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Old 26th January 2010 | 11:25
  #2454 (permalink)  
chuks
 
Joined: Apr 2003
Posts: 1,567
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From: Germany
Blame, in a crash report?

These crash reports try to establish probable causes but they explicitly avoid putting blame on this or that.

From what I have read we might see something along the lines of one probable cause being the interaction between the defective radar altimeter and the autothrottle. Given that if the systems had been working free of fault and as designed then there's no way you should see the engines pulled back to idle by the autothrottle system with the aircraft nowhere close to touchdown; that is rather obvious.

It seems to be the autothrottle system being "told" by the radar altimeter to pull the power off because the aircraft was at touchdown height that set off this fatal chain of events but we will have to read the full report to see if that is correct. Too, this was a "chain" made up of multiple links that ended in a crash. You might well argue that if the throttles went to idle with the aircraft still a long way from landing then it must be up to the crew to push them back up again so that this inaction was the next link in the chain. It's too simplistic to say that either the autothrottle or the crew was to blame for the crash; you can only say what helped to cause the crash.

What a layman wants or expects to read, that the "blame" for the crash lies with this defect, won't be there. At the most you might see that as a "cause" or a "contributing factor." I think people watch too many episodes of Miss Marple and expect something similar from a crash investigation, someone in a white lab coat holding up a mangled gadget to tell us, "This is the thronomister valve that was to blame for XYZ Airlines fatal crash." ICAO doesn't work that way so that you will only see "This is a thronomister valve that did not operate as designed because of..." It is pretty boring stuff when you get right down to it but that might be because a crash investigation, a real one and not the bastard child of one you see on R&N or some TV program, is not entertainment but a safety tool. It is meant to educate aviation professionals so that we can avoid the next accident.

"Blame" will come into play in the court cases that are sure to follow. If you have any knowledge of those you will know that it's often so that the blame goes to the entity with the deepest pockets and has little or nothing to do with the cause of the accident.

For the purposes of safety blame is useless. If I am told that a certain crash was 100% down to Joe Bloggs totally making a mess of things, what should I do about that? Joe Bloggs messed it up and Joe Bloggs is dead, end of story! If I am told that poor old Joe did something that proved fatal because of the following factors, then that is completely different and gives me something to work with to achieve improved safety.

For the purposes of winning a fat settlement from 12 good men and true who often hardly know how to spell "airplane" blame will do quite nicely. I was struck by reading an account of an undershoot on an instrument approach with the wreckage consumed by fire when the plaintiff's attorney successfully argued that the blame lay with the aircraft, that it was on fire before the CFIT (Controlled Flight Into Terrain), when the jury bought this seemingly specious argument. The odds were that it was a perfectly good airplane that was mishandled but, yes, it could have been on fire on final; you couldn't prove that one way or the other thanks to the fire that consumed the evidence. The clever attorney managed to persuade the jury where the blame lay and that was that! Of course the NTSB had a very different probable cause in their crash report but that had nothing to do with assigning blame. Just as they will not assign blame they will not absolve anyone of blame. They are not in the "blame game."
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