The United Kingdom Air Accidents Investigation Branch (AAIB) is part of the Department for Transport and is responsible for the investigation of civil aircraft accidents and serious incidents within the UK. The Chief Inspector of Air Accidents reports directly to the Secretary of State for Transport.
The fundamental purpose of investigating accidents is to determine the circumstances and causes of the accident with a view to the preservation of life and the avoidance of accidents in the future; it is not to apportion blame or liability.
OBJECTIVE OF THE INVESTIGATION
3.1 The sole objective of the investigation of an accident
or incident shall be the prevention of accidents and incidents.
It is not the purpose of this activity to apportion blame or
liability.
I find it hard to conceive how one could attain that objective without a determination of causes.
Further, it later states:
Quote:
ORGANIZATION AND CONDUCT OF THE INVESTIGATION
Note.— The Manual of Aircraft Accident Investigation
(Doc 6920) contains guidance material for the organization,
conduct and control of an investigation.
RESPONSIBILITY OF THE STATE CONDUCTING THE INVESTIGATION
Note.— Nothing in the following provisions is intended to
preclude the State conducting the investigation from calling
upon the best technical expertise from any source.
General
5.4 The accident investigation authority shall have
independence in the conduct of the investigation and have
unrestricted authority over its conduct, consistent with the
provisions of this Annex. The investigation shall include:
a) the gathering, recording and analysis of all available
information on that accident or incident;
b) if appropriate, the issuance of safety recommendations;
c) if possible, the determination of the causes; and
d) the completion of the final report.
When possible, the scene of the accident shall be visited, the
wreckage examined and statements taken from witnesses.
5.4.1 Recommendation.— Any judicial or administrative
proceedings to apportion blame or liability should be
separate from any investigation conducted under the
provisions of this Annex.
(my emphasis)
Annex 13 is specific about not apportioning blame, but contains the expectation that causes will be determined.
(Taken from Ninth Edition July 2001)
As far as I know all (including NTSB) accident investigators are performing their function so as to prevent further accidents. This includes establishing all causal factors that can be defined and to address same with appropriate recommendations.
Unfortunately the NTSB is saddled with a mandate from congress to satisfy the public with a voted "probable cause" which often detracts from the publics understanding of a causal chain.
Nevetheless the NTSB often issue recommendations against multiple causal factors thus meeting the essence of ICAO Annex 13
Is there any guarantee, accident investigators from certain countries, are free from political interference, when the findings are not to that government's liking?
If your answer is yes, you are out of touch with reality.
'First kill all the lawyers'. I didn't say that, it was written by another Will.
Too much knee jerk here. Mind your ACL's, and listen. The system is not working. Screw the lawyers, this is about power, and its misapplication. The Federal Government, here, the FAA, NTSB, etc. doesn't do stuff as in days of yore. Ask a Boeing tin monkey or a line mx for SWA. The power is having an affair on our dime. Safety? You are in la la land. The NTSB is an advisory Board, the FAA has rulemaking and punitive power.
Did no one else see the attempts by AF and ABI to massage and 'guide' the press, the people and the investigators to entertain positions that were outlandish?
The Naivete of otherwise intelligent, sage folks is showing. Building fences and hiring armed guards to repel 'onlookers' from testing and 'evidence' exposure smacks of 80's Eastern Europe. Get a clue.
I would propose an 'ombudsman' like panel, to keep the suits and the badges out of eachother's pants.
The NTSB is close, but since the FAA doesn't listen, except to 'craft suitable compliance measures in league with the rascals', we need the Court or some authority to guard the Industry from 'relaxed' pitot tube R&R.
Agreed, joe. I don't think that is likely in this case. It was, however, the situation after the American Eagle ATR72 accident at Roselawn, Indiana in 1994. The inquiry castigated ATR out of hand and totally exonerated the flight crew, who had been blatantly ignoring manufacturer's recommendations about flying in icing conditions, the skipper had been down the back chatting up the hosties, leaving a very inexperienced FO alone on the Flight Deck. They had already commented on the apparent difficulty the A/P was having with the ice accretion yet did nothing about it. And yet the NTSB put all the blame on the aircraft manufacturers.
Will, I think you're taking problems with the FAA/NTSB relationship and extrapolating to the rest of the world.
The CAA/AAIB don't work in the same way. Nor do the DGAC/BEA. No, we do NOT need lawyers muscling in on investigations by professionals who have no particular axe to grind, whose interest is only in discovering the causes of the accident and making recommendations to ensure they do not recur. If subsequently the regulatory authorities decide not to implement or mandate those recommendations, then they will be in danger of a corporate manslaughter charge if such non-compliance leads to a future accident.
The NTSB are required to include a "Statement of Probable Cause" in their accident reports.
ICAO does not require a "Statement of Probable Cause": Annex 13 states only that the report shall include if possible, the determination of the causes (and note the plural).
The objective of ICAO accident reports is to recommend measures to prevent future accidents or incidents. The object of US NTSB reports is to deduce the cause of the accident. This difference in objectives may be subtle, but it is very important to understand the effect which that subtle difference has on the way an investigation is conducted. NTSB accident investigators certainly have their own reservations about the Probable Cause requirement and they would prefer have it removed. Or so their lecturers say during their foreign seminars.
Having got that out of the way, in pursuing ways to prevent an accident or incident, the AF447 accident information currently available from live ACARS messages suggests that a possible contributory factor is loss of reliable airspeed data. The root cause may possibly be iced air data sensors, we shall probably never know for sure, for even if the DFDR is recovered it records no data that can confirm or deny that possibility. In the meantime, the industry is quite properly currently examining ways to deal with that possibility.
Last edited by Blacksheep : 12th June 2009 at 16:32.
The NTSB answers to Congress, the FAA to the President, or his authority, 'Executive' under 'Administrative Law'.
There is a clue there about what is getting done. IMO there is nothing necessarily wrong with a determination of cause, if done with care and professional process. Remember the ice occluded pipes re: BA038? That wasn't even our a/c (except the Boeing part). AAIB hasn't bothered to add anything to the party, except some grudging parroting of the FAA. Twas the NTSB, Boeing, etc. that forced a peek at the intestines of the big Boeing. That is a good thing. Secrecy or 'Data Management' is the enemy of safety. The longer it takes, the greater the continuing danger, don't we see that? In this country, though open to interpretation (sic) Congress works for the people, the authority works for?
Woe to UK. At least it's better here, we have a fighting chance. The animations within 60 days of BUF? The authority here is at least forthcoming, even though FAA drags its industry hobbled ankles along at a snail's pace.
The UK AAIB were the responsible agency to investigate an accident occuring to a UK registered aircraft on UK soil. As the aircraft was designed, built and Type Certified in the USA, the Manufacturer (Boeing) and the US invesigators (NTSB) were, as is the usual global practice, invited to participate.
Quote:
The NTSB answers to Congress, the FAA to the President, or his authority, 'Executive' under 'Administrative Law'
Quote:
The accident investigation authority shall have
independence in the conduct of the investigation and have
unrestricted authority over its conduct...
I wonder if anyone can see any inconsistency in the above two statements?
It certainly wasn't the NTSB, Boeing or anyone else for that matter who "forced a peek at the intestines of the big Boeing". The NTSB and the AAIB take their responsibilities very seriously and jealously guard their independence.
I agree, and extrapolation is my middle name. It is my version of 'where is this going'. Looking ahead with feet on the deck serves me well. Your point is well taken, and my disgust with the 'legal' profession rivals anyone's. I don't approve of capricious action. The French have a mechanism in place, ostensibly to protect the interests of the French, when mishap befalls them abroad. I can easily empathise with the heirs and families when I read tripe from AF and ABI in the press. Airlines and manufacturer's are frequently treated with parity and deference in investigations, rather than as we say here, 'persons of interest'.
Blacksheep
Inconsistency? All bodies in government derive from authority. "Independence" is in the eyes of the beholder, how sharp is your critical eye?
For those arguing about the NTSB verus ICAO and/or different countries accident investigations and the possibility of local bias determining the cause of any given accident you need not look much farther than the midair collision over Brazil last year.
Brazil, primary cause of accident; crew error.
NTSB, primary cause of accident; Air Traffic Controllers error.
Also, I can tell you from personal experience there have been accidents that the NTSB has determined the cause of an accident has been ruled, unknown. This is very rare, but it does happen.
One case in point was a Jet Commander accident that happened back in the mid 70's. The Jet Commander was cleared from FL 24.0 to FL37.0 somewhere around FL28.0 radar contact was lost and about five miles from the last radar contract the Jet Commander verticaly impacted the ground. The weather was perfectly clear VMC. The aircraft was so completely destroyed that the NTSB never determined the cause of the accident.
I know how completely the aircraft was destroyed because I was at the accident site the next morning with the son of the pilot. The pilot was one of my best friends whom I had flown with for years. It was crew only on board and we found a total of 47 pounds of human remains left from the two pilots.
I have a feeling that any bu||sh1t coming out of AF is from their PR department rather than based on much that is factual. I have in the past worked very closely with AF's Safety Department and I can tell you that they are very, very efficient and professional, and would not sanction release of any nonsense. They have a good appreciation of what Flight Safety means to the wider aviation community.
This is my first post regarding this tragic accident but I have been following some if not all the developments.
I do, however, have a bone to pick with this statement:
Quote:
The root cause may possibly be iced air data sensors,
With respect that will never be a 'root cause'. It may be a causal factor but, given that it appears that this was a known failure, (i.e. that such an occurrence had happened before and was a known factor/condition) I would suggest that the root cause may lie elsewhere.
Not for me to make wild guesses but you could start asking WHY a known problem led to the loss of an aircraft. Simple Tagamoda 5 why analysis or apply 'Taproot or 'Why Tree'.
That is not only so in France. Any ICAO language can be spoken in the respective country. Like in for example in China you will be listening to Chinese for hours and so on....
I do share your views on that subject. I would think it would need a change in legislation, this would need the political will to do so. Could imagine an implementation by ICAO rules that lawsuits could only be accepted after completion of an ongoing accident investigation.
Would think that IFALPA could address this in order that national Pilots Asssociations would be urging their national politicians. Would be a long process but surely serve the cause.
I had a post in R&N deleted soon after I posted. They probably thought I was just rattling on again about the power of thunderstorms, and about how I got a 4" hole right through the wing having gone round the fuel. Boring.
What's no so boring is the power in a storm cell. I likened it to an atomic explosion in terms of total power. Perhaps they found that boring as well, or maybe they didn't believe me.
I rechecked the figures which are easily researched with G**gle. The total energy is mind-bogling, and it wouldn't require more than a small percentage of this to 'vaporize' the aircraft. This doesn't happen, because the energy just isn't focused in the right way, but even a tiny part can be catastrophic.
I can see how just trying to fly an attitude would be very, very difficult when over-speeding was a hair's breadth on a dial or screen that's shaking violently. The other way, a fraction away from stalling. But really, all this talk about speed indication? My experience is that pressure instruments go wild. They are quite meaningless for minuets at a time if you're in a bad one. Why is there all this talk about the 'Sensors'? A blinkered approach to problem solving I would have thought.
Imagine trying to keep wings level and some sort of slightly nose-down attitude. A fraction down buys a lot of stability, but also an over-speed in a second. But really, it's the only action to take in the very bad moments. Any attempt to climb as you feel the aircraft fall away beneath you, is fraught with danger. This is why you can't practice in a simulator, so much of coping with violent turbulence is interpreting the thermal lift by human senses. Yes, this totally contradicts the basic "Believe the instruments" doctrine. But it's only in one dimension and only for moments at a time. Sometimes it's all you've got when the wings go into resonance and instruments are nothing more than vertical blurs of light.
My guess would be the poor souls just lost it - in an aircraft who's computers can't interpret long periods of 'Rubbish in' so they gave 'Rubbish out'. Also, it's an aircraft that doesn't lend itself to going aerobatic.
I can imagine their last moments, and I feel so deeply sorry.
It\'s a good point about NTSB impotence and FAA incompetence. Un lubricated rudder screws and badly designed cargo doors allowed to proliferate come to mind. Incidentally a woman involved with Air Alaska management electing to extend the maintenance period on rudders assemblies by some 200 % is now in a senior position at FAA.
CR2 -- I'm hoping the answer is that the MS Flight Simmers, conspiracy theorists, spouses of PPRuNe addicts, and other ne'er-do-wells usually don't find their way to JB. So, ironically but not unexpectedly, professionals and long term ppruners end up on the forum that caters to sundry other subjects. I say "ironically" because when I first signed up and took my PPRuNers' Oath I felt that most of the arcraft accident discussions would be better placed in the "safety" thread. I now know that any thread about a specific accident on that forum would -- in light speed -- be as infested as R&N.
So . . . CR2 . . .
If I'm correct, let's all be vewwy vewwy quiet . . .
Linear Mode
