Mouri?o y la Certificación del Piloto

Why Training, Certification, Audits and Accident Analysis are Interrelated

It was November 4, 2008, the Mexican Secretary of State, Juan Camilo Mouri?o, was flying back in a Lear Jet 45, XC-VMC, rented by the Secretaría de Gobernación, from a trip to San Luis Potosí, near Mexico City.

The plane crashed some 10 Kms from the Mexico City Airport, in a plush neighborhood, Lomas de Chapultepec, killing all aboard and some on the ground.

There have been multiple theories and there are several videos available in the "cloud". Most of these videos claim that the cause of the crash was due to the proximity to a Mexicana Boeing 767-300 and that the plane entered into the turbulence of the Mexicana flight.

This is possible, but I would like to propose a different scenario. One that has similarities with other accidents. I used to work in a company that owned a fleet of Lear Jets, with some Falcons and other planes including a Westwind and a King and Queen Air. A Lear Jet was lost taking off from Cancun. That was a call to study the flying characteristics of the Lear Jet.  It is not an easy plane to fly, you really need to know how to do it. So training the pilots is paramount. It is important, in every plane, but in the Lear Jet it is more so. Specific training in specific equipment is important, not only in planes, it is important in cranes, power stations, oil companies, mines or nuclear plants.

If there is any Lear Jet pilot reading this I would like his feedback, as I am not a pilot myself. I did study Aero and Astro though and accumulated some hours in light propeller planes. 

The Lear Jet is a plane that needs to fly fast to keep a level flight.

The Secretary's flight was inserted between two scheduled flights, so there was a small window for this type of plane to land between these two planes. The plane was going fast so the pilot raised the nose to decrease speed. At least this can be concluded from the recordings. This would normally cause the plane to go up, nevertheless you can change the attack angle and reduce speed likewise. It is clear that they were going to land, although they had not reached the external marker and were not aligned. 

It is not clear if they had already lowered the landing gear. Somewhere they mention they had 20 degrees flaps. The landing gear in Mexico City is normally lowered before passing the outside marker. This needs to be verified as each plane has a different response.

Is there anybody there that knows the stall speed of the Lear Jet, at 2300 meters, with 20-degree flaps? 

I could not hear a stall warning similar to the ones used in the school planes. Before the plane goes into stall, some planes have a stick shaker and some simply push the nose down to increase speed. If you are already flying low, you can panic and, the data suggest that this is what happened, you should accelerate and leave the approach profile, otherwise the plane will just plummet.

Some recordings suggest that the pilot was fighting the plane, not the turbulence, if so, the plane just stalled and there was nothing to be done. The same thing happened to the plane that was going from Brazil to France. The pilots panicked and fought the plane's automatic response to stall. This would be expected from untrained pilots, not from a crew from Air France.  

·      The question here is, how were the pilots certified?

·      What is, if any, the certification process?

·      Does it include simulator time?

·      Or just a paper exam?

·      Who validated the certification process?

·      What criteria was used to validate it?

This we face everywhere.

Many years ago I had to analyze a client's crane accident that, by a strike of luck, had no fatalities. The crane overturned, when going down slope after a bridge.

To begin with, the driver increased gear after the bridge, he should have lowered the gear to help him slow down the equipment. The motor stalled and he tried to stop the equipment using only the brakes. The brakes had been modified and did not work, foolishly modified, but the problem was the equipment had been recently certified. When I interviewed the mechanic and the company man, they told me the brakes were hydro pneumatic, they were not. They had cancelled the water tanks drain lines and seriously modified the air piping. 

The company had a complete handbook with diagrams, although they were in Italian, nevertheless the mechanic never saw this handbook, nor the diagrams and he was left to find out how to arrange the piping on his own. They had also made him believe he was very smart, because he was able to interconnect the piping without the diagrams.

This brings us back to the issue of certifying the mechanics, pilots and drivers, the audits and the certification of the auditor.

Again, you cannot stop at what caused the incident, you need to go beyond, you need to find out what allowed that cause to cause the incident. If necessary, audit the auditor and check the audit procedure. In my case, there was no audit procedure and, I am sorry to say, that this is more frequent than you would expect. I have found the same problem in oil companies, nuclear plants, power stations and mines.

Some are easy to explain, but, in an airline, an oil company or a nuclear station, the lack of a certified audit procedure can lead to significant damage or multiple deaths.