­cardiogram machine? “We have brought in technicians to repair it. It should be up and running a few days,” says Chand.

 

The hospital has had eight heads in past nine years, an apparent sign of excessive politicking. It was only in October 2016 when Chand replaced Dr Shyam Sundar Yadav, who is credited with important reforms in the hospital’s functioning. The appointment of Chand, a junior radiologist, has not gone down well with the staff and is apparently against the Health Guidelines, which stipulate that only someone from the ‘General Health’ category can be appointed medical superintendent.

 

Usha Shah, who currently heads the Hospital Development Commit­tee, blames it all on lack of funds. “We are committed to quality care. We have asked the government for additional resources,” she said.

 

By Govinda Devkota

Not many tourists opt to stay overnight in Lumbini

Lumbini, the birthplace of Gautam Buddha, has drawn 276,620 tourists in the two months of January and February, accord­ing to the Lumbini Development Trust. This is almost 100,000 fewer tourists than in the first two months of 2017, when 376,600 visitors had come to Lumbini.Of the 276,620 tourists visiting Lumbini this year, 223,016 were Nepalis, 24,095 were Indi­ans while 29,509 were from other countries, according to the trust’s information officer Rajan Basnet. While the number of Indian tour­ists increased slightly this year, the number of Nepali tourists went down considerably. The number of tourists from other countries also declined. According to Basnet, tourists from over 50 countries have already visited Lumbini this year. In this period, besides India, Thailand has sent the most number of foreign tourists (7,928) to Lumbini, followed by Myanmar (6,689), Sri Lanka (5,733), China (2,821) and South Korea (1,406).

 

Tourist arrival had suffered in 2016 because of the twin effects of the earthquake and the blockade. It picked up steam in 2017 only to slow down this year. “Most tourists to Lumbini come via the Nepal-India border. Although their primary destination is Lumbini, they don’t stay here overnight,” said Achyut Guragain, vice-chairman of Nepal Tour and Travels Asso­ciation. “That’s because they come here with Indian guides, who tell them that although Buddha was born here, other significant places associated with his life all are in India.

 

As a result, local businesses haven’t been able to flourish as much as they would if the tourists stayed here longer.”

 

 

 By Salman Khan