Nightmare in Beirut: The crash of Ethiopian Airlines flight 409

Military personnel recover part of Ethiopian Airlines flight 409 from the sea off Beirut, Lebanon. (BBC)

On the 25th of January 2010, an Ethiopian Airlines Boeing 737 climbing out from Beirut, Lebanon suddenly departed its cleared route, entered a tightening spiral, and plunged into the Mediterranean Sea from a height of 9,000 feet. All 90 people on board were killed, the worst air disaster in the history of Lebanon. In a country which had only recently ceased to be at war, the crash immediately raised concerns of sabotage — an assumption which refused to go away, even as investigators started to piece together an entirely different sequence of events. Over the protests of Ethiopian Airlines, they revealed the story of a flight that was in chaos almost from the moment it took off, as two badly fatigued pilots fought to control an airplane which they themselves had configured incorrectly, until their erratic inputs finally sent it tumbling into the sea. The sobering story of a routine flight gone horribly holds lessons about the vulnerability of pilots to a deadly elixir of fatigue, overwork, and insufficient training — that is, if Ethiopia is willing to learn them.

A promotional banner for Ethiopian Airlines, celebrating 75 years of flight. (Ethiopian Airlines)

Founded in 1945, Ethiopian Airlines, the state-owned flag carrier of Ethiopia, is the largest airline in Africa. The airline has long been considered one of the continent’s safest and most professional, with a modern fleet of passenger jets, a significant pool of home-grown expertise, and a training program replete with the latest innovations. Nevertheless, the volatile politics of the region have led to a number of sometimes fatal incidents caused by hijackings and other forms of sabotage, a phenomenon which drove the airline to employ “In-Flight Safety Officers,” who, much like US Air Marshals, fly under cover in the passenger cabin and protect the crew against potential intruders. Even today, Ethiopian Airlines considers sabotage to be one of the main threats to the safety of its passengers — despite one major black mark which suggests that problems might run much deeper.

ET-ANB, the aircraft involved in the accident. (Savvas Garozis)

It was a stormy night in Beirut, Lebanon, in the early hours of the 25th of January 2010, when Ethiopian Airlines flight 409 prepared to depart for Addis Ababa. Scheduled to take off shortly after 2:30 a.m. local time, the red-eye flight was only half full, with 82 passengers spread through the cabin of the eight-year-old Boeing 737–800. The flight also featured eight crewmembers, including two pilots, five flight attendants, and the safety officer (disguised as a passenger).

In command was 44-year-old Captain Habtamu Benti Negasa, a veteran pilot with twenty years of experience and 10,300 flight hours, although he had upgraded to captain on the 737–800 less than two months earlier. Assisting him was a much less experienced First Officer, 23-year-old Aluna Tamerat Beyene, who had 673 total flying hours, including 350 on the 737, and had been with the airline for less than a year.

The route of Ethiopian Airlines flight 409. (Google + own work)

As they approached the scheduled departure time, Negasa and Beyene fired up the engines, and the cockpit voice recorder began to pick up their pre-flight conversations. The topic of choice appeared to be their dinner the previous evening.

“What was in that food we had? Was there weed in it?” Captain Negasa joked.

First Officer Beyene chuckled. “Did you feel dizzy?”

“Oh, I couldn’t sleep,” said Negasa.

“Well! Me too,” said Beyene.

“Weed! You’re kidding me, I don’t know what you’re talking about,” Negasa said, and the cockpit erupted into laughter.

There was certainly no reason to believe that their meal, obtained at a reputable restaurant, actually contained marijuana. But one way or another, the heavy meal right before bed seemed to have affected their ability to sleep, and both pilots admitted in those brief moments that they had received insufficient rest. The possibility of fatigue would go a long way toward explaining the bizarre turn their flight would take just minutes after takeoff.

However, the first error of many actually occurred while the plane was still on the ground. Before every flight, the pilots must take into account the weight, center of gravity, and configuration of their airplane in order to calculate where to set the horizontal stabilizer for takeoff. The stabilizer determines the pitch angle at which the plane is stable, allowing the plane to enter a steady climb or descent without continuous pilot inputs. In this case, the pilots should have set (or “trimmed”) the stabilizer to 6.9 units nose up in order to obtain the desired climb angle, but for reasons which could not be determined, they set it to 5.9 units instead.

How a trimmable horizontal stabilizer works. (FAA)

As flight 409 climbed away from Beirut, Captain Negasa followed his flight director, an overlay on his primary display which indicates the control inputs needed in order to obtain a programmed heading or vertical speed. Because the stabilizer was set too low, the plane naturally attempted to climb at a shallower angle than that programmed into the flight director, forcing Captain Negasa to continuously pull back on his control column to raise the nose and achieve the proper pitch. In such a situation, the plane is said to be “out of trim,” and the correct response would be to increase the stabilizer setting until the plane naturally assumes the desired pitch angle. The plane will thenceforth be “in trim,” and the pilot can let go of the controls.

But on flight 409, Captain Negasa did not touch the trim switches for nearly a minute following takeoff. Although the climb was otherwise normal, the requirement to constantly pull back on his controls represented a significant distraction. Simultaneously, he started to steer right to assume the departure heading assigned by air traffic control.

A change of plans occurs shortly after takeoff. (Google + own work)

At that moment, the Beirut controller contacted flight 409 and said, “Ethiopian four zero nine, turn right initially heading three one five.”

“Three one five, roger,” said First Officer Beyene.

The order to fly a heading of 315 degrees was a change of plans. Initially the pilots had expected to fly a more northeasterly heading to a waypoint called Chekka, but a number of factors were coming together to force the controller’s hand. Several thunderstorms over the Mediterranean Sea blocked most of the routes out to the west, south, and north, while mountains to the east prevented planes from climbing out in that direction as well. Simultaneously, a sudden influx of traffic blocked flight 409’s original route to Chekka, and the controller was forced to send them northwest instead. This would involve a right turn smaller than that which the pilots originally anticipated.

In response to the new order, First Officer Beyene programmed the heading of 315 degrees into the flight director, and the tower controller handed flight 409 off to the area controller.

But right when he should have been paying attention to the new heading, Captain Negasa was busily trying to adjust the stabilizer setting using the electric trim switches, slowly driving the stabilizer in the nose up direction in an attempt to bring the airplane in trim. As he pushed the stabilizer past six units nose up and on towards seven, he failed to level off the plane on the authorized heading of 315 degrees. Despite the flight director telling him to level the wings, he let the plane keep rolling to the right, banking ever more steeply as they overshot their desired heading. As the roll exceeded 35 degrees, a computerized voice suddenly called out, “BANK ANGLE! BANK ANGLE!”

The flight begins to go off course during the very first turn. (Google + own work)

By this point the plane was rolling through due north, 45 degrees to the right of their authorized course. Noticing that flight 409 was now off course and flying toward a thunderstorm, the area controller called the crew and said, “Sir, I would suggest for you due to weather to follow heading two seven zero to be in the clear for fifteen miles, twenty miles, then go to Chekka, and it is up to you, just give me the heading.” His intention was to provide a helpful suggestion, steering the plane due west to cut between the storm cells, but he had no way of knowing that his message had only further complicated an escalating situation in the cockpit.

“Two one, say again?” Captain Negasa asked, apparently having misheard the transmission. Simultaneously, he tried to correct the excessive bank, leveling off at a heading of 003 degrees before beginning a turn to the left.

“Confirm heading two one zero?” First Officer Beyene asked the controller.

“Ethiopian four zero nine sir, negative, to proceed direct to Chekka sir, turn left now heading two seven zero,” the controller replied. Now the suggestion had become a command.

In the cockpit, Captain Negasa was still trying to trim the stabilizer, only now he had moved it too far, and he had to push the control column forward to prevent the nose from pitching up too steeply. Distracted by numerous simultaneous tasks, he again let the bank angle go unmonitored, and the plane rolled too far to the left.

“BANK ANGLE,” the computer said again, “BANK ANGLE!”

Flight 409 continued turning through the heading of 270 degrees, overshooting the authorized course and flying directly into a thunderstorm. First Officer Beyene had not yet set 270 degrees into the flight director, which was still instructing the crew to fly heading 315, and Captain Negasa had no idea how far he was supposed to turn. By the time Beyene set the heading, the plane was flying almost due south, rather than west.

The plane goes off course a second time. (Google + own work)

A dull roar suddenly filled the cockpit as the plane flew into an intense rain shaft. The warning system again called out, “BANK ANGLE! BANK ANGLE!” The plane was rolling more than 60 degrees to the left, way outside the normal flight envelope, and climbing steeply due to the excessively nose up stabilizer setting.

Lapsing into his native Amharic, Captain Negasa said, “Okay, engage autopilot!” Too many things were happening at once; he was falling behind the airplane and he knew it. Engaging the autopilot would relieve much of the workload.

But First Officer Beyene did not respond to the order, and the autopilot was never engaged. Perhaps Beyene simply never heard his captain’s request. But even if he had pressed the button, the autopilot could not have engaged, because Captain Negasa was still applying force to the control column, overriding any attempt to give the autopilot control of the flight path.

Noticing that flight 409 was not following his instructions, the controller called the crew and said, “Ethiopian four zero nine, follow heading two seven zero, turn right heading two seven zero.”

“Right heading two seven zero, roger,” First Officer Beyene replied.

“Okay, what heading did he say?” Captain Negasa asked, his voice strained.

“Two seven zero set,” Beyene replied.

“What is that?” Negasa suddenly exclaimed. “Speed!”

Due to the steep climb and excessive bank angle, the plane was decelerating dangerously. If the pilots didn’t intervene fast, the wings would lose lift and the plane would stall. At that moment the stick shaker stall warning activated, filling the cockpit with a deafening rattle.

“BANK ANGLE! BANK ANGLE!” said the computerized voice.

“What is that? What is that?” Captain Negasa shouted again. “Go around! Go around! Go around! Go around!”

“Roger, go around!” said First Officer Beyene, advancing the throttles to takeoff/go-around power. Someone grabbed the throttles and quickly reduced thrust again, then slammed the throttle levers all the way to max power with so much force that their impact against the stop could be clearly heard on the cockpit voice recording.

Moments later, the airplane stalled, reaching a peak altitude of 7,700 feet before beginning to descend. The stick shakers continued to rattle, the speed dropped to a mere 118 knots, and the bank angle reached 68 degrees left. As the plane entered the stall, the nose naturally fell through, sending the 737 diving nose-first toward the Mediterranean Sea.

The flight path becomes erratic in the vertical direction as well. (Google + own work)

At that moment the controller again contacted the crew and said, “Ethiopian four zero nine, follow heading two seven zero sir, follow heading two seven zero, turn right heading two seven zero now!”

The stick shaker stopped as the dive caused the plane to rapidly gain airspeed. “Roger, roger,” First Officer Beyene hurriedly said to the controller. But no one tried to turn the plane to 270 degrees.

Hopelessly confused, Captain Negasa flailed with the controls, turning the yoke hard to the left while using the rudder to steer to the right. Turning in both directions at once caused the two inputs to cancel each other out. At the same time, the increasing speed and nose-high stabilizer setting caused the plane to pull out of the dive at 6,000 feet, zooming upward into a second, even steeper ascent.

“The speed is dropping!” First Officer Beyene cautioned. Switching to Amharic, he repeated, “Speed is going down!”

“Okay, try to do something!” Captain Negasa exclaimed. But it wasn’t clear to Beyene what the captain wanted him to do, so he did nothing.

“BANK ANGLE! BANK ANGLE!” the warning blared, as the plane again rolled hard to the left.

“Hold this thing!” Negasa shouted.

“Speed!” said Beyene.

As their speed dropped, the stick shaker activated again, warning of another stall. Captain Negasa kept trying to roll left, turning the plane practically on its side as it climbed to its last, desperate zenith. Banked ninety degrees to the left, the plane stalled a second time. The wings lost lift and the nose once again fell through, sending the plane into another, even steeper dive.

“Ethiopian four zero nine, Ethiopian four zero nine, you are going into the mountain, turn right NOW!” the controller exclaimed. First Officer Beyene keyed his mic to reply, but words failed him, and he broadcast three seconds of silence instead.

In the final stages of the flight, control is lost completely. (Google + own work)

From a maximum height of 9,000 feet, flight 409 entered a terrifying spiral dive toward the night-dark water, pitched 48 degrees nose down and banked 118 degrees to the left, completely inverted. Captain Negasa let out an unintelligible cry of terror as he furiously manhandled the control column and rudder pedals, sending the plane rapidly rolling and pitching. The 737 started to roll right side up, the bank angle fluctuating between 35 and 75 degrees left, but the dive grew even steeper. The airspeed skyrocketed past 280 knots, silencing the stick shaker, only for the chilling clackclackclack of the overspeed warning to take its place four seconds later. Several loud noises rocked the airplane. Captain Negasa uttered another cry of terror. The robotic voice called out, “BANK ANGLE!”. The airspeed reached 407 knots, subjecting the occupants to an unimaginable 4.4 G’s, way beyond the structural limits of the aircraft.

A CGI animation of the loss of control and crash. Although the animation gives a basic sense of the trajectory, it becomes inaccurate about half way through. In reality the plane did not continue banking after 118 degrees left, but spun back the other way, and impacted the water pitched 32 degrees nose down and 61 degrees to the left. (Mayday)

At a height of 1,300 feet, the flight data recorder ceased recording under the enormous G-forces. Less than two seconds later, traveling at immense speed, Ethiopian Airlines flight 409 plowed directly into the storm-tossed waters of the Mediterranean, obliterating the aircraft and instantly killing all 90 people on board.

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At the moment of the crash, air traffic controllers and others along the coast of Lebanon witnessed a bright flash near the place where flight 409 last appeared on radar. When the flight failed to respond to repeated radio calls, air traffic control notified Lebanese emergency services, and a search and rescue mission kicked into high gear.

This was one of the largest pieces of the plane which remained intact. (BBC)

Within hours, debris from the shattered 737 washed up on the coast south of Beirut, and a sea search confirmed the presence of wreckage under 45 meters of water about two kilometers off the town of Naameh. It was obvious that the plane had impacted with great force and that no one could possibly have survived. With 90 people dead, it was by far the worst plane crash ever to occur in Lebanon.

Following the discovery of the wreckage, divers were able to locate the flight data recorder on February 7th, followed by the protective casing of the cockpit voice recorder on February 10th. However, the memory unit was not attached, and it took a further six days of painstaking manual searching under poor sea conditions before it too was found.

A 3-D picture of the flight path helps visualize the plane’s movements. (BEA)

The flight recorders revealed a bewildering sequence of events. No mechanical failures of any kind were recorded and the plane appeared to be reacting correctly to all pilot inputs. The plane did not break up in midair, although investigators could not exclude the possibility that it did start to come apart about two seconds before impact due to the extreme G-forces of the dive. None of the recovered wreckage, amounting to about 8% of the plane, showed any signs of having been exposed to fire.

Despite all of this evidence, the Ethiopian representatives assisting the investigation insisted from the very beginning that an explosion had occurred on board the plane, probably due to some form of sabotage, leading to a loss of control. Sabotage was not in principle an unreasonable theory, given Lebanon’s recent history of civil war and sectarian violence. But the evidence did not seem to be pointing in that direction. The Lebanese investigators, and a group of American investigators sent to represent the manufacturer, speculated from an equally early stage that human error was the likely cause. This disagreement, which was never resolved, would go on to overshadow the remainder of the two-year inquiry.

Pieces of the plane washed up on the coast between Beirut and Sidon in the hours after the crash. (New York Times)

The problem faced by Lebanese investigators (albeit one of many) was that while they could easily rule out what didn’t happen, explaining what did happen was considerably more difficult. Over four minutes and seventeen seconds of flight, the pilots of Ethiopian Airlines flight 409 seemed to become more and more confused, their inputs becoming increasingly erratic, until eventually they flew their plane into the sea. Every action they took created waves of unanticipated after-effects which in turn led to further errors, escalating like compound interest into some kind of hellish aerodynamic nightmare. The plane deviated from its assigned heading twice, banked too steeply four times, stalled twice, went inverted, and exceeded its maximum speed, all in the space of about three minutes. The pilots had good training records and there was nothing wrong with the plane — in short, no reason why the flight should have gone so horribly wrong.

Military personnel recover various items of wreckage from a trash-strewn beach. (Gulf News)

The origin of the crew’s troubles seemed to be the incorrect stabilizer setting, a small error during the pre-flight setup which significantly increased Captain Negasa’s workload once the plane became airborne. In this task-saturated environment where he was trying to fly out of trim, climb to their cleared altitude, and interpret multiple orders from air traffic control, he started to fall behind his airplane.

A pilot should at all times remain mentally ahead of their airplane, anticipating its movements well in advance. An old airman’s saying goes, “don’t let your plane take you someplace your brain hasn’t been five minutes before.” But in the case of flight 409, it seems that Captain Negasa became so saturated with tasks that adding one more to keep track of — a sudden change in their authorized course — caused him to lose situational awareness. He quickly found himself in a situation in which more processes were occurring than he could simultaneously keep track of. Whenever he focused on the plane’s pitch, the bank angle would go out of bounds, and vice versa. Unaware of what was going on behind the scenes, it seemed to him that some new problem presented itself every time he glanced at his instruments. It only took about a minute of flight under such conditions before he started to show symptoms similar to a mild panic attack.

Soldiers carry pieces of the plane along the beach. (CNN)

This is a phenomenon which human factors experts call “subtle incapacitation.” A pilot who is subtly incapacitated appears physically healthy and awake, but has in fact lost the ability to assimilate contextual cues and make rational decisions. Such a state may arise due to various combinations of fatigue, stress, physical discomfort, and task saturation, resulting in symptoms which include loss of judgment, failure to react to stimuli, illogical decision-making, and irrational control inputs. All of these symptoms were apparent in Captain Negasa during the final minutes of flight 409. In fact, the progressive degradation of his flying ability could be discerned quite clearly in the recorded data. During the initial climb, his inputs were normal; once he started to lose situational awareness, his inputs became exaggerated or belated, but with a clear purpose in mind; and then, following the first stall, his inputs ceased to have any relationship to reality whatsoever.

Another view of the piece of the winglet which was found on the beach. (Reuters)

One question that the investigation needed to answer was why Captain Negasa became subtly incapacitated in the first place. Even in a perfect world it is rarely possible to prove subtle incapacitation, and the circumstances of flight 409 were far from ideal. Nevertheless, some possible contributors were identified. First, although the pilots’ flight schedules technically complied with duty time limits, they had been flying close to the maximum number of allowed hours for weeks on end, which could have caused chronic fatigue. The pilots’ statements while on the ground also suggested that eating a heavy meal right before bed negatively affected their ability to sleep, to the point that they joked about whether the meal was in fact spiked with weed. Operating on inadequate sleep could have degraded their mental acuity and increased the risk of subtle incapacitation. Stress and task saturation, two other triggers of the condition, were also present during the accident flight, exacerbated by the fact that this was Captain Negasa’s first time flying out of Beirut, he was new to the captain’s position on the 737–800, it was 2:30 in the morning, and there were storms in the area. But these factors by themselves don’t necessarily lead to subtle incapacitation, and the mechanism by which they do so, or do not do so, is not well understood, so their mere presence can’t be considered a conclusive explanation.

The main section of the horizontal stabilizer is recovered from the sea by a salvage ship. (Lebanon Ministry of Public Works and Transport)

Once Captain Negasa began to lose situational awareness, he decided (correctly) to relieve some of his workload by engaging the autopilot. This would have significantly reduced the number of tasks he needed to monitor and might have allowed him to stabilize the situation. But the autopilot was never engaged, either because First Officer Beyene didn’t hear him, or because Beyene attempted to do so but failed because Negasa was still applying pressure to the control column. In either case, the failure to engage the autopilot should have led to further communication. Upon receiving no response, Captain Negasa should have repeated his instruction, and if Beyene heard him but could not engage the autopilot, he should have explained this to Negasa. Had this basic communication occurred, the pilots might have been able to solve the problem and engage the autopilot.

A soldier inspects pieces of seats washed up on the coast. (CNN)

While Negasa’s failure to communicate could be pinned on his subtle incapacitation, it was harder to explain why First Officer Beyene, who by all accounts was an excellent pilot and one of the best in his class, failed to take any action of his own. Not only did he not engage the autopilot, he also neglected to call out most of the captain’s mistakes, such as the steep bank angles, and did not respond when Negasa became overwhelmed and asked for help.

However, it was possible to understand why Beyene, who appeared to maintain a greater degree of situational awareness than Negasa, did not simply take over the plane. After all, if a captain with 20 years of experience couldn’t control the airplane, how could he possibly expect to do better?

A comment by an instructor on one of Beyene’s early training flights added further clarity. The instructor apparently admonished Beyene for “unnecessarily interfering” with the pilot flying and asking too many “irrelevant questions.” The comments, at a formative stage of his career, could have made him self-conscious about his naturally assertive personality, leading him to avoid “interfering” with Captain Negasa out of an abundance of caution. Nevertheless, those who knew the first officer said that his behavior on the cockpit voice recording left them baffled — it was hard to imagine that so many things could be going on around him without eliciting any reaction.

A piece of the plane with Ethiopian Airlines livery is recovered from the shore. (Reuters)

Investigators also examined Ethiopian Airlines’ pilot training program, which seemed to be well-run, albeit with some blind spots. The program included Upset and Recovery Training, which was not required but had been voluntarily adopted by the airline. This training — in theory — puts pilots in dangerous situations and forces them to fly their way out. But Ethiopian Airlines simulators were only capable of replicating the most basic upset events, so most of the recovery techniques were taught in an academic setting. The only maneuver pilots actually got to practice in the simulator was the recovery from a nose-high upset with wings level, a scenario which merely requires the pilot to push forward on the yoke and lower the nose. Recovering from steep bank angles, developed stalls, high-speed dives, inverted positions, and combinations thereof were covered as theory only. In a series of simulator tests after the accident, investigators were able to prove that recovery from the final dive was possible as late as four or five seconds before impact, when the plane was passing through 3,000 feet. But with the training they received, it was unlikely that the pilots of flight 409 could have pulled this off even if they hadn’t already lost all spatial awareness.

The Ethiopian reply to the Lebanese report did not mince words. (Ethiopian Civil Aviation Authority)

In their final report, investigators blamed the crash on the captain’s subtle incapacitation and the crew’s loss of situational awareness, which caused them to make a series of inputs that led to the loss of control of the airplane. However, this explanation did not sit well with the Ethiopian side, who immediately denounced the report and published a strongly worded 10-page rebuttal. The Ethiopian report called the Lebanese inquiry “biased, lacking evidence, and incomplete,” and directly accused Lebanon of picking a cause on day one and ignoring contradictory evidence. In fact, the Ethiopian report might have been the most hypocritical rebuttal ever submitted in response to an aircraft accident report.

The Ethiopian position was that there had been a conspiracy to frame the pilots from the beginning. The rebuttal cited the fact that both Lebanese and American investigators had been quoted sharing their suspicions that pilot error was to blame as early as two days after the crash. However, while the Lebanese investigation did display poor media discipline with its excessive sharing of speculative information, treating these statements as evidence of a conspiracy was completely disingenuous. It was obvious to most experts from the immediately available data that the actions of the crew likely played a central role in the sequence of events. The similarities to previous accidents, all of them caused by human factors, were already quite apparent. There was no conspiracy, just common sense.

Debris including a child’s toy lies strewn on the beach after the crash. (AP)

The rebuttal argued instead for the same completely baseless position that the Ethiopians had held since day one: that there was an explosion on board the plane, leading to a loss of control. The only direct evidence for this were several witness statements claiming that they saw a ball of fire descending at the moment of the crash. But witnesses are notorious for reporting that crashed planes were on fire when they were not, a fact which the Ethiopian investigators should have known perfectly well. The Lebanese side concluded that the “ball of fire” was actually the airplane’s exterior lighting, which suddenly became visible when it dropped below the cloud base.

Other than this useless piece of evidence, the rebuttal relied entirely on classic conspiratorial logic. They contended that no evidence of the crew responding to a mechanical failure was recorded on the CVR because this evidence was hidden during two 10-second periods which were missing from the tape, one during the takeoff roll and another four minutes later. Lebanese investigators determined that these gaps were caused by a faulty memory chip. Similarly, because no evidence of fire was found on the parts of the plane which were recovered, the rebuttal concluded that the evidence would surely be found on the 92% of the plane which remained on the sea floor (never mind that the pieces which were recovered came from a variety of locations and did not leave any major blind spots in terms of possible locations for a catastrophic fire). Lebanon’s chronically cash-strapped government in fact lacked the funds to retrieve the rest of the wreckage; Ethiopia claimed it had offered to pay for the recovery itself, only to be rebuffed, but provided no hard evidence substantiating such an offer.

The Ethiopian report came to an entirely baseless conclusion. (Ethiopian Civil Aviation Authority)

The rebuttal also made a number of other unsubstantiated claims, including that the plane’s movements were not commanded by the pilots; that the pilots made no mistakes; and that the captain could not have been subtly incapacitated because he continued to make active control inputs, never mind that those inputs were nonsensical and contradictory.

The Ethiopian side further claimed that the Lebanese investigation was poorly organized and that they struggled to gain full access, an assertion which was probably true, given that Lebanon is famous for its long tradition of spectacular governmental mismanagement. But these grievances fell flat when included in a rebuttal which was internally inconsistent, ignored well-established aviation knowledge, disregarded available evidence, and failed to present any coherent counter-narrative. One can only wonder whether the Ethiopian investigators, who were presumably aviation professionals, were forced to write this spurious report by some high-ranking government official who wanted to defend the country’s reputation at any cost.

The question of whether Ethiopian Airlines was being honest about the internal state of the company is still relevant today. In the aftermath of the crash of flight 409, the airline presented a clean face to Lebanese investigators, providing them with a treasure trove of information which seemingly indicated that there were no problems with skill levels or training among its pilots. In their report, the Lebanese side questioned how, if this was true, the crash of flight 409 could have occurred.

The aftermath of the 2019 crash of Ethiopian Airlines flight 302. (New York Times)

Following the crash of Ethiopian Airlines flight 302 near Addis Ababa in 2019, history seems to be repeating itself. While Boeing was primarily at fault in the crash of the brand new 737 MAX 8, the publication of the final report has become bogged down by a dispute between Ethiopian investigators and their counterparts at the American NTSB over the extent to which the investigation should examine other factors. A comprehensive analysis of the events would ask whether the pilots were properly trained to handle a major emergency, and whether Ethiopian Airlines was properly maintaining its planes’ angle of attack sensors (one of which failed, triggering the software system that caused the crash). If, as industry experts widely believe, the state-owned airline is stalling the investigation in an effort to avoid asking these tough questions, we can certainly point to Ethiopian Airlines flight 409 as precedent.

Protestors call for an end to the Tigray War in Ethiopia. (Hussein Ery)

The behavior of Ethiopia with regard to its flag carrier is not conducive to safety, and if the country keeps finding excuses to deny the existence of systemic problems, Ethiopian Airlines may yet have another fatal accident. Furthermore, the future of the country itself is in doubt, following the outbreak of civil war in November 2020 and the near-collapse of the central government in 2021. In this new political environment, it is becoming increasingly clear that Ethiopian Airlines serves as a vessel for the whims of the political establishment. Amid accusations that the Ethiopian army is committing genocide against the Tigrinya ethnic group, the government banned the airline’s Tigrinya chief executive from leaving the country and dismissed other Tigrinya employees. A CNN report in October 2021 also found that Ethiopian Airlines is using its planes to smuggle arms into the country from Eritrea, a practice which flies in the face of flight safety and violates international law. The report questioned the airline’s membership in the Star Alliance group and its permissions to fly to the United States in light of these revelations. Ethiopian Airlines issued an aggressive but unconvincing denial of the story. Once again, the airline and the government officials who control it seem to be more interested in maintaining the image of a safe airline than they are in the actual safety of Ethiopian air travelers.

A Qatar Airways plane takes off from Beirut as searchers comb for debris on the beach near the airport. (The Telegraph)

Looking back today, the crash of Ethiopian Airlines flight 409 stands out as one of the most bizarre accidents in recent years. Even after an exhaustive analysis, it’s still hard to understand how events spiraled so catastrophically out of control. But the accident also feeds into one of the great debates of modern airplane design: how much authority to give the pilots. The crash of flight 409 seems superficially similar to the crash of Air France flight 447, an Airbus A330 which plunged into the Atlantic after the pilots reacted to a minor instrument failure by pulling up and stalling a perfectly functional airplane. On the other hand, it is at its core quite different. Air France flight 447 probably wouldn’t have crashed if it were a Boeing; the accident scenario relied on the sudden withdrawal of flight envelope protections that don’t exist on Boeing aircraft. At the same time, flight 409 wouldn’t have crashed if it had been an Airbus, because computers would have protected the plane against the pilot’s attempts to overcontrol it. For aircraft designers, it’s a trade-off: do they prevent pilots from repeating Ethiopian Airlines flight 409, while risking a repeat of Air France flight 447 if those protections unexpectedly fail? Or should they take the opposite stance? It’s a question that may never be fully resolved. And for those 90 souls who perished in the stormy Mediterranean, it’s also hopelessly esoteric — in the end, no amount of speculation will ever bring them back.

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Analyzer of plane crashes and author of upcoming book (soon™). Contact me via @Admiral_Cloudberg on Reddit or by email at kylanddempsey@gmail.com.