Investigators analysing aircraft accidents these days mostly look for human factors, as the trend of global air accidents shows technical reasons in the decline whereas the share of human factors is increasing. Pilot error, fatigue, distraction, lack of situational awareness or poor decision-making are the most cited reasons for crashes. However, there is a need to go beyond these reasons to understand why crashes happen.

One of the dominant paradigms for analysing aircraft accidents and serious incidents is the Swiss cheese model proposed by James Reason. As per this model, in a complex system, hazards are prevented from causing accidents by a series of barriers. Moreover, it says most accidents can be traced to one or more of four levels of failure, namely organisational influence, unsafe supervision, preconditions for unsafe acts, and the unsafe acts themselves. These completely unrelated events occur in a sequence, each of which, had they occurred in isolation, would have no or little bearing on safety.

However, when the weaknesses or faults momentarily align together in the defence mechanisms of these barriers, a hazard passes through holes in all of the defences. As a result, it leads to catastrophic accidents—that is why accidents are the outcome of this so-called “cumulative act effect”. So most aircraft accidents are likely to be the result of an accumulation of minor difficulties and seemingly trivial malfunctions.

Cultural factors

One of the fascinating yet neglected aspects in such accidents is the cultural factor. Geert Hofstede, a renowned HR psychologist, proposed a cultural dimensions theory in 1980, in which he examined people’s values in the workplace and created differentiation along different dimensions. One key dimension is Power Distance Index (PDI), which measures how much a specific culture respects authority. High PDI countries are characterised by centralised organisations, more complex hierarchies, wider gaps in compensation, authority and respect between top and bottom level employees. Malcolm Gladwell has written on similar lines in The Outliers, where he says cultural legacy is one of the prime culprits in air mishaps.

A classic case that proves this hypothesis is the crash of Avianca flight 52 bound for New York from Bogota, Columbia on January 25, 1990. The flight faced various issues including poor weather, flight delay, minor technical malfunction, and three holding patterns. There was little conversation between the pilot and co-pilot, leading to a miscommunication. It caused the plane to run out of fuel when attempting to land at the JFK Airport in New York. Two key findings pointed to a cultural problem: Colombian culture has a high PDI (i.e., subordinates are expected to be deferential to their superiors).

On the contrary, New York, USA is a low-PDI culture (i.e., Air Traffic Controllers in New York are known for being direct, even with superiors). The crew wanted to declare a fuel emergency to ATCs at the JFK Airport. However, they could not communicate this information assertively. The co-pilot used a mitigated speech to the captain, an example of cultural legacy—a way of communication that shows respect to a superior or downplays meaning to prevent embarrassment or offence–leading to miscommunication. The ATCs at the JFK Airport failed to understand the pilots’ hints because they’re accustomed to directness.

In another accident, Korean Air Flight 801 crashed on August 6, 1997, bound for Guam, encountering a technical issue and bad weather along with a tired pilot. To mitigate these, the crew would need to communicate assertively and work together, failing which resulted in the death of 228 people on board.

These accidents are the outcome of poor communication resulting from a lack of awareness of cultural legacy. The PDI might have been a factor which adversely impacted the communication and teamwork in the cockpit. By examining and addressing the cultural legacy, Korean Air improved its safety records. Researchers have found that countries with high PDI scores tend to be the countries with the most plane crashes. In 2017, Enomoto and Geisler estimated the effects of a number of flights, GDP, severe weather conditions, and culture on plane crashes in 86 countries. Their results were fascinating—countries that score high on the cultural dimension of power distance are directly related to aircraft accidents.

Crashes in Nepal

Aviation is considered the safest mode of commercial transport, but safety performance is not uniformly distributed across all states and regions of the world. A 2013 research found that developing nations have poorer safety records compared to advanced ones. In light of the number of accidents and serious air incidents in Nepal, there is a huge concern about public air transportation safety. As per the Aviation Safety Report published by CAAN in 2018, a total of 21 accidents claimed 164 lives in the country between 2009 to 2018. The major culprits in these air accidents included Controlled Flight into Terrain, CFIT (74 percent fatalities) followed by loss of control in flight (24 percent fatalities), and runway excursion.

In Nepal, many instructor captains with several flying hours of experience have been known to meet with fatal air crashes. The underlying reason could be related to cultural dimensions. The existing PDI score of Nepal is 65, which is relatively high and implies that Nepali society accepts a hierarchical distribution of power. Put this context in the cockpit environment, which is designed to operate best when two pilots cooperate. In many cases, captains and co-pilots have huge differences in terms of age, experience and training. If the co-pilots can’t speak up in the circumstances where the captain is committing an error, it can jeopardise flight safety. Thus, we need to assess cultural dimensions at the national and/or organisational level in the aviation industry.

In many situations, air crashes arise from errors in teamwork and communication. Thorough awareness of cultural legacy and search for ways to break cultural barriers are important to help bring successful outcomes. Comprehensive training for pilots and copilots tailored for direct cockpit communication can counteract such cultural barriers. Encouraging co-pilots to communicate with captains and airline management in cultures with high PDI is key to improving safety standards of flight operation. For instance, airlines must train their first officers (co-pilots and junior captains) to escalate concerns using direct speech.

Encouraging open communication and transparency, including between management and staff, to create a culture of trust and mutual respect is essential to improving air safety. Also, practising equality at the workplace, in which employees feel comfortable reporting safety concerns without fear of retaliation, is critical to improving aviation safety. In a nutshell, there is a need to strengthen three basic defences in aviation safety—technology, training and regulation.