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Old 7th Feb 2004, 22:24
  #58 (permalink)  
694c
 
Join Date: Mar 2003
Location: hamble
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320driver - don't worry, only a joke. Well spotted anyway. Actually there is something wrong: in the given configuration the warning flag should be visible on the standby horizon. Now back to the serious business...

Three things disappointed me in the accident report:

1/ The reference to the inverted No.1 oil instrument without any further investigation or explanation.

It's as though this was a piece of dirt thrown in to make one think "yeah, ****e maintenance, cr@p pilots, not at all Swiss-watchmaker-like to have clocks and gauges upside down". I guess it went something like this: the original failure was on the No.2 engine oil indication; the only spare was an older item. If you look at the illustration on page 157 of the report you can see that this was a different instrument, probably with different wiring connections, and it fouled the others on being slid into the recess, the only solution was to invert No.1 gauge. The scales for temperature and pressure have green arcs so it's easy to see at a glance if all is normal even when upside down; quantity might require a closer look but it's not an important parameter in the short term. I would consider this an acceptable fix until the correct spare part became available.

2/ The glib statement that 'The accident was only survivable by chance'.

I saw one of the survivors interviewed on television on the day of publication and he was deeply insulted by this remark. He'd moved aft from his originally assigned seat to avoid disturbance from an African-American pop singer (ex La Bouche) and her entourage and fortunately registered that the closest exits were now behind him. After impact he was hanging upside down amongst twisted metal and branches with an inferno in front. He managed to get out by the remains of the aft galley and then helped other passengers. I would say that the accident was survivable thanks to two important points: the strength of construction of the Avro RJ and the incredible initiative and willpower to survive shown by those passengers and crew who were not immediately incapacitated. This should have been recognised.

3/ The omission of a full cockpit voice recorder transcript.

Only edited highlights were presented, which gave one the impression that the investigators only released those parts that suited their conclusions. It's usual to provide a full transcript with timeline that includes all that was recorded, including coughs, whistles, rustling paper etc.. The recording from the Korean 747 at Guam (another NPA disaster) is fascinating in that it does just this; throughout the entire approach the Captain was adjusting his seat electrically - probably a nervous reaction - it provides an interesting insight into the atmosphere in the cockpit during those final minutes.
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