"Drug found in Pilots of Jet Crash"

[srs what?]

Bit of a sensationalist headline. Taken from BBC News:

Drug found in pilots of crash jet:

Traces of a non-prescription drug were found in the pilots of a plane which crashed in Birmingham killing five people, a report reveals. The nine-seater Canadair Challenger jet crashed during take-off in 2002.

A report into the crash said frost on the left wing led to the plane going into a rapid roll.

But investigators also concluded the judgement of both pilots may have been impaired by the combined effects of the drug, jet-lag and fatigue.

The plane crashed at Birmingham International Airport in sub-zero temperatures on 4 January.

All five people killed in the crash were US citizens.

Both pilots had disturbed and inadequate sleep for the two nights preceding the accident and it was possible they were suffering from jet-lag .

A report by the Air Accidents Investigation Branch said the plane had been kept on the airport apron the night before the crash where temperatures dipped to minus nine celsius.
The crew did not ensure the wings were clear of frost prior to take off, the report said.

An aviation pathologist found traces of the drug diphenhydramine, a sedative anti-histamine found in a number of products used to aid sleep, in both pilots.

The report revealed: "He concluded that both pilots had disturbed and inadequate sleep for the two nights preceding the accident and that it was possible they were suffering from jet-lag.

"Evidence indicated that both had consumed some alcohol on the evening of 3 January and diphenhydramine was found in their tissues."

The pathologist said this had all "combined to impair the ability of the pilots to deal with the situation with which they were faced."

Two executives from Agco, the US's third biggest farm equipment maker, were among the victims.

The company is best known for making Massey Ferguson tractors and the executives were returning from a management meeting in Coventry.

[Paracab]

I guess the headline 'Anti histamine found in pilots of crash jet' wouldn't attract as much attention... :rolleyes: :mad:

[BoeingMEL]

Very sadly, this was not Massey-Ferguson's first fatal execjet accident. They lost a Lear 25 in January 1979 at Detroit with the loss of all on board...including 2 executives. I seem to recall that, as a result of that accident, they disposed of all their aircraft worldwide. (Including G-MFEU then based at CVT).

Seems that all this great technology is of little use without basic airmanship.... frost and ice on wings at time of walkaround... what a shocking and un-necessary waste. bm

[mutt]

IMHO the topic header is slanderous and should be changed!

25.
Crew rest periods were in accordance with FAA regulations but the performance of both crew members may have been affected by jet-lag and fatigue.

26.
Traces of a non-prescription drug containing diphenhydramine, typically used to aid sleep, were found in both pilots.

27.
Specialist medical opinion was that it was possible that the judgement and reasoning of both crew members had been adversely affected by a combination of jet-lag, tiredness and the effects of diphenhydramine.

28.
Typically there were no warnings about drowsiness or avoiding operating machinery on the packaging of sleep aid drugs sold in the USA containing diphenhydramine.

Mutt.

[zerozero]

In American English the word 'drug' doesn't seem to have quite the same connotation as it does in Europe.

In fact, we buy our anti-histimines and de-congestants at "Drug Stores," sometimes "pharmacies," but rarely "apothecaries."

And you better check my spelling on that last one.

:cool:

[ironbutt57]

We don't have "duty chemists" in America either..sad lot aren't we;) :rolleyes:

[Wig Wag]

the performance of both crew members may have been affected by jet-lag and fatigue.

A definitive statement and one which will have useful currency in sustaining the argument against fatigue inducing FTL's.

[con-pilot]

I’m’ with mutt all the way with this one, talk about sensational and misleading. The report (and I read the entire report) said they found a TRACE of the drug that is contained in some legal over the counter, non-prescription cold medicine and in some pain relief medicine.

The cause of the accident was failure to de-ice the aircraft, the left wing in particular as the exhaust from the APU apparently had removed the frost from the right wing.

This accident was tragic enough with the press sensationalizing headlines to promote sales.

[Tartan Giant]

I wish to open by expressing my sincere condolences to the family, and friends of those who perished in this tragic and sad accident.


The first thing I want to say is directed at the "Press" for their predicable puerile attacks on the pilots, trying to pin the cause of the accident on DRUGS. Shamefull headline grabbing garbage as usual gentlemen.


Whilst I have always been an ardent admirer of AAIB Accident Reports, I am dismayed at the numerous factual errors and anomalies littering this particular report.

The various off duty times.
Commander:
Previous rest period: Off duty: 2109 hrs on 3 January 2002
On duty: 1100 hrs on 4 January 2002

SIC (Handling Pilot):
Previous rest period: Off duty: 2109 hrs on 3 January 2002

On duty: 1030 hrs on 4 January 2002

1.17.2.1 General

They went off duty at 2130 hrs on 3 January and were due back for duty at 1000 hrs on 4 January, a rest period of 121/2 hours.

---------------------------

The anomaly about the alcohol content of the flight-deck crew:

1.13.2 Toxicology
Toxicological examination revealed detectable amounts of diphenhydramine in both the commander and the handling pilot. No alcohol or drugs of abuse were found in the specimens from either pilot.

Both men had consumed a moderate amount of alcohol on the evening before the accident.....


Yet Appendix 3 states,
"In their hotel, both pilots had a meal that included some alcohol. It is estimated that each man consumed some five units of alcohol before retiring to bed at approximately 2330 hrs.

Records indicated that they checked in at approximately 21.15 hrs and had a meal and some alcohol between 2144 hrs and 2315 hrs, before retiring to bed.
------------------------


How can it be no alcohol was found, yet 0.04mcgs per millilitre of diphenhydramine was detected in the handling pilot, and 0.12mcgs per millilitre in the Commander?
The half-life of five units cannot be that short as to be missed and undetectable in that time frame stated.

Flying hours errors:

Appendix 4:
5 Experience: The captain had roughly 8000 hours experience

Para 1.5: Commander Flying experience:
Total all types: Approximately 10,000 hours

---------------------------------------------


Appendix 3 - Medical Report Addendum

DIPHENHYDRAMINE

2. Toxicological examination revealed 0.12mcgs per millilitre of diphenhydramine in the commander. Diphenhydramine was also detected in samples from the handling pilot, at a level of 0.04mcgs per millilitre.

3. The level of diphenhydramine in the commander was a therapeutic level and suggests that the drug had been taken within a few hours of his demise. The half-life of the drug is between 5-8 hours and comparable levels to those found in the commander were seen experimentally two hours after a therapeutic dose of diphenhydramine.

Technical difficulties made interpretation of the level in the handling pilot more difficult but the evidence indicated that it was highly probable that it corresponded to a therapeutic concentration of diphenhydramine.
[with such a tiny amount detected and the stated technical difficulties, it must be highly debateable why the medical examiner decided to use the words, "highly probable" in such limiting circumstances, given he even mentions that interepretation can be "very difficult"].......
I believe that this indicates both pilots took the drug sometime between 12 to 24 hours before their deaths. However it must be stressed that the problem of post mortem redistribution of drugs makes the interpretation of the levels very difficult (Pounder and Jones 1990).
------------------------------------

I know I'm not medically qualified but I would say the limited amount of this drug in their bodies would not have been sufficiently debilitating to prevent proper and corrective control inputs - as proven by the FDR and the valiant attempts by the Handling Pilot in trying to prevent the aircraft crashing...........
The handling pilot's response was immediate and indicated that he was trying to correct an uncommanded movement of the aircraft............... Therefore, from witness comments, the pilots did not appear to be incapacitated in any way.
----------------------------------

Other guys here have hit the nail on the head - Ice/frost on a supercritical wing do not add up, and there lies the root cause of this accident.

1.18.4.2 Supercritical Wing

The Challenger wing has supercritical aerofoil sections

----------------

Appendix 3:

5. Why both these men should be taking diphenhydramine is open to speculation. [did anybody ask their wife's? Was not the postulated explanations given not enough to overcome speculation?]


1.13.3 Diphenhydramine

Diphenhydramine is a sedative anti-histamine used in a number of cold and allergy preparations on sale to the public. It is also used in a number of products used to aid sleep. Examination of the luggage removed from the wreckage site revealed a number of medications within the baggage belonging to the crew. [is that so rare?]

It is possible that the handling pilot had a cold or similar upper respiratory tract infection and was taking diphenhydramine [did the hotel staff notice or the dispatchers/hear them coughing and sneezing?].

Had the commander developed a similar cold, the handling pilot may have shared his medication with him. It is equally possible that both men had taken this drug to aid sleep and prevent jet-lag. There is no way of knowing [positively] why they took this medication.

In my opinion the most likely explanation is that they took the drug to aid sleep [so why was there other medicinal items in their luggage?]. However, it is certain that both men had taken the drug.

------------------

From the web:
Diphenhydramine, an antihistamine, relieves red, irritated, itchy, watery eyes; sneezing; and runny nose caused by hay fever, allergies, and the common cold. It also may relieve the itching of insect bites, sunburns, bee stings, poison ivy, poison oak, and minor skin irritation. Diphenhydramine also is used to prevent and treat motion sickness, induce sleep, treat Parkinson's disease, and relieve cough caused by minor throat or airway irritation.

-----------------

A huge amount of effort and space in the report gravitated to the "drugs" aspect and not nearly enough on the CLEAN WING.


There's the lesson.

RIP

TG

[Lost_luggage34]

TG,
I tend to agree with you re. the AAIB report. If it's of any help ;

In a typical male, with normal liver function, 5 units will take 5 hours and around 40 minutes to be processed - I.e. back to an undetectable level in blood, breath and urine.

Excluding the fact that the body can produce it's own alcohol up to a level of around 20milligrammes / 100ml of blood (1/4 of the UK Drink Drive limit), I would be very surprised if any amount of alcohol would have been detectable bearing in mind the duration of the rest period (taking into account the end time of the meal/alcohol consumption).

For sure, to a limited extent, tiredness can have an effect, the type of alcohol consumed, and the fact that the alcohol was consumed with a meal.

I can't comment on the way in which the diphenhydramine is processed by the body or what effects it may have produced at the levels detected.

It is certainly in the family of medicines which can increase the affects of alcohol. However, in light of what I have written above I don't see how the two can be related.

A very sad read, and I also echo your condolences.

[411A]

Sleep inducing medications and flying certainly do not mix..and just perhaps they (the crew) were distracted just enough to ignore the icing on the wings.

A very deadly mistake.

De-icing after a night of below freezing temperatures is common practice...wonder just why these guys did not call for same?

Certainly a lesson here for all...:uhoh:

[mutt]

411A please never ask me to write your obituary :(

Is it more possible that commercial pressures or an on-time departure were the driving factors?????

Please do not tell me that you have ever met two crewmembers that took nasal spray and were totally unable to fly the next day!!!!!

Mutt.

[411A]

Mutt,

Having done a fair bit of business flying, have found that the 'boss' was totally receptive to a crew who mentioned...hey, we are fatigued, give us a few more hours rest.

Not that these guys didn't have enough.
Anyone who has spent any time at all in BHX for crew rest, has only to turn on the tv and watch the BBC....instant snooze.

zzzzzzzzzzzz:suspect:

[Oasis]

Bosses come in different shapes and sizes. I'm sure everyone would rather have a lie-in versus some drugs in their system.

[Non Normal]

There is something I cannot figure out in the report. (My highlighting below). Aren’t these two sentences contradicting each other? If not, could someone explain to me why?


2. Toxicological examination revealed 0.12mcgs per millilitre of diphenhydramine in the commander. Diphenhydramine was also detected in samples from the handling pilot, at a level of 0.04mcgs per millilitre.

3. The level of diphenhydramine in the commander was a therapeutic level and suggests that the drug had been taken within a few hours of his demise. The half-life of the drug is between 5-8 hours and comparable levels to those found in the commander were seen experimentally two hours after a therapeutic dose of diphenhydramine.

Technical difficulties made interpretation of the level in the handling pilot more difficult but the evidence indicated that it was highly probable that it corresponded to a therapeutic concentration of diphenhydramine.

I believe that this indicates both pilots took the drug sometime between 12 to 24 hours before their deaths. However it must be stressed that the problem of post mortem redistribution of drugs makes the interpretation of the levels very difficult (Pounder and Jones 1990).



TG where you say “with such a tiny amount detected”, I believe 0.12 mcg/mL is not such a tiny amount. Excedrin PM that was mentioned in the report to have been found and suspected to have been taken, contains 38 mg of diphenhydramine citrate (as well as 500 mg acetaminophen <= that’s paracetamol for us UK/Aus people) per tablet, and the instruction on the package says to take two. According to one of the studies, “A 60 mg dose intake resulted in average maximum serum concentration of 0.07 µg/ml (SD = 0.02, n = 6) at the point of 1, 2 or 3 hours”. This data was based on diphenhydramine hydrochloride, so you need to adjust it for diphenhydramine citrate. I believe diphenhydramine citrate 1.5 g is about equivalent of diphenhydramine hydrochloride 1.0 g. The recommended dose for Nytol, which is the British version of the diphenhydramine HCL based non-prescription sleeping tablet, is 2 x 25 mg tablets. So you can probably see that 0.12 or 0.04 mcg/mL isn’t such a small amount - certainly 0.12 is within the therapeutic range. It can have quite a long half life too (I understand the plasma half life to be around 3-8 hours although it varies on the individual). Anyway, what I’m trying to say is that 0.12 mcg/mL or 0.04 mcg/mL is not insignificant and that it fits in with the therapeutic level of diphenhydramine and I don’t think it would be right to write it off as being insignificant, considering the effects it can have.

Combine that with fatigue etc, it could be a factor in impairing judgement etc.

Correct me if I’m wrong though...


P.S.
For anyone interested, CAMI’s page on diphenhydramine is here: http://www.cami.jccbi.gov/AAM-600/Toxicology/Drugs/Diphenhydramine.html
It now does have the warning - “Warnings - may impair mental and/or physical ability required for the performance of potentially hazardous tasks (e.g., driving, operating heavy machinery).” I don’t know if it was there prior to the accident.

[Skunkie]

:( as long as sleeping pills and also antihystamine are part of the job of a pilot , coz of jet lag and other personal disease, I believe theat they can be assumed with a lot of precautions....i.e. no alchool, lot of hours before etc.
Unfortunately in a lot of new company (don't know if this is the case) exploit crews at the maximum, so if someone sufferrs of some of the over mention disease, has no material time to leave the effect goes by.
It is a bad situation that is becoming most common expecially after deregulation and use of pilots "h 24".
Not everyone has the strenght to cope with certain rythm and someone has to assume antihyistamine as a doctor prescription...... I think this phenomena will increase more and more up to other crashes....so the fault can be done all on pilots!

But remember that pilots are human and even if they know that the use of these drugs must be limited during the stop overs...well...who still has stop overs and REAL crew rest????

Or maybe , if one assume smtg should remain at home with the incubus of being expelled from the company?Aren't these disease as headahche or similar that must be cured?

After deregulation I noticed a great increase in the use of this kind of drugs...not to praise certainly but seems that sleep problems are not pilots problems...and this is a non sense!

Surely one must be follow by a physician and do not diy! but as long as the phenomena is increasing, I think that fatigue, insomnia and similar should be emphasized during CRM and Human Factor courses, remember that a lot of people is really unaware of secondary effects of antisthamynic! If u sum this to the pressure and hurry pilots are subjected nowadays - and I am absolutely not speaking of alcohol! - with the quickness, more and more of turn arounds in short range or hours and hours in long range, the effect could be disastrous!

Anyway, statistically...how many accidents are due to pilote dizziness because of a pill instead of other kind of disguides?

FAA JARs and all other institution involved should made a lot of attention before charging pilots who works too much because there is a lack of qualifyed people and much better would be explain them thedangers of these kind of pills, taken from a chemistry or from a drugstore

does anyone want to come back to amphetamine or cocaine to stay awake???????




Skunkie

[fireflybob]

I think a lot of this is really down to education and training of pilots.

In the industry I am currently working in (the railways - due to no flying jobs!) much stress and education in the initial training was placed on the effect of drugs and alcohol on ones performance and also the company's drugs and alcohol screening. ie random checks and automatic screening in the event of incident or accident.

As has been intimated previously the culture we are living in is awash with drugs of some form with the mass programming in the "datasphere" encouraging people to take a "quick fix" whether with prescribed or non prescribed drugs rather than tackling the root causes.

Nothwithstanding that all accidents are a combination of many factors it would seem that the major cause of this accident was taking off with ice on the wings which is, I believe, a fairly basic airmanship matter as is ensuring that one is fit for flight in everyway.

My condolences to all concerned. We like to think that things are black and white but with experience you learn that it's all a load of grey and no criticism of the crew is intended by my remarks, the objective being that we all learn from past incidents/accidents.

[Tartan Giant]

G'Day Non Normal,

When I was saying, "such a tiny amount detected" I was relating, as you probably realise, to the Handling Pilot and the obvious great difficulty the medical examiner had procuring that finding.

Technical difficulties made interpretation of the level in the handling pilot more difficult but the evidence indicated that it was highly probable that it corresponded to a therapeutic concentration of diphenhydramine.

You are probably more medically qualified than I am, and can attest why 0.04mcgs per millilitre is not such a tiny amount.

I also agree with you, and cannot explain the contradiction between the drug had been taken within a few hours of his demise and then changing to the wider interpretation both pilots took the drug sometime between 12 to 24 hours before their deaths.

As I was saying in my earlier post, it again points to a sloppy, slack AAIB Report - which is not what we expect from the AAIB.

Combine that with fatigue etc, it could be a factor in impairing judgement etc.

Far from correcting you, I agree with your summation about the fatique factor. I would certainly not be happy flying from W-E across the pond, then the next day plan to fly back again with not a lot of shut-eye.

Given everybody and his uncle was de-icing that morning, why it was not brought up by "the witnesses" is another weak link in that fatefull accident chain.

Given there were three very experienced pilots (the observer getting Trans Atlantic time) and the two dispatchers in the equation, it is very sad everbody missed the VITAL de-icing decision.

CLEAN WING or you don't fly - not much education needed.


Take care all.

TG

[Non Normal]

G'Day to you TG too.

It does indeed seem strange that the AAIB report seems so slack on this occasion. I don't recall seeing any from them that was so slack as this one.

As for the question of 0.04 mcg being a tiny amount, 0.04 mcg isn't that hugely far off the therapeutic level, even considering the therapeutic level we're interested in discussing might be for for sleep-inducing effects (although CAMI states the therapeutic low as 0.1 mcg, it doesn't say for what - see below). Also, according to one of the reports that I saw, drowsiness can be observed at 0.03-0.04 mcg/mL, and mental impairment may be observed with concentrations above 0.06 mcg/mL. Therapeutic level for antihistamine effects are >0.025 mcg/mL according to the same document. So you could say that at 0.04 mcg/mL, it was in the therapeutic level, if the PH took it for antihistamine effect, although it was stated in the AAIB report that the likely reason was to aid sleep. Hence my thinking that it wasn't really a tiny amount as such. (Yes I did realise you were referring to the PH.)
I hazard a guess to say this would probably have been the rationale used by the pathology specialist in stating that "but the evidence indicated that it was highly probable that it corresponded to a therapeutic concentration of diphenhydramine.".


By the way, I am starting to wonder if "12 to 24 hours" wasn't a typo for "2 to 24 hours". This would make a little more sense in terms of what was stated elsewhere and the numbers.


Now this is purely a hypothetical question.
I am wondering if there could have been any factor that contributed to this accident, or more precisely to the failure to de-ice, from the human factors point of view, in that two captains were flying together. In my very unscientific research I have heard many stories that when captains fly together, their general alertness in relation to their airmanship can be reduced, thinking that the other pilot knows what he/she is doing, and that the authority gradient not being quite so clear can mean that they are a little more relaxed, possibly too relaxed. Does such a potential over-relaxation happen, and if so, could this have been a contributory factor in not de-icing the aircraft and not turning the anti-ice on, thinking "if the other guy thinks it's OK, it must be OK, as he must know what he's doing"? Any people with knowledge of human factors care to comment?

[Tartan Giant]

G'Day Non Normal,

I'm glad you agree that this particular report is not up to the highest AAIB standards we all have come used to.

I must admit I'm not too clued up on the levels of "drugs" in these amounts do to a human, who must already be a mite tired and jet-lagged - you cover it well though.

There could be typos as there are larger holes one can see.


Your other question is a thorny one! Lots of info in this thread.

http://www.pprune.org/forums/showthread.php?s=&threadid=124593&highlight=captains+flying+together

I wonder what each of the three of them thought?

If you doubt it, MOUTH it!


Cheers

TG

[Non Normal]

Thanks for the link TG, I've just started reading it and it's very interesting.

As you've spotted before, there seem to be a lot of holes in the report indeed. I am quite susprised as I find most AAIB reports to be of very good standard. There seem to be a lot of contradictions in the facts they quoted, e.g. hours, time etc.

Cheers.

NN

[Skunkie]

hello everyone.... I'm Jar ops qualifyed CRM and Human Factor instructor, and both flying with two Captains and under influence of any kind of drugs, should be REMARKED more and more during CRM sessions....a lot of other problems can happens during thr flight. The fact that 2 Capt find difficulties on their own role is very important and leads to forget F/O duties. This shouldn't happen obviously, but I find awful that all the responsibilities are strictly connected with medicines that 2 pilots dead ( so not able to defense themselves) assuned before the flight! I agree that the time should pass after taking sleeping pills or antihyistaminic is quite long, but once again I think that Pilots in general should be advised by their phisycians...and this is an argument that CRM should treat more than now (together with the fact that 2 Captains together are not really safe for fly....).
In this case other factors i.e. ice, worsened the situation and I don't find right to give all the fault to Pilots...as long as they are humans not machines!!!!!

Skunkie

[Non Normal]

Skunkie, I don't think anyone here was blaming the pilots as such. I certainly wasn't. If you saw my discussion of the effects of diphenhydramine as blaming the pilots for having ingested these substances, that was not the case. My view is that had they needed to ingest substances to assist them with sleep due to the effects of jet-lag and needing to sleep, as it was quoted to be the likely purpose of taking them in the AAIB report, it was more the problem at the organisational level than the problem that the pilots "caused" as such. By saying “organisational level”, I am talking about the regulations that permit them to work these hours, and rostering practice. I am not totally alien to the concept of sleep deprivation, fatigue inducing rosters etc and I do see that there are major problems in the current FTL.

After all, it was stated in the AAIB report that there was no warning of possible impairment on the packet - it just said to avoid mixing with alcohol. Pilots are not medical professionals and they cannot be expected to know everything about every medicine they might take (although one would hope that they would exercise common sense when taking something). If you read the report, it made safety recommendations about giving proper warnings on medicine packets etc. I got the impression that the AAIB report did deal with failure of the systems (I don't mean aircraft system here, but the whole organisational system including the lack of warning from FDA regarding the effects of the medicine, and the strange point made about "polished frost" by FAA etc).

I think it would be quite important to focus on WHY some pilots are needing to turn to pharmaceutical aid to sleeping. I would hazard a guess that in many cases, it is as a result of sleep disturbance and fatigue caused by rostering and/or circadian dysrhythmia. Often, one would find that being fatigued does not necessarily mean that one could easily get to sleep. Fatigue seems to be cited more and more as a contributory factor to accidents nowadays, and I think it is about time the authorities re-examined why fatigue-inducing patterns are still permitted despite all the evidence presented by aviation medics and psychologists that many rostering practices permissible under various FTL systems are fatigue-inducing.

Having said that, education on the effects of medicines (prescription and non-prescription) on flying, would be very beneficial. You suggested that they should be advised by their physicians. That’s all fine, but it is quite hard to see a physician about every non-prescription medicine someone would take (for instance, in the UK it can take days before one can see a GP, and it would cost some money to see one in Australia). A better plan would be for the aviation authorities to issue clearer guidelines on certain medicines that have a potential to affect alertness or other aspects of a person pertinent to flight safety. I feel this would be particularly important for non-prescription medicines as it would be harder to be guided by a physician than regarding prescription medicine.

As for the issue of two captains flying together, I guess avoiding rostering them together as much as possible, and education and awareness would be the key. At least being made aware of the potential problems would mean that they would be more alert to them and can take preventative actions. It is at times hard for companies to avoid rostering two captains together and therefore the pilots should receive at least some sort of training.

Skunkie, out of curiosity, what do you feel about this company’s practice of permitting non-commander handling pilot to fly from the left hand seat, from the CRM and human factors point of view?

It is very unfortunate that the media chose to sensationalise the findings by reporting it the way it did, but I guess that’s what they do - make things sound newsworthy.


Cheers,

NN

[Skunkie]

NN I perfectly agree with u! I didn't mean anyone was pointing out pilots in this thread (at least it doesn't seem to me...) but I know what can do medias emphasisying on one point of a whole accident!
I've been flying 14 years while studying pharmacology and medicine in general that's why I'm so touched by this discussion.

To answer your other question... well I simply think it is WRONG! Unfortunately many people has not the same idea! there is a deep difference between flying on right seat as an instructor or flying as First Officer, but companies (in general, and nowadays always more) seem to look only at economic questions (until something happens....)
In 1993 I was on a plane that tried two landings on an island, wind was 45 knots gusts over 60 from left side, structure limit I think about 30 knots....Captain seated on left side was flying that a/c for the 2nd time and Captain on right seat ....well I think he was simply scared like dead of the other and luckily quite experienced, but first attempt to land he did F/O work and the result was a kind of kangaroo touch down and then go ahead. Second attempt (same conditions and same runway) was a 7 crash/touch then Captain/pilot took commands and plane crashed out of runway but no injuries...it was classified as heavy landing and never revealed to authorities as we had no passengers and I was the only witness......there's a lot to say about that day, but I always remember the fact that maybe a Captain and a Pilot would have acted in another way.

another fact that let me think is the Alitalia accident in zurich in 1992...the procedure of flying on QFE instead of QNH was changed then...an was changed also another thing: pilot could take commands immediately and in case explain later (possibly on ground...) and it was forbidden to try a landing in the same place after the 2nd go ahead...3 things that I think basic and it was only 12 years ago....

Skunkie

[KAT TOO]

The amount of alcohol and trace of a `drug` used for a cold will have had no affect on their performance once the aircraft had started its take off roll. Far more likely is that it was a cold frosty the guys probably turned up got the APU cranked up, wamed the aircraft up, jackets off a quick walk roundinto that cold still bright morning, saw no ICE on the wing (they looked at) and off they went, the rest is history

I very nearly saw a BRAL J41 get caught out a couple of years back at Aberdeen, remeber when the BA computers crashed, well these guy had to sit on the ramp for about 3 hours in Feb?March? nice day CAVOK as the sun went down the temp plunged, these guys were sat there in their short sleave shirts with warm air pumped in from a ground supply, as i took my seat i could see the wings had frost on them in the apron lights. i thought they might be waiting for the pax to board before de-icing, but no they weren't aware of the frost, after the hostie did a welcome aboard i asked to let me speak to the Captain before he started his engines, as they were already late he wasn't best pleased, but he got the ground engineer(who was already hooked up) to do a check, he confirmed that the wings did now have frost on them and they had to de-ice, as lesson for them, for me and i hope for all. It might be warm when you leave the sunny south, but i gets cold bloody quickly up north, buy a jumper and always do a walk round before you go or get the ground guy to do a last check if there is any doubt

[Non Normal]

Kat Too,

Did you read the report? It does say they knew about the frost... It's the contributory factors to their inaction to deal with frost that is being discussed here.


Skunkie,

Thanks for sharing your story. It was very interesting to read your views on non-commander in LHS and also about the experience you had. From a simplistic point of view, I don't like the idea of frequent seat swapping anyway (slower scans unless the instrument arrangement on the LHS and RHS are the same, differences in situational awareness and in information processing, potential ergonic differences etc, as well as having a different perspective among other things) but it was even more interesting to read the actual experience you had of the danger that it contributed to (along with two captains flying together perspective).

NN

[Ranger One]

I wouldn't be too hard on the AAIB... yes the report was perhaps less complete & conclusive than we would like, but the decisions that led the crew to fly are in my view largely inexplicable. They fingered the *possible* contributing factors - fatigue, effects of drugs - I'm not sure what else the AAIB *could* have done/said.

Definitely worth waving around when issues of fatigue and FTL come up for discussion however!

I was moderately impressed with the tests they did which appeared to confirm the APU running had likely led to asymmetric icing as the proximate cause of the unrecoverable roll - that's a very nasty 'gotcha'. Does anyone know of any other accident where *asymmetric* icing was a factor?

R1

[Basil]

Appendix 3 - Medical Report Addendum

Between 1994 and 1998, 1,683 pilots were killed in the United States.

420 a year seems rather a lot to me ??