POH - the holy writ?

[james ozzie]

In many of the debates in this forum, there is the often repeated position "follow the POH / manufacturers recommendations". This is obviously a sensible and safe option - it would be exceptional to not do so. BUT, have there been any instances of errors / bad info in these publications, given that they are prepared by us fallible humans (albeit assisted by our infallible computers...)? Has an accident investigation ever traced an accident cause to erroneous info in a manufacturers publication?

[stator vane]

i've got it----i've never seen the POH directly telling the pilot--

"do not fly into mountain!!!"

"do not crash airplane!!!"

"never run out of fuel!!!"

why even mcdonalds tells us that the coffee cup is HOT!!!

[WhiskeyDelta]

My ab initio instructor summed it up thus:

"If, when the fish pie hits the strawberry cheesecake, you are found to have been following the POH to the letter you will be exonerated. On the other hand if you are found NOT to have been following the POH to the letter you probably will not, regardless of circumstance"

I do not have either the experience nor the expertise to say whether or not ALL POH's are accurate and correct to the final punctuation mark, but the little experience and minimal expertise I DO have suggests to me that if you operate the aircraft within the boundaries laid out by the POH then there is probably sufficient margin for error as to keep you out of trouble. After all; the writers of the POH have their own reputations (not to mention liability suits) to worry about.

WD

[Clarence Oveur]

There are times when I think people would jump around on one leg singing the HMS Pinafore Overture if the book said so.

[Gooneyone]

While I do believe that we are required to follow the POH, I strongly believe that we are not required to follow it BLINDLY.
Sooner or later you will encounter a situation that is not covered by the POH and will have to act based on experience and knowledge. That is when you earn your salary.
And always be prepared to justify your actions to those who cannot think for themselves and will follow the POH regardless, as they will cast the first stone.

[john_tullamarine]

I will probably upset a few people as this gets into "secret certification business", to misquote an Oz phrase ...

First, a very brief bit of history.

If we go back many decades to when aeroplanes were either little (Tigers etc.) or "big" (DC3, DC4, etc.) the top information (for pilots) document was the Certificate of Airworthiness.

Eventually, it became impracticable for all limitations etc., to be specified in the CofA or placards and a document anciliary to the CofA (the Flight Manual) came into being.

In the US experience this eventually evolved into a Pilots' Operating Handbook (POH) which incorporated both OEM "good guts stuff" (but not approved by the Regulatory Authority) and the Flight Manual information (approved by the Authority).

Later on, the General Aviation Manufacturers' Association (GAMA) published a POH format style for light aircraft which the bulk of such manufacturers has since adopted. I don't recall whether the GAMA format adopted the very similar ICAO Operations Manual recommendations for light aircraft .. or vice versa .. not that it matters all that much, I guess...

Generally, these days, one finds that the ever-present spectre of litigation causes the POH to contain much less than we might desire but that is the nature of life today.

...the often repeated position "follow the POH / manufacturers recommendations".

First, one definitely needs a very good reason to NOT follow the Regulator Approved bits of the POH (the Flight Manual bits) - these are not recommendations - they are instructions. However, there are procedural rules which permit the pilot in command to do just this if the situation so warrants ... but be very prepared to argue your decision at the enquiry ... believe those of us who have been in such positions ... not fun ... no fun at all.

The OEM (non-approved) bits should be viewed as guidance material and not mandatory. The sensible operator will seek to get quasi concurrence from the OEM via a No Technical Objection (NTO) process if it is desired to do something different.

If can paraphrase a checkie from long ago (and, for whom, I had the highest regard) .. "most of these documents leave an important bit out on the front page - to be used with a bit of commonsense ..."

have there been any instances of errors / bad info

You betcha sweet bippy there have been ...

I have picked up numerous such errors over the years ranging from isolated errors (which, when reported to the OEM, usually - but not always - get corrected in subsequent POH revisions) through to my best effort quite some years ago in Oz where I discovered that a particular model of helicopter was flying with the wrong Flight Manual - quite a few helos involved with that one - it was fixed reasonably quickly.

Overall, though, and considering the litigation potential, the POH is subject to a reasonable level of checking and the error rate is pretty low.

Has an accident investigation ever traced ..

Can't bring an example to mind but, I suggest, especially in the avionics/FMS arena, there is plenty of potential.

I commend reading what you can find on the NZ Apia B767 incident ... also a good example of how an airline can proactively and sensibly approach such matters. As an aside, I got a fair bit of privileged information at the time due to my then contract work and I have to say that I was pretty impressed with the Air New Zealand management folk who were involved ....

[411A]

Some time ago, I worked for a small SE Asian airline (now a whole lot bigger) who operated 10 B707's, two of which they ordered new, and the remaining eight from three different Boeing customers.
Switches/lights here and there, all somewhat different.
However, the AFM/QRH's all came from one source...Boeing.
The instructions from the company were quite clear...please operate in accordance with the therein stated Boeing procedures, thank you very much.
Worked like a charm.
Then, one day I approached the 707 fleet manager and suggested a slight change...a flap 40 landing SCD, under certain circumstances.
Reason, less noise and fuel.
He wanted to know...'Just who operates this way?'
PanAmerican, says I.
After I provided the relevant operating data, a change was made to permit flap 40 landings (ISO flap 50)...all of course SCD.
For this small suggestion, I was awarded one months additional salary, and a nice 'thank you' from management.
At this point I also offered another suggestion.
The company should adopt, as the last item on the before takeoff checklist, a configuration check...

Flaps set correctly.
Speed brake lever checked fully forward.
Trim in the takeoff range.
Compass/RMI heading checked/agreed with the mandated takeoff runway.

This was considered and rejected. Don't know why.
However, shortly thereafter, one of the companies B747's was involved in a wrong runway departure (Melbourne, departure on runway 27 instead of 34), with nearly disastrous results.
Checklist change now accepted.
PanAmerican had several mishaps in the early days of jet transport operations, and learned their lessons well.
However, change came more slowly to other operators.:ugh:

[james ozzie]

Thanks for the input folks - appreciated

[Flight Detent]

Hi guys,

Just thought I'd add my little bit of knowledge of this area of Boeing operating manuals, now known as AFM and FCOM.

The AFM, the highest authority as far as Boeing FCOMs is concerned, has an applicability section in it's preface. This specifies the actual airplanes by their manufacturing serial numbers that the AFM refers to, and adds that no other airplanes are included.

It's all related to FAA approvals.

Cheers...FD :\

[Brian Abraham]

This is my layman’s view of where we sit, bearing in mind that rules are for the obedience of fools and the guidance of wise men. Unfortunately the courts assume we are fools.

RESPONSIBILITIES OF THE PILOT IN COMMAND

The scope of responsibilities of the pilot in command is contained within CAR 224, which provides;

‘(2) A pilot in command of an aircraft is responsible for:
(a) the start, continuation, diversion and end of a flight by the aircraft; and
(b) the operation and safety of the aircraft during flight time; and
(c) the safety of persons and cargo carried on the aircraft; and
(d) the conduct and safety of members of the crew on the aircraft.

(2A) A pilot in command must discharge his or her responsibility under para (2)(a) in accordance with:
(a) any information, instructions or directions, relating to the start, continuation, diversion or end of a flight; that are made available, or issued, under the Act or these Regulations; and
(b) if applicable, the operations manual provided by the operator of the aircraft.

(3) The pilot in command shall have final authority as to the disposition of the aircraft while he or she is in command and for the maintenance of discipline by all persons on board.’

The pilot in command is also responsible for ensuring that certain duties have been performed before flight. These duties may be performed by other persons, however pilots in command have final responsibility to “ensure” that tasks entrusted to them have been complied with. CAR 233 states the pre-flight duties as follows;

‘An aircraft shall not commence a flight unless evidence has been furnished to the pilot in command and the pilot in command has taken such action as is necessary to ensure that;

 all required instruments and equipment are functioning properly
 the gross weight of the aircraft does not exceed the limitation
 the aircraft is correctly loaded for all stages of flight
 the fuel supplies are sufficient for a particular flight (CAR 234 details the factors to be considered by the pilot in command in calculating the fuel requirements)
 the required crew members are on board and in a fit state to perform their duties
 the air traffic control instructions have been complied with
 the aircraft is safe for flight in all respects; and
 all relevant aeronautical maps, charts and other documentation are carried.’

CAR 138 requires ‘If a flight manual has been issued for an Australian aircraft, the pilot in command of the aircraft must comply with a requirement, instruction, procedure or limitation concerning the operation of the aircraft that is set out in the manual.’
Penalty: 50 penalty units.
LIABILITIES OF AIRCREW

There are various sources from which the duties of the pilot in command and other aircrew derive. It is important to understand the difference between these sources as the nature of the responsibilities created by each of these sources varies considerably.

An important consideration which flows from the various duties imposed on aircrew is the consequences of a breach of such duties. In some instances, particularly statutory duties, the duty imposed is one of strict liability, the breach of which may attract criminal sanctions.

The main sources from which aircrew duties derive are;

contractual duties
a duty of care: arising from the law of tort; and
statutory duties: imposed by the regulations and other legislation

Contractual Duties: are imposed on the pilot in command and other crew members by the terms of their contract of employment. Another source from which contractual duties may arise is from the contract of carriage. In the majority of cases there will be no contractual agreement between aircrew and the passengers or owners of cargo. Unless someone is a party to a contract then that party is not liable, nor can they claim any rights under the terms of that contract. Pilots and other crew members have contracts with the operator and so do the passengers and owners of cargo. There is no contract between the passengers or cargo owners and the crew of an aircraft. The only exception is the pilot that enters into a formal contract with a passenger or owner of freight. This might occur where the pilot owns the aircraft or is a freelance pilot offering aircraft charter services.

A Duty of Care: is another source of liability to aircrew. This duty is created by the existence of a certain relationship (neighbour principle) recognised at law. (Neighbour Principle: The rule that you are to love your neighbour becomes in law, you must not injure your neighbour; and the lawyer’s question, who is my neighbour, receives a restricted reply. You must take reasonable care to avoid acts or omissions which you can reasonably foresee would be likely to injure your neighbour. Who, then, in law, is my neighbour? The answer seems to be --- persons who are so closely and directly affected by my act that I ought reasonably to have them in contemplation as being so affected when I am directing my mind to the acts or omissions which are called in question.) The pilot in command owes a duty of care to a great number of people including passengers, fellow crew members and other persons both on the ground and in other aircraft. Once qualified or licensed, lack of experience is not sufficient grounds for imputing a lower standard of care for an individual.

The following example serves to provide a reminder as to the extent to which the courts may hold a pilot liable.

A railroad worker was killed when the canopy of a military aircraft struck the employee while he was eating his lunch on a railway right of way. Evidence disclosed that the pilot, who had ejected, had been negligent in not avoiding a thunderstorm, which had resulted in the subsequent loss of control.

The pilot whose carelessness has brought about the error will be held to be negligent provided the resulting injury was reasonably foreseeable.

Statutory Duties: are those imposed on aircrew by the volume of aviation related legislation that specifies the duties required of the individual. The most obvious legislation relating to the duties of aircrew is CAR’s. Other documentation, such as the operators Operations Manual, is equally binding on aircrew.

Aviation personnel are trained to deal with abnormal and emergency situations. Therefore during an aviation emergency situation, a person who deviates from established emergency procedures without reasonable cause, may be liable for damage so caused.

Evidence that a pilot or other crew member acted contrary to published procedures would be prima facie evidence of negligence. The burden to show that the deviation from standard procedures was justified is a heavy one and firmly on the shoulders of the plaintiff.

Negligence: In certain situations the law will require an individual to ensure a requisite level of care with regard to the welfare of other persons. If, as a result of the actions or omissions of that person who owes a duty of care to the other person, that other person suffers injury or damage, then the person who has breached their duty is guilty of negligence.


Professor Reason in Human Error (1990) distinguishes between active error, the effects of which are felt almost immediately, and latent error, the adverse consequences of which may lie dormant within the system for a long time. This can clearly be seen in aviation, where pilots at the sharp end make an active error, while latent error lies behind the lines within the management support system. Many of these are already there awaiting a trigger, usually supplied by the pilot. ‘There is a growing awareness within the human reliability community that attempts to discover and neutralise those latent failures will have a greater beneficial effect upon system safety than will localised efforts to minimise active errors.’
As long ago as 1980, Stanley Roscoe wrote that:
The tenacious retention of ‘pilot error’ as an accident ‘cause factor’ by governmental agencies, equipment manufacturers and airline management, and even by pilot unions indirectly, is a subtle manifestation of the apparently natural human inclination to narrow the responsibility for tragic events that receive wide public attention. If the responsibility can be isolated to the momentary defection of a single individual, the captain in command, then other members of the aviation community remain untarnished. The unions briefly acknowledge the inescapable conclusion that pilots can make errors and thereby gain a few bargaining points with management for the future.
Everyone else, including other crew members, remains clean. The airline accepts the inevitable financial liability for losses but escapes blame for inadequate training programs or procedural indoctrination. Equipment manufacturers avoid product liability for faulty design,. Regulatory agencies are not criticised for approving an unsafe operation, failing to invoke obviously needed precautionary restrictions, or, worse yet, contributing directly by injudicious control or unsafe clearance authorisations. Only the pilot who made the ‘error’ and his family suffer, and their suffering may be assuaged by a liberal pension in exchange for his quiet early retirement – in the event that he was fortunate enough to survive the accident

Yet it is only recently that very dubious management malpractices are being identified and their contribution to accidents given sufficient weight. For though the pilot’s actions are at the tip of the iceberg of responsibility, many other people have had a hand in it – faceless people in aircraft design and manufacture, in computer technology and software, in maintenance, in flying control, in accounts departments and in the corridors of power. But the pilot is available and identifiable.

Read the last two para and give pause to Air New Zealands stance with regard to the Erebus accident. Thanks to Justice Peter Mahon they didn’t quite get away with it. They obviously learnt their lesson though, by their consummate and exemplary handling of the Apia B767 incident which can be held as an example of how accident prevention is supposed to, and should, operate. The upshot is when standing before the Coroner you better have a damn good reason why you didn’t comply with the rules, regs etc.

I spent 27 years with Esso in its Bass Strait operation, leaving in 2004. On the 25th September 1998 the company suffered an explosion in the gas plant which killed two men, injured eight others and completely cut the gas supply to the state of Victoria for two weeks. Dr Andrew Hopkins wrote a book (Lessons from Longford) of the event and of the subsequent Royal Commission as briefing material for the legal profession. Some extracts,

“….a practice which had developed of operating the plant outside the design limits…..this practice had been allowed to develop because of inadequate oversight by Esso and that, in any case, the practice was sometimes necessary to achieve production targets.”

“Alarm Overload – The operators job was to keep the process within specified limits of temperature, volume, flow and so on. The alarm problem when limits were exceeded was compounded enormously by the sheer number of alarms which operators were expected to deal with – at least three or four hundred a day! On one occasion an incident occurred which led Esso incident investigators to count the number of alarms. The figure for a 12 hour shift was 8,500 or 12 alarms every minute!”

“……the accident was quite preventable. It was caused by a series of organisational failures: the failure to respond to clear warning signs, warning signs which management ignored, communication problems, systematic lack of attention to major hazards, superficial auditing and, as much as anything, a failure to learn from past experience. There is nothing unusual about any of this – organisational failures lie behind most major accidents.”

"…..Esso did its level best to avoid being incriminated. This is presumably why it chose to place its own accident investigation in the hands of outside lawyers and to claim legal professional privilege, that is, that anything to do with that investigation, particularly any finding, was confidential because of the lawyer/client relationship. According to critics this is standard Exxon practice around the world, whenever Exxon or its affiliates suffer major accidents, and it has prevented at least one coronial investigation in the past from getting to the truth.”

“Esso’s explanation for the accident was of course quite predictable. The company was facing claims totalling more than a billion dollars from gas customers who had been affected by the loss of supply. If it could argue that the accident was not its fault, but rather, the fault of some of its employees, it might escape liability. Moreover, if it could shift blame for the accident to the operators it would be able to defend itself against any prosecutions which the authorities might initiate.”

All the above points made applied equally well to the manner in which we conducted flying operations. Personally I made sure that the mainframe contained reports of our failures (to protect myself) and the companies failure to address those concerns. But what chance CASA taking the worlds largest multi national to task? TRANSAIR represents CASA’s inability to adequately oversee aviation operations, and that may be due to understaffing and inadequate funding, among other failings, but I’m not in a position to judge, other than something’s rotten in the state of Denmark. As posted on another thread the problem may very well lie here,

First priority in Casa is to not rock the boat
2nd priority - set up your super
3rd priority - sit out the frustration to retirement
4th priority - try and arrive at retirement intact

Sorry to be so boring, irritating and verbose. Had to cough up the phlegm and get it off the chest.

[stator vane]

wow--

something that long has to be very good

or very bad

will let you know after i read it----

that will take a while--

but thanks for putting it on.

i read one report of a cargo ship's captain being nailed in court for taking a different route to avoid adverse weather that he had encountered on a previous trip. the route took longer and thus delayed the arrival of the goods that were contracted to arrive before a certain time. they put it all on him.

the bastards that "drive" the big oak desks will win every time that they and their solicitors can make it possible!!!

[Nubboy]

Just bear in mind that several operators have command course selection procedures that have scenarios/dilemmas that will have no clear cut answer.
If you can't argue your case for a decision in the sim against an experienced training captain, that may have been outside the limits placed in the POH or AOM, depending on what it's called, then are you sure this is the career for you?

As other people have already stated, the guys on the ground have big expensive lawyers, and all the time in the world to review a decision you might have made in a very small period of time.
In most cases the POH is the best source of info and ideas you can have, but it aint perfect.
At the end of it all, you're the most visible target the lawyers will go for.