SQ006 Revisited

[Insider107]

I’m relatively new to SQ but I’ve certainly had time to absorb the subtleties of the company culture and I now await, with considerable interest, publication of the interim findings of the Taiwanese Accident Investigation Board’s examination of the SQ006 disaster, which will, I suspect, point to either one of the two local SQ mind sets as being the root cause of the accident.

SQ pilots will long be familiar but outsiders may care to note that, in general, one of two thought processes generate any flying decision made in the course of SQ operations. They are:
1. Whatever happens, I must not take any action which will invite an admonitory/intimidatory phone call from the fleet management and which call will certainly be the culmination of a previously conducted, secret investigation involving the sustained interrogation of the FO(s) in an effort to establish inconsistency of story which could then lead to an adverse report being attached to a personal file/demotion without appeal or summary dismissal.
2. Under all circumstances, cover yourself by conducting operations absolutely within a highly legalistic interpretation of limitations and procedure without taking any overview or exercising any judgement, both of which will, necessarily, be subjective and hence open to fleet evaluation and criticism after any event.

Case in point was last year’s Kuching overrun, ostensibly blamed on the recently promoted young captain, terrorized into the first mind set, when blame really rests with the breathtakingly arrogant management which some years ago severely sanctioned a training captain for very reasonably going-around at Bombay during a Second Officer’s approach to land. Needless to say, this action sent a very clear message to the airline that you had better not go-around if you knew what was good for you. Needless further to say, post Kuching, large notices now exhort pilots to go-around at the first sign of a bolting horse and all will quickly be forgotten.

However, back to Taipei on 31 Nov 2000 and, as I recall, the weather was something along the lines of:
RCTP 2000/10/31 17:00 UTC
RCTP 03042G58KT 0400 R05/0600D R06/0600D +RA SCT001 BKN003 OVC006 20/20 Q1000 WS

Apocryphal evidence indicates that the apron was flooded at the time and this would perhaps lead to the supposition that the runways may also have been in a similar condition, in light of the approaching typhoon front. Similarly the aircraft was reportedly strongly buffeted by high winds whilst still at the gate.

I hypothesize that the crew now adopted either of the two institutionalized mind sets as follows, with results that are history:
1. They realized, in light of the above, that conditions were unsuitable for a safe take off but decided, nevertheless, that a take off in the prevailing conditions was infinitely preferable to the inevitable management witch hunt that would follow any decision to delay the flight and await safer conditions. I may be alone but if I am doing something which I know to be fundamentally wrong, I feel very guilty, become very distracted and wish as soon as possible to return to a non guilty and hence non distracted state. I suspect that the three pilots may have been in this frame of mind, having became guilty with the prospect of a highly questionable take off and, in a very distracted state, rushed to distance themselves from the situation causing their guilt, by getting airborne as soon as possible and, in their haste, convinced themselves that they were on 05L rather than 05R.
2. They were perfectly relaxed about the situation, as the second mind set allowed them to ameliorate any adverse conditions by the wholly legalistic application of the manufacturer’s/operator’s limitations. In this case, cross wind was finely calculated as just within limits, visibility was verified as just above take off limits and reported wind shear after take off was taken care of by requesting the longer 05L rather than the initially offered 06. No overarching view of the situation would arise with this mind set, hence it would not be possible to consider that whilst technically within the cross wind limitations, prevailing gusts, low visibility, low cloud base, very heavy rain and a possibly flooded runway would lead to a take off in conditions somewhat different from the steady wind/good viz/dry runway conditions of test flying demonstrations. Similarly, whilst the book had been narrowly followed in that the longest runway available had been selected, to take account of wind shear, no account was taken of the many showings of manufacturers’ wind shear videos, which, as far as I remember, recommend the best way of dealing with the phenomenon is not to take off into it. The word seems to be that the FO was PF whilst CPT and third seat FO continually distracted themselves during taxi with ongoing legalistic justifications of the decision to proceed. Take off then started on 05R.

As you will note, I am not an inveterate “poster” and hope therefore that, despite the length of this missive, it will be published to provoke further discussion and, of course, contention. In particular, I would urge my local colleagues, who I regard in a wholly favourable professional light, to attempt to shake of the years of bullying perpetrated by their management and further shake off the above mind sets that this bullying has produced, and enter into positive discussion of a deeply rooted safety issue that may again embroil the carrier in further tragedy.

Finally, as I think all will realize, it is not yet possible to discuss safety or indeed any other issue with the very brittle egos in SQ management, nor is it prudent to reveal either local or ex-pat identities incase the boys from the ISA come knocking!

[Gladiator]

Gutsy post. Your courage is admired. Good luck.

Minor detail, revise the accident date from Nov 31 to Oct 31.

[Insider107]

Yup. Slip of the keyboard!

[Farside]

Insider 107, you state that you are relatively new to SQ, but reading your excellent article proves that you are a quick learner and sharp observer. I am an optimist and I believe that things are changing all over the world , even here in Singapore. I agree with your assesment of the management culture we have here in Singapore but I beleive that someone with your obvious auditable talents can put this talent to good use in SQ. This is the time that the higher and newly reqruited management ( higher than the 4th floor) will be very interested in your views, as long as you follow them up with positive ideas. I am sure that you not only have the talent to clearly see the problems you might also have some suggestions to tackle them. There are new ways in SQ to do this (OSIG might be one of them) and I wouldn't be too concerned about the midnight knock on your door, again I could be totally wrong, but as I said before I am an optimist.

[Sunny]

Good post, But I heard a different word about who was PF. Also heard that the FO called out max left deflection on the PVI but to no avail. Guess we will know more when we meet up with them.

[AEROVISION]

Insider 107

I think your missive is the first post in this forum which describes in detail the thoughts a lot of us had on this matter for the last few months. Well done.

Now for your hypothesis, para.2 and especially the last sentence.
Did you have acces to the FULL transcript of the CVR read out, or, did you actually hear
the full read out, or, did you speak to one of the pilots after his return to SIN, or, is your thesis a reflection of a situation you found yourself in, one dark and stormy night.?
The truth on how and when the crew came to their deliberations and conclusions could indeed lie in the 30 minutes time span before take off. We all read the last three minutes of the tape transcript and i wonder why the
remaining 27 minutes not have been disclosed.
If you did read the full transcript, please email me on how and when.
As for Farside's suggestion, yes, but do your groundwork first. Caution is advised.

[Farside]

We will have the possibillity to talk to the SQ 6 crew tommorrow when the union is organising a dinner with the members and the crew. ( members themselves) It could be a very interesting evening with a lot of good information and fact finding. It also could be a polite waste of time where the crew is instucted not to disclose any details as long as the investigation is running. I for one believe the last will be the case but I hope that we can learn a few things to stop the flow of rumours. It will take an awfull lot of energy and bravoury to change some attitudes here with management, but given the time it could be done. There are some conflicting stories out here on the actual configuration during take-off and if the PVD was selected on or not. Also what was on and what wasn't on the Flight Recorder is guess work with the line pilots. One thing is for sure: If the PVD is selected on ( Both PVD on on EICAS ) and you are not within 40 degrees of the RWY hdg and within one dot of ILS localisor of the active rwy ( 05L) the PVD indicator on the glareshield will be off, not turning, and not lighted. In other words no indication. This in itself could have been a trigger for the crew , but again we are just guessing. (hope I spelled that correct)

[Insider107]

Farside

Thank you for your post. Yes I agree that there is a slight sniff of change in the air in Singapore, attributable, I think, to the characteristically mercurial intelligence at the very pinnacle of the republic’s power structure. Transmitting an entirely correctly formulated revised philosophy downwards, however, to more pedestrian intelligences or to those who’s noses are firmly in the trough, of course, will prove problematical. Notwithstanding, as SQ is merely a microsm of the republic, I do believe that our newly acquired, similarly mercurial higher management will be able to make headway but only after the full removal of the present tired, discredited but extended subordinate incumbent plus team and the blocking of a conceited arrogance that masquerades as an heir apparent. Meanwhile, extreme caution is the watchword.

Aerovision

Thank you also for your post. No I do not have access to the transcript – my original post was based on my analysis of the published facts (I am merely one of scores who have made a similar analysis and come to the same conclusion), information gleaned from this website, yes, my own experience of past events but, most importantly, information passed on by my FO colleagues, who all seem to be well and truly in the loop and able to cogently fill in the 27 minute CVR gap, the contents of which we await with bated breath. These self same FO’s seem to me, to a man, to be of the highest caliber, superbly educated, disciplined and at the start of their careers (before becoming fire-blackened and cynical), keen and well motivated. Why then does SQ squander this “human capital” with their disgustingly poor treatment of this group, when, according to the highest in the land, they should be nurturing it as part of the future asset base of the nation? Perhaps the new higher management may like to consider harnessing some of this talent hiding under his nose – a move that will prove potently catalytic in an organisation increasingly and urgently requiring fresh thinking.

Sunny

Thank you for yours. Yes the PVI allegedly was on but I didn’t want to discuss it as the subject corresponds with some potentially pivotal CVR dialogue.

Gladiator

Thanks for your support. Good luck.

[PILLOW]

Insider 107 , for someone new to SIA you certainly knows a lot of details.
But I cant help noticing Gladiator reply to your posting within 8 minutes and you responding within 8 minutes .
Probably coincidental

[Farside]

Pillow we here in flytown call that time difference, or different time zone's, or to make it even simpler: when Insider is behind the computer at 8 in the morning before starting the rest of the day our friend the Gladiator is finishing a days work at the end of the same day , also behind the computer. Not so difficult you see and you are right just coincidental!!

[Gladiator]

Everything anti-establishment (Singapore and entities) are different identities of Gladiator. Get a life PILLOW.

Insider107, I wish I was as good a writer as you.

[SKYDRIFTER]

Insider107 -

Appreciate the update; good summary. Looking forward to knowing more. We can't change history, but we're fools not to learn productive lessons from it.

The fallacy in the crosswind limitation is the 30 knot limit on the escape slides.

In the USA, the argument is made that the crosswind data is an information provision of "demonstrated' performance, as opposed to a hard limitation. The joke is in the FAR 25 Certifications standards, which compel the specification of limitations.

I'm not privileged to know the extent of the trend, but many American airlines neither issue nor adequately teach regulations - contrary to the FARs. Thus, an SQ-006 is in waiting on the American end.

While American airline pilots resent the European & Japanese discounting of our ATP standards, there's a damn good reason for it. We need to change that.

Posts such as yours illuminate core facts and the changes needed; thanks.

[SKYDRIFTER]

Pillow -

I have a distinct hunch that you've already forgotten more than I'll ever know know.

In 'flytown,' 8 minutes difference is the same in Australia London or ALaska - the last I checked. Must be cooincidence. I don't know how your comment stirred any debate.

[Strikie]

Oh, so the time is not in UTC...

Anyway, good posts Insider107, and I don't care if you are linked in any remote way to Gladiator. What has to be said must be said...

[Insider107]

Just for the record, I'm not linked to Gladiator (even remotely) and the reply timings were purely coincidental.
I will, however, monitor future reply timings, to take account of the paranoid sensibilities of some readers.

[Strikie]

Insider107: not to worry mate. now that this post is gonna be quite close to yours someone out there might be tempted to put 2 and 2 together and get ... nought. But of course I digress.

[Lee]

For the record too, I'm not linked to Gladiator in any way, either remotely or nearly! Cheers, and keep them going Gladiator!

[AEROVISION]

Farside,
Can you please check in this frequency when practical if you have been at "the dinner"
Hope you can enlighten us.

[titan]

Insider107:

Congratulations on an extremely well written, thoughtful and insightful posting.

[John Barnes]

Does anybody in Singapore know what went on in the last meeting with the union members and the crew of SQ 6. Was it a lot of Makan Kechil or was it realy substantial with some rumour killers. ( Did they have the PVD selected on yes or no!!) That is the place to find out when you can straight foreward ask the question.

[Sunny]

No such luck, they made a statement and then the meeting adjourned for dinner. No Q and A session.

[AEROVISION]

Sunny, Farside,
Really?? Nothing??
Not even the most elementary?
Time frame for the initial report?
Nothing??

[John Barnes]

Sad to say but the meeting was a total waste of time and noboby learned anything that could help to prevent the next disaster. A lot of polite waffling but nothing with any substance. As with so many other incidents and accidents, what happened in the cockpit will remain a big mystery. The new problem now is not minimum crew but minimum fuel!!!

[Insider107]

My aficionado colleagues tell me that to expect anything other than a total waste of time - as accurately relayed by John Barnes - when attending the Makan Kechil, in honour of the SQ006 trio, was to stretch the boundaries of optimism to hitherto unimagined dimensions. The trio, for their own legal survival in Singapore, or indeed anywhere else in the world, will have rapidly concluded, individually and collectively, that to reveal incriminating details of their thoughts and actions on the night of 31 Oct 2000 would be tantamount to requesting permanent assignment on Mars, beyond the jurisdiction of any meaningful court.
Further, the senior echelons of the present flight ops management are known to be vindictively resentful of the trio's actions in bringing about the accident, following which their "exemplary safety record" has been besmirched in such an abrupt manner. Forgetting, of course, that they are the compliant architects, within a broader national psychology, of the flight ops culture which has borne this accident and the many past serious incidents and potential disasters which have so far been successfully covered up. In particular, one unprecedented and highly lucrative two-year appointment extension could now be called into question following the hopeful publication of a Taiwanese interim safety report. Hence, the trio knows that it has serious enemies in this quarter and, even if fielding only a modicum of intelligence, will tread very warily.
Similarly ALPAS - an association, not a union, the latter having power to withhold labour - has been particularly witless in the present circumstance in that it has not seen the need to appoint independent legal counsel in Singapore, to act on behalf of the trio but has rather, to this date, pathetically relied on the good offices of the SQ retained "top legal representation". The trio will doubtless have concluded that the trusted maxim "he who pays the piper, calls the tune" is particularly apt in these trying days and will be further forced into isolated silence.
However, notwithstanding the above local difficulties, the major point at issue will be the class action against SQ, to be brought by the US survivors/relatives involved in the SQ006 disaster. Any American aviation law firm, with a reasonable reputation for competence and tenacity, heard before a US court, will be able to take SQ apart (see Gladiator passim) on the direct and subsidiary issues arising from the accident. Hence two points come into play, in generating the trio's present and ongoing silence:
1. SQ, as a means of safeguarding it's own legal position, has formally warned the trio to keep silence in anticipation of a class action in a US court in the event that it's initial seemingly magnanimous offer of settlement is rejected by survivors/relatives (it will be).
2. The trio as a means similarly of safeguarding it's position will not wish it to be conclude that either thought process, detailed at the beginning of this thread, came into play either individually or collectively, so demonstrating either a reckless or culpably negligent approach to the prevailing situation. In this matter they will be in harmony with SQ which will, in this event, have corollary charges of recklessness or culpable negligence made against it.
The trio is, I'm afraid, between a rock and a hard place - ALPAS please note and do something about it as there are a number of Singapore law firms not in thrall to either SQ or the CJ who would be both willing and able to cut a safeguard deal with SQ's lawyers and so prevent the boys from being thrown to the wolves in the rough days ahead.
Readers watch this space.

[ExSimGuy]

Check the small print near the bottom of the page "all times UTC".

I post (usually) from UTC+3, and the time here right now is 13:10

------------------
What Goes Around . . . . .
. . often makes a better landing

[PILLOW]

Strange that you mention " ( see Gladiator passim ) " .

Gladiator settled out of court and paid a six figure payout . Thats in addition to his own legal fee ! . I would have thought that if gladiator is so confident of winning the court case ( as he has always boasted ) , he would have gone to court , win the case and dont pay a cent . Plus SIA will pay his legal fees and expenses

[sia sniffer]

It's not only the crew involved with the accident who are been silenced by Singapore Airline's management.Current "Intams", ie messages to crew regarding company policies, state that no member of Singapore airlines shall speak of the incident, both publically or privately.

What right do SQ have to silence a none Singaporean? Company loyalty, ha, don't make me laugh. The sycophants of the B777 or A340 are all clambering to be promoted to the 747-400, and at what cost? It's not going to be pretty in this culture that made back stabbing an art form.

Contained within the same set of intams, are references to PA's made by commanders initial greeting to pax. Apparently, several local commanders have unwittingly made referrals to the SQ006 incident during their initial PA.The company has now had to issue a special set of instructions to prohibit this.

"Ladies and Gentlemen, you are now aboard our "Rainbow" 747-400 service, the only one now left in this unique colour scheme"

[titan]

Insider107:
Once again a well written and informative posting.
The travesty is not that SIA ordered over 1000 pilots into silence, but they believe they can. Will the fools never learn that it is this exact authoritarian behaviour that is the foe of air safety. How many more people will perish before SIA evolves into a safe airline. The postings here over the last couple of years have exposed a multitude of near misses and incidents which SIA desperatley tried to cover up. That not more people have died on this airline is a grand commendation to the airframe makers, and in no way imparted to SIA's operational prowess.

..... and what was the SIA share price today?

[SKYDRIFTER]

BEING SUBMISSIVE -

I can't speak to the SIA pilots, but in the States, such heavy-handed 'control' techniques have been successfully used.

The style is to tell a lie with great passion, then repeat it as often as possible until the pilots pick up on it.

For example, one of the USA 'Corporate Stockholm Syndrome' techniques has been to successfully NOT issue regulations to the pilots, take out FAR references in the Operations Manual (illegal), then convince the pilots that the OPS manual is an FAA accepted substitute for the regulations.

The unions even buy into it; it's killing people.

In the Alaska 506 incident, the copilot was successfully violated for questioning, but not overriding the captain. Even the FAA pushed corporate policy over regulation (authority of the PIC).

The technique works along with the politically correct phrase, "You can't say that." Imagine that expression being so common in the 'Land of the Free.'

Protests aside, SIA management might just get their way. A couple of terminations would convert the silence policy into a 'norm.'

Watch out.

[A Few Good Men]

I think I believe Gladiator.
P ilot
I n
L ee
L and
O ver
W orked

[Insider107]

ExSimGuy

I’m afraid that your 568th posting, of 29 Jan, immediately following mine of the same date, was just a little too oblique for me. I do not understand the significance of “check the small print at the bottom of the page, all times UTC”. Can you explain?
I’m also in the dark with your equally cryptic “what goes around…..often makes a better landing”. I avidly await enlightenment.

Pillow

“See Gladiator passim”. Please go to search and then type in “gladiator” specifying Far East forum – all will be revealed.
I believe that most people are of the view that gladiator negotiated a “pro-bono” deal with a US law firm (any John Grisham novel refers on the meaning of pro bono), which then counter sued SQ on the basis of unsafe flight operations practices by the airline, as a defence manoeuvre against the airline’s pursuit of gladiator’s bond. The action took place in a US court and swiftly came to an end following the serving of subpoenas on both the SQ CEO and the SVP Flt Ops. Under the terms of the out of court settlement, gladiator was constrained to silence on details of these terms.

Titan

Precisely put. SQ’s consistently authoritarian behaviour is both the enemy of safe flight operations and of intelligent evolutionary change. As I have mentioned before, until such time as the present corrupted and ossified flight ops management retires, we will see more of the same. Unfortunately, the system perpetuates itself by promoting the sycophants, both local and ex-pat – sia sniffer refers . Perhaps our new general can figure this out and do something about it?

Whilst alluding to management style, readers may be interested to note the content of a poster currently gracing the walls of 4th floor STC. It quotes Sir Richard Branson, SQ’s co-shareholder in Virgin Atlantic Airways and gives an intimation of his management style (whether true or illusory is open to debate).

“I believe the highest priority is your employees. Then you take care of your customers and only then do you look after your shareholders’ interests. You see, if you bend over backwards to take care of your staff, ensuring they are happy and enjoying their jobs, they will take care of your customers for you. And in the long run, when employees continue providing customers with superb service, the customers’ referrals and repeat business will take care of our shareholders’ interests”

Readers will be interested to note the parallel philosophy practiced by 49% Virgin shareholder, Singapore Airlines.

[Insider107]

I feel bound to write, having seen alien779’s contribution, on another thread and the heavy-handed intervention on behalf of SQ that it represents and use this thread to maintain continuity.

The smart money down here in Singapore is that the Taiwan trio will shortly be fired, though for what exact cause, remains shrouded in mystery. It is felt, however, that the upcoming interim Taiwanese report on the SQ0006 disaster is going to prove so damning that SQ will have to take steps to quickly distance itself from its employees and take refuge in the stance that the tech crew members did not follow laid down company procedures. ie you’re on your own boys. Will ALPAS finally wake up and quit spending members’ cash on beer and food and divert some funds to independent legal council for these colleagues?

In light of what seems to be about to be perpetrated, it is interesting to put it in context with the much vaunted SQ “Core Values”, which, being a relatively new joiner, I’m in a position to remember from my indoctrination course – I can’t, however, oblige with the company song as I’ve forgotten the words.

Of particular note is the Value, “Concern for Staff”, which states “We value our staff and care for their well-being. We treat them with respect and dignity and seek to provide them with appropriate training and development so that they can lead fulfilling careers”. SQ employees will note the forgoing with some irony, against a background of daily plummeting morale and disintegrating industrial relations.

Similarly, the SQ mantra “Industrial harmony is a critical success factor of a company’s continued prosperity and growth and Singapore Airlines is no exception. A strong working relationship between management, staff and the unions is the foundation which enables us to share pride in the Company, a vision of excellence and a determination to stay the best airline in the world. There are many instances to demonstrate theses shared values, whether within the Company or in the larger community”, is now wearing extremely thin.

Our present inept Association President, in his last missive of 19 January, tells us that SQ has summarily refused to negotiate further on the now 26 month out of date Collective Agreement (CA) and that he feels “like a virgin at a mass wedding”, having had no previous experience of events such as the upcoming, SQ forced, government arbitration of the CA case. Two points arise – when SQ don’t have complete and absolute acceptance of their diktat they take their bat and ball away and refuse to play, making something of a mockery of their foregoing public stance and, secondly, should the ALPAS President not be thinking seriously about getting a contract law firm to cast their eye over what we laughingly call the employment contract and should he not also be organising some professional assistance in his upcoming case?

Finally, given that arbitration goes along the SQ lines (it will), the CA will be dated February 2001 instead of November 1998 and, given that it will run the usual three years, it will effectively become a 5 year 3 month agreement, clearly demonstrating the SVP Flt Ops tried and trusted skill in industrial maneouvre.

Life goes on in Wonderland.

[sqrew]

insider whatevr,
wellu said it man .we are gonna get totalled in the IAC. one question ..has there ever been a situation when we did win at these so called "arbitration" courts?the current president? he is a good man no doubt but what confidence huh?

[Tans]

Can anyone explain what a PVI or PVD is? Is this an SQ option on the -400?

Am familar with PFD, but it is pretty much always selected on unless things are not working out too well.

And what is the indicator on the glareshield? All I have ever seen is a "Master Warning/Caution Reset Switch and Light".

Never seen anything on the glareshied "turning" as such. As I said is this an SQ option?

[Insider107]

Sqrew

I’m certain that ALPAS has never won an action in the Singapore IAC – Industrial Arbitration Court. Perhaps this is because:
1. It has never been properly legally represented at any hearings
2. As in the latest case, it has never troubled to present a cogent, reasoned and logical counter case to that presented by SQ and authored by the former DFO, now metamorphosised into SVPFO.

Tans

PVI/PVD is Airbus/Boeing speak respectively for Para Visual Indicator/Para Visual Display – both terms are current within SQ.
PFD is Airbus speak for Primary Flight Display.
Are you sure that you are a pilot?

[titan]

Sadly, until LKY and his cronies pass away I don't see how ALPA-S will ever have the courage to fight a real Industrial Relations battle. Everyone fearfully remembers the night that LKY had the senior ALPA-S people arrrested and threatened with life in Changi Prison for not just themselves but their families as well.

If only all IR negotiation could be THAT effective!

[Established !]

'Arrested','threatened with life in prison'? I was there and this is news to me indeed. I thought they were summary executed!

[cyclops]

Executions? Not any more. Too much public opinion. If the union rep gets too popular or sounds as if he has a case, make him Minister Without Portfolio. One day he is promoting the members' views, next day is saying, "Toe the party line." Works in Sg

[titan]

Established !
Arrested? Well what would you call being ordered to appear before the Ministry of Labour in the middle of the night in a country with the power to arrest without cause?
They were given until 6am the following morning to resolve the "go-slow" or face the repercussions as previously outlined.
I completely understand your distaste in confronting the real-politik of Singapore and even ignorance at what happened; the ostrich factor thrives in Singapore, similiar to how Shultz would exclaim "I know nothink.. nothink!!".

Is lifetime incarceration on Sentosa still fashionable there in the Lyin City?

[Insider107]

Farside - what excellent articles written by yourself and posted by John Barnes on the “Management sweep at Singapore Airlines” thread, started by titan on 06 Feb 01. John Barnes was rather clumsy in posting without your consent but he has done us all a great service by airing your views and I’m sure that you’ve now forgiven him. I agree 100% with everything you write and I would like to develop a subject which you touched on in your second Article – the Tenerife disaster of 1974.

I’m using this thread as my subsequent subject matter is entirely consistent with the SQ006 debate and hence it is eminently logical to keep it under the “SQ006 Revisited” banner.

Titan - thank you for starting your thread – you are absolutely correct in that the “higher management”, EVPT Lt-Gen Bey will be taking over the helms of both Flt Ops and Engineering – with the assistance of Air Force subordinates! It is to be hoped that he performs the kind of turnaround job on SQ, in terms of arresting and reversing plummeting morale, as my FO colleagues tell me he crafted with the Singaporean Air Force. Despite rumours that he maintains an authoritarian stance with the FO’s (he is more conciliatory with the captains – ex-pats at least) he really does deserve our support and forbearance. The alternative to his successful handling of events that can easily develop to threaten the very existence of the company is hinted at by gaunty’s post of 11 Feb 01 and his particular encouragement for us all to study the word hubris. In terms of SQ’s behaviour and development over the past 20 years a particularly Homeric paraphrase comes to mind – “whom the gods would destroy they first blind with hubris”. It is to be hoped that SQ’s “best airline in the world” and “world’s most profitable airline” rhetoric has not blinded them to the increasing likelihood of nemesis at the hands of SQ006 and any future disaster which their present culture is inexorably heading them towards.

As a peripheral issue, it would seem that SVPFO’s lucrative (S$3M per annum bonus for keeping flight ops costs to target – that is pilot salaries and allowances!) extended non-flying appointment to the age of 62, after 19 years in position, is shortly to be terminated. SQ’s lawyers are positioning for the flak to be unleashed, following the Taiwanese interim report on SQ006 and the required distancing from the tech crew “trio”, by their dismissal, which this will occasion, can only be morally upheld by a similar departure of the notional”man in charge”. Standby, therefore, for a form of words not unadjacent to “the SVPOF has now reconsidered his acceptance of the board’s request that he extend his appointment by a further two years beyond normal retirement age, with a view to now spending more time with his family”. SIA sniffer tells us on 09 Feb 01 that F.K is also to go – unsurprising, as the board had recently declared him “unacceptable” for promotion to the SVPFO position. Hence we can be free, at last, of his malign influence – things could indeed be changing! However, of final note on this theme, the other member of the troika, Director of Flt Training surely should also consider that the only honourable course of action is now to tender his resignation. He, after all, has moulded the training culture that has directly contributed to the Taiwan disaster!

Moving to Farside’s example of the Tenerife disaster, the parallel circumstances of SQ006 are noteworthy, whilst the directly comparable “stress events” of adverse weather/NOTAM conditions and company pressure/culture inputs are startling. In fact a good road map is now provided by events leading to Tenerife and subsequent correctional activity by KLM, to keep on the straight and narrow and avoid such further catastrophes.
I flew into Las Palmas (LPA) a couple of days after the tragedy and was thus able to get a pretty detailed idea of events at Tenerife North (TFN) – the only airport on the island at the time, before the opening of TFS and, being sited in a saddle, approx 2040 feet abmsl, subject to frequent closure by low stratus/fog. Such were the conditions on the day and the KLM flight plus many others diverted to LPA to await Wx improvement. A hoax bomb threat at LPA contributed to the mayhem and added further delay to KLM’s departure for TFN and then home to AMS. Following KLM’s arrival and turnaround at TFN the Wx fogged in again, though RVR was just in limits for take off. Meanwhile, (you’ve guessed it) the company urgently wanted the aircraft back in AMS for a subsequent service and FTL’s were now rearing their ugly heads. Wait for it! There was WIP on the parallel taxiway – the NOTAM’s for which were subsequently shown to be remiss and not widely available – which required taxiing aircraft to exit the parallel, enter the active, exit the active and re-enter the parallel before reaching the holding point. KLM went through this rigmarole in approx 300M vis and by the time they had lined up, the captain (training captain) was champing at the bit to get airborne and thus relieve himself of the intense frustrations of the day and rid himself of the FTL/Company pressure by just squeaking into AMS inside FTL discretion! All sound familiar? KLM was then given “line up and wait, call the tower on …..MHz”. Meanwhile, unbeknown, a Pan Am 747, on ground frequency followed the same taxi procedure, with the intention of clearing the active to allow the KLM take off – all in 200-300M vis and hence neither aircraft in visual contact with the other and, of course, no airport ground radar in those days! Back to KLM, where the highly stressed captain had now convinced himself that he had take off clearance so, despite the vehement protests to the contrary of his very junior FO, started the take off roll and so fatally collided with the Pan AM 747 still on the runway.

We have heard from Farside what KLM did in the aftermath, to avoid a repetition of this disaster and we still, of course, await similarly positive action from SQ. Meanwhile, in the interim, what, as captains, do we need to do to avoid the Tenerife and Taiwan situations, as factually stated and reasonably hypothesized respectively?

In my own very humble opinion (humble because I’ve made so many past foul-ups and have been fated to get away with them), I think that as a start, we should perhaps individually consider our own mind sets and examine whether we are truly acting as aircraft captains or are we passing the buck on just about every occasion and reverting to “just following company policy”. By which I mean are we substituting policy for good judgment and as individuals do we exercise the morale courage to coolly assess the rights and wrongs of a given operational situation, calmly formulate a reasoned solution with the assistance of the crew and available company resources and then stick with the derived decision, modified by equally reasoned evaluation of changing circumstances and so provide solid and reassuring leadership to our crews and passengers?

If we can say that we do, then we are earning our money as decision makers on the spot, safeguarding our passengers, crew, aircraft and our company’s reputation and operating as efficiently as possible in all circumstances – very much as captains seemed to do so effortlessly when I first started flying and before the oversight and carping of cost accountants and lawyers emasculated their scope for effective action in all circumstances.
If, however, we take expedient recourse to what we know the company will favour as the “low cost solution”, we are abrogating our above responsibility and become mere ciphers of a bureaucracy ever more consumed by corporate greed, forgetting all our commitment to common sense and airmanship.

Moving on, it would seem that the captain of SQ006 received a phone call from SQ Ops at the Taipei hotel, prior to reporting for duty on the fateful night, to the effect that the typhoon front was imminent and “could he make best efforts to get airborne before the event”? All members of SQ will appreciate the pregnant significance of this “request”.

I suggest that if the captain had been operating in the morale climate that made possible the thought processes described above, then he would have been able to make reasoned and calm judgment and concluded a delay until post-front conditions prevailed, safe in the knowledge that he would not be “witch hunted” and that his command decision would be accepted without question as that emanating and expected from a seasoned professional.

I would further suggest, in conclusion, that if we only realised it, we do now operate in such a morale climate, post SQ006 (how can SQ now possibly carp at a weather delay decision?) and that, in the characteristic absence of any kind of lead from SQ, we should re-take our responsibility, reassert our professionalism and regain our pride as independent minded highly competent, reliable professionals, to be respected as prized assets. Only if we start thinking of ourselves in this manner can we expect SQ to do so and so stifle our new general’s present derogatory view of us.

Post Script. Danny. If you read this, I do hope that it reinforces to you the wonderful value of your web site and the ability of new technology to disseminate information and ideas between colleagues employed in companies where such dissemination is problematical. Keep up your superb work.
Kindest regards.

[Anti Skid On]

What a thoughtfully written posting; I did not know about the phone call, that came as a surprise (althought given the business culture it doesn't come as too much of a shock) - but to what extent would the Captain been scapegoated if he did not follow the 'request' - and this raises another issue - when does a request become an instruction or indeed a demand?

We all know that in every day life planners have a thing called consultation, where the thoughts of others are heard, but a decision is made, often without any regard to those views - is this the same?

Titan - Sentosa still has the remains of the old fort, but is a bit like hard labour, given that it is like a large public park with ageing attractions!

[titan]

Anti Skid On
I am actually talking about LKY's nemesis. LKY has had him incarcerated there for over 30 years because he refused to lower himself to replying to LKY's accusation that he was a communist. I never heard anyone talk about it in Singapore; it was a forbidden topic.

[titan]

Insider107
Once again an eloquent and erudite posting. If only it would appear on the front page of the Straits Times.
The fallibility of your arguement and pleading, although thorough and logical, is, as always in Singapore, who shall be the brave soul to cast his fate by going first??

Regards

[PPRuNe Towers]

Insider, I'm afraid Danny isn't around at the moment to personally comment on your final paragraph but I know that it is something that he feels very strongly about.

Free interchange of safety information was one of the main themes that Danny and I reviewed when we were opening speakers at the excellent Flight International Crew Management Conference held in London recently.

We are acting to make this site a portal to safety and training resources for the aviation industry worldwide. We too were deeply impressed by the writing on the subject by farside. I wrote to him a week ago requesting permission to place his thoughts permanently on the main home page of the site and we hope that he will agree.

With over 140,000 individual readers per month our ability to disseminate human factors, safety, CRM and training information worldwide is unparalelled. While the tabloid nature of the site makes senior figures in these fields uncomfortable they are also beginning to find the immense (and totally cost free) communication power of PPRuNe impossible to ignore.

Quietly and in the background we continue our negotiations to bring together the best resources and have PPRuNe act as a conduit to them.

Incidently, one of our journalist friends has just written to let us now that the initial report on SQ006 will be released very shortly.

The press release stresses that the 380 page report from the Taiwanese Safety Council is factual only. Analysis will be confined to the final report. Publication will be 'next Friday.' From the dating on the report this could actually mean today but is probably more likey to be in a week.

------------------
Regards from the Towers
Rob Lloyd
[email protected]



[This message has been edited by PPRuNe Towers (edited 16 February 2001).]

[Farside]

What an excellent article. I am off tomorrow for a two week period, but would very much like to continue on this thread. I have some information on the KLM disaster and lots of parallels could be drawn between that accident and SQ6. I will have to think about it a little but suggest that we come back to this subject and spent some time on it.
We must be able to learn from it . The only reaction so far from our management is an itam which states that we have to check that we are on the right runway. Nothing else. Complete silence. That is what I call lack of leadership. But then again this is PPRUNE at its best!!!

[SKYDRIFTER]

INSIDER -

Another great posting. You're quite correct in your comparison of the KLM - PAN AM accident. Personally, I find it quite strange that for all the historic examples used, the KLM - PAN AM collision is not used as another deadly example of CRM failings. Admittedly, CRM wasn't a science in that time frame. Not that I have any ill feelings toward KLM; I hold them in high regard.

I've never been able to discover the details on the crew-rest issue in that accident - anybody know?

I'm curious as to the U.S. reaction to SQ-006, as SQ-006 is not the least bit different from the corporate mentality licensed by the FAA in the case of U.S. carriers.

As illustrated on the Airline Safety 'Net site ( www.webpak.net/~skydream (http://www.webpak.net/~skydream) ) in the CS-985 matter, the FAA made the original incident disappear, created a fictitious one two days later & pressed a violation on a captain who fell into an FAA negligent oversight trap. With the company and the union facilitating that process against the captain, one has to question the industry sanity standard in the U.S. The most amasing part of the Hong Kong affair was that despite the threat, the captain successfully used 'the book' to an extreme to save lives.

With Alaska 261 and American 1420 still to analysed by the NTSB, the treatment of facts will be interesting, by itself. Personally, I'm expecting a sham investigation in both accidents.

[turbosheep]

Insider107, Farside and John Barnes,
Great postings, brillant effort.
Let's hope managements (the world over) take note and aviation learns from this horrible accident.

[gaunty]

Insider 107

Well said.

<font face="Verdana, Arial, Helvetica" size="2">I would further suggest, in conclusion, that if we only realised it, we do now operate in such a morale climate, post SQ006 (how can SQ now possibly carp at a weather delay decision?) and that, in the characteristic absence of any kind of lead from SQ, we should re-take our responsibility, reassert our professionalism and regain our pride as independent minded highly competent, reliable professionals, to be respected as prized assets. Only if we start thinking of ourselves in this manner can we expect SQ to do so and so stifle our new general's present derogatory view of us.</font>

In my business we call this posture.
You cannot think in any other way, the privileges and responsibilities of your position and licenses require that you do so.

It is an indictment of a management safety culture extant, that this, as a concept, has to be even articulated.
The similarity between the SQ006 and Tenerife drivers is compelling.

The military mind is mutually exclusive of the civilian imperative. Military decision-making is premised on obtaining an objective, with the least loss of life and assets possible, but with the expectation that there will be. It is axiomatic that whilst there are mechanisms based on experience in place to minimise casualty, the fact that your enemy is equally resolute brings you to the point where the inherent risk in conflict is many many orders of magnitude greater than is acceptable in the civilian environment.

In the civilian environment there is absolutely no necessity to even visit this level. If the risk is beyond that which experience command judgement can accept you just don't go. Period.
Whilst the art of leading men is universal in its application, military discipline is top down with little room for interpretation, whereas civilian discipline is a little trickier.
If the two professions have anything in common it is that in the final analysis and the chips are down, there is no room for dissembling, ingenuousness, treachery, obloquy, or as us uncouth colonial Aussies are wont to say, bull****.
The new general may find those experienced civilians who hold a well-earned posture a little different and more difficult than he is used to in his military role. If he is the leader it is suggested he is then, he will listen with deep respect and take advice with humility.
If he does not have any actual international heavy operating experience he would be wise to do more listening than talking. If these fora are even remotely close to the flavour of the situation, he will need all of his people skills just to sort out the men from the seemingly ingrained culture of sycophantic boys both local and expat.
<font face="Verdana, Arial, Helvetica" size="2">to "just following company policy". By which I mean are we substituting policy for good judgment and as individuals do we exercise the morale (sic) courage to coolly assess the rights and wrongs of a given operational situation, calmly formulate a reasoned solution with the assistance of the crew and available company resources and then stick with the derived decision, modified by equally reasoned evaluation of changing circumstances and so provide solid and reassuring leadership to our crews and passengers?</font>
Quite so, weasel wordsmiths and sycophants need not apply.

One of the great mysteries of life these forums seem to disclose is the low esteem towards and general bastardry visited on expat crews by this company.
There may be two possible reasons or a combination of for this.

I used to think that one of the truly clever traits partly responsible for the rise of the Asian economy (particularly Singapore) from third world status less than 30 years ago to their strength today, was their ability to use effectively external resources not then available to them to gain an objective. It cannot be denied that the use of expat staff, pilots and engineers were not just helpful but desperately needed to start and grow their airline.
Certainly national pride demands as a goal, that nationals eventually and as quickly as is possible take the reigns, but, is it reasonable to expect that a population of what, 3.5 million people, can produce locally the number of engineers and pilots necessary to man such a large and eminently commercially successful airline to the technical standard to which they aspire. Particularly when you consider that the Singaporean puts more store in their son as the doctor/lawyer/accountant than other equally worthy professions, the statistics (and relative pay scales it seems) are against it. It should be clear to them by now that simply throwing money at the problem and demanding that it be so (at least since the early seventies) just doesn't and isn't ever going to work. At least not without lowering the bar with a diminution of technical standards.
All of the great civilisations of history used, respected and handsomely rewarded expatriate (call it mercenary if you wish) help in their endeavours. Those that didn't rarely made it past 30 or 40 years before being reduced to supplicant status.
The current expansion and new orders can only exacerbate the "local" resource issue.

Expatriate crews are a fact of life worldwide in countries with relatively small population numbers. The "truly clever" would accept that as a fact of life, be welcoming, supportive and actively seek to make expat employees who choose to make the airline and country their new home really comfortable and equally part of the family. Use it to ensure their airlines pre-eminence. To continue to treat them as second-class citizens will tend to attract that standard of person. The real professionals will not have any trouble finding employment elsewhere.

The second reason may well be the attitude that some expats may hold towards the locals.
Which generated what is now of no consequence, suffice it to say that the fact that SQ took some pains to point out that SQ006s' Captain was "Malaysian" not just one of their Captains, with the implication that a Singaporean would not have erred so, stands as a sentinel as to whether they can take the road to survival as a vibrant and mature organization or whether they will remain blinded by their own hubris.

They simply do not have the human resources to do it on their own. There is no loss of face in using the best resources you need regardless of whence they come. There is much strength in understanding and taking steps to mitigate your weakness. This will take mature, wise and inclusive leadership. It would be truly stupid if they do not. Hubris and Nemesis are bedfellows.

It is a big bad world out there and to survive you need in the words of Farside
<font face="Verdana, Arial, Helvetica" size="2">As a wise man said once before, " Problems can not be solved by thinking in the same way in which they were created. "
I therefore believe that if we want to be serious about our effort to improve the safety culture in SIA we have to embark on a complete new road and leave a lot of our old habits behind.</font>

SQ006 will be a turning point for SQ as an airline.

They can take the road to mature survival illuminated by Farside in his brilliant post.

The hubristic alternative is the guaranteed and inevitable relegation to the "once were".

I hope a culture that has so wholeheartedly embraced modern technology will heed a message that could not otherwise have been delivered but by that very technology.

The choice and consequences are theirs. In the meantime there are alternative carriers for the enlightened travelling public.

[titan]

Gladiator, my friend, I think the tide is turning ....... at long last.

[Farside]

I never realized there was so much talent among the troops, and although there is no sign yet of any change here in Singapore, we must be able to start the ball rolling. It is really exciting to see that with all the different angles we are coming from the end result might be a very positive improvement in Singapore Airlines in general, especially in the Flight Ops department. I hope that the outcome of the Taipeh audit next week will result in a positive discussion, although there will be reasons enough to descent into a mudslinging match. I believe that some very serious acquisitions will be made, which most probably will all be true as well, but again we can learn from it , move forward and try to prevent the next disaster. I am off now 2 weeks sailing

[Insider107]

I’m sure that all colleagues await with avid interest, publication on 23 Feb 2001 of the Taiwanese Aviation Safety Council interim report on the SQ006 disaster of 31 Oct 2000.
Of particular interest will be mention (or not) of the captain’s rest period subsequent to his previous Melbourne COP and prior to duty report for SQ0006.
It would seem that he was a day short of statutory rest requirement but it is believed that this oversight has swiftly been rectified by firing the rostering girl “responsible”.
Who says SQ hasn’t got a modern, effective management?

[0.88M]

I seriously doubt SQ will ever change at all.
Since the same cronies are still at the helm.
Maybe a total revamp might change a bit but the s0-call "culture" will always thrive.
It's a local thing LAH

[Insider107]

Gaunty

Absolutely beautifully put:

"I hope a culture that has so wholeheartedly embraced modern technology will heed a message that could not otherwise have been delivered but by that technology"

You have distilled to the very essence!

Kind regards

[Lee]

The Singapore Government has all along controlled the people's mind, will, destiny, hope, lives, jobs, etc. However, they have no control of the Internet, and certainly does not realise the power of Pprune!

The wings of change are near at hand, thanks to the courageous Gladiator, Titan, Farside, Insider007 and others who stand for righteousness.

The truth will set us free.

[titan]

The irony of Singapore is that the government has gone to such great lengths to educate their citizens, but then refuse to let them think. Such a terrible waste.

[Insider107]

Lee

May I quote you?

"The Singapore Government has all along controlled the people's mind, will, destiny, hope, lives, jobs, etc. However, they have no control of the Internet, and certainly does not realise the power of Pprune!"

Maybe you could reinforce the above to the ALPAS members, who I'm trying to move from their paralysis, on the "SQ Pilots - Give ALPAS Your View" thread? It really is so easy for them to make a risk free move!

Kind regards

Insider107

[Tosh26]

I understand that the Taiwan Safety Council will be publishing its interim findings on the SQ006 crash today - 23 Feb. As well as publishing a hard copy report, I seem to remember that the Council will also put it on a dedicated web site. Anyone know the URL?

[InitRef]

Taipei Times reports "Communication error behind crash" - supposedly F/O tried to tell the CAPT that "something was wrong with the Nav Display" but was interrupted.

For the full story click here:
http://www.taipeitimes.com/news/2001/02/22/story/0000074678

In case the linked page moves/disappears, here is the cut and paste:

"Communication error behind crash
FLIGHT SQ-006: A navigation display indicating the plane was on the wrong runway was ignored because a pre-flight safety check being done by the co-pilot was interrupted by the pilot, aviation insiders say
By Patrick Kearns and Chuang Chi-ting
STAFF REPORTERS
Poor communication in the cockpit of Singapore Airlines flight SQ-006 caused the accident in which the plane crashed and burst into a ball of flames last October, killing 83 of the 179 passengers aboard, aviation sources said yesterday.

The flight, which mistakenly headed down a runway closed for repairs, smashed into concrete barriers and heavy construction machinery during take-off, while Typhoon Xangsane lashed the airport with torrential rain and high winds.

According to two aviation industry insiders who requested anonymity, communications between the captain and his two-man crew broke down when the captain failed to heed a warning that the plane was not on the correct runway assigned for its takeoff.

Co-pilot interrupted

Lined up on what was believed to be the correct runway on Oct. 31, 2000, first officer Latif Cyrano ran the pre-flight checklist, pausing to tell Captain Foong Chee Kong that something was wrong on the navigation display, but was cut off in mid-sentence.

"The pilot cut off the first officer, assuming he was referring to the poor weather conditions, saying `Oh no problem, in this kind of weather we have everything we need ...'" said an air safety expert.

And with the captain apparently distracted by typhoon winds and rain outside, he discounted crucial information from the first officer.

"Investigation officials listening to the CVR [cockpit voice recorder] asked the first officer what he was trying to say before he was cut off," said the safety expert. "His reply was `I tried to tell him the situation was unstable.' Unstable means you are not on the center line."

The fact that the plane's triangular image appeared offset on the navigation display -- a cockpit screen showing the plane's runway alignment -- clearly shows that they were on the wrong runway.

Off center

If the plane were not on the right runway -- runway 05L -- "The crew would have seen the triangle indicator was off center," that's what the first officer was pointing out, said the expert.

"We were all shocked when we heard [that the cockpit conversation regarding the co-pilot's warning was misunderstood,]" said a senior 747-400 pilot close to the investigation. "The pilot thought he knew what the co-pilot was trying to tell him," when in fact he had misunderstood what was being said.

Still, questions remain as to why the crew's first officer -- or the other co-pilot, the cruising captain -- didn't insist that the captain listen to what he had to say.

"The communication problem resulted when the first officer failed to fulfil his responsibility and pursue the issue with the pilot," said the expert. "The pilot cut off the first officer, assuming he was referring to the poor weather conditions, saying, `Oh, no problem, in this kind of weather we have [checked] everything we need ..."

But flying a plane is a team effort, a basic rule that the crew of SQ-006 failed to follow.

"One should always mind suggestions from others [in the cockpit]. If the captain could have [followed the advice of the first officer,] taken a look at the navigation display and avoided rushing the take-off, the jet wouldn't have crashed," said the senior pilot.

Yet the crew, perhaps intimidated by the leader of their team, simply followed his lead.

"I believe the whole crew was affected by the pilot's arrogant attitude, otherwise they would have insisted proper take-off procedures be run step by step," the expert said.

"The pilot was trying to instill confidence in his crew and give the appearance that everything was all right, despite the storm raging outside."

Prior to the crash, Singapore Airlines had a virtually flawless safety record.

"If they followed standard airline take-off procedure for pilots, the [crash] would not have been possible -- it would have not been possible to take off from the wrong runway," said the expert.

The news came just two days prior to the scheduled release of the crash report tomorrow by the government body spearheading the investigation, the Cabinet-level Aviation Safety Council (ASC,*¸¦w©e*û·|).

Kay Yong (¦¥³Í), managing director of the ASC, did not dismiss the information provided by the two sources saying, "Such speculation will be clarified at Friday's press conference when the factual report on the crash is disclosed," he said yesterday.

Singapore Airlines spokeswoman Sharon Wu (§d»_«n) declined to comment on the information and said the airline "has not been informed of it. ... We would prefer to comment on the case after the investigation is completed," Wu said."

[Rockhound]

I've just returned from a long trip (as a pax, I hasten to add, in deference to the professionals) and have read this thread with interest.
In reference to Insider107's posting of Feb 16, wherein he draws a parallel between the SQ006 accident and the Tenerife collision of 1977, I believe he errs when he asserts that the KLM captain, van Zanten, began his takeoff roll over the "vehement protests" of his FO, Meurs. According to the CVR transcript as contained in the official Spanish report on the accident, after KLM was lined up for takeoff and Meurs had finished the T/O ckeck list, Meurs reminded van Zanten they had not received "ATC clearance". Van Zanten acknowledged this and asked Meurs to request it. Meurs did so and the controller proceeded to give a route clearance. Van Zanten apparently began to advance the throttles and released the brakes some 6 seconds before Meurs finished reading back the clearance, ending with , "We are now at takeoff". The controller's response to the readback, "Stand by for takeoff...I will call you", was overlain by a simultaneous transmission from Pan Am to the controller, and the interfering transmissions came across in the KLM cockpit as a shrill squeal. By then, KLM was already stabilized in the takeoff roll.
In short, there is no evidence, as far as I am aware, that Meurs harboured any serious reservations that KLM had not received takeoff clearance. If Insider is privy to additional information, I would be interested to hear it.
Rockhound

[titan]

"Prior to the crash, Singapore Airlines had a virtually flawless safety record"

What an absolute load of rubbish! A simple search through Pprune for "Singapore" or "SIA" will show otherwise.

The cause of the accident, as most of us here presumed, is mired in cultural matters. Questioning authority in Singapore is a risk, and then even if you have the courage, there is the added burden of considering how to do it without letting the authority lose face. It may well be that those few seconds needed for this consideration were what fixed the aircraft's fate.

This problem starts at the very top of their society. LKY tells Minister to jump, Minister tells public servant, public servant tells Grandfather, Grandfater tells father, father tells mother, mother tells child, child tells maid ..... and the maid goes outside and kicks the dog.

Most of the foreign nationals that left SIA empathise with the dog.

A point that is raised regularly here is "do we as outsiders have the right to judge on another country's internal cultural matters? A most arguable question in this day and age. For those that believe in the negative, then that is always conditional on the proviso that the people that perish in their accidents are restricted to those of their own society. Sadly, this is not the case with international air travel, which is a point worthy of reflection by all those that are blinded by company loyalty.

[WSSS]

The factual report has been released by the Accident Safety Council http://www.asc.gov.tw/uw/uw_disp.exe/easc/home/asc/asc_disp.appl?asc_oid=@720|30|1

The CVR transcript just prior to line-up makes interesting reading.

[JR_wilco]

Downloading is a bit tricky there..
Any idea how to avoid the notorious 'glosend.appl'..??

best
JR

[WSSS]

JR_wilco:

Rename glosend.appl with doc1.pdf, doc2.pdf and so on....

You'll need Adobe Acrobat Reader to read them (which you can download from http://www.adobe.com )

Cheers

[Belgique]

"ONE RUNWAY light was broken and another was not bright enough when the Los Angeles-bound Flight SQ006 tried to take off on the wrong runway during a fierce rainstorm caused by an approaching typhoon, Taiwan’s chief crash investigator Kay Yong said in a preliminary report on the Oct. 31 accident.
Kay also said that the runway, closed for construction, should have been marked by a big cross, warning planes not to use it."

The real cause for SQ006 goes a lot deeper than the superficiality of missing markings and some dud lights - and is all to do with the "passivity of unfulfilled non-expectations".

a. If you're actively looking for something that constitutes guidance and it's needed to affirm the correctness of what you are doing (approach lights, runway edge lights, runway number marking, lit signs etc), you will be concerned about finding it (and anxious and anguished if you don't).

b. However if you are in a familiar situation, your alertness levels will be low and the absence of visual cues will be largely inconsequential (a complete non-starter as far as getting your attention and stimulating any mental alarms). It's not so much apathy or nonchalance as the "non-distraction of absent unsought cues". Situational awareness is a mighty fine thing but it has to be somehow kick-started. In the best of crews it does not sit there in the background ready to alert - not when it's a totally passive and innocuous scenario that's building up to the accident.

c. This crew was not really under a lot of pressure nor anticipation - even though they knew that the weather might worsen. Their plight started when they taxied out along the ramp taxi-route and not via the ramp-exit and down the "ex-runway" taxiway. They were, it appears, in the mind-set that, as they had done before, they were taxiing down the disused runway and would take a 90 right (at the end) followed by an immediate 90 right to line up on their departure runway threshold. But unfortunately, from the ramp area that put them on the right-hand runway and set them up for the accident. The mere absence of visual cues (approach lights, white runway edge lights, etc) was insufficient to alert them in their cocoon of reduced visibility. ATC were unconcerned because the crew had correctly read back their clearance. And I think that possibly the CRM situation was a typically Asian one - both F/O and S/O being mentally unprepared and characteristically unwilling to adopt a protectively questioning and cynically quizzical mind-set. The misunderstanding that may have otherwise saved the day just before they rolled tends to confirm that CRM needs to be active, assertive and then interventionist. But I'd not totally blame the crew...... it was simply a nice setup.

d. The only way to guard against a recurrence is to actively alert crews to these possibilities and potentialities. Attention-getting flashing strobe lights or noisy taxi barricades (road humps) are an easy solution to what happened. Without a clear recognition of this, nothing will be learnt from SQ006. It's simply symptomatic of the runway incursion problem that's plagueing aviation and which will no doubt generate further trauma. So if ICAO was genuinely in the business of Safety they'd have a small team of inspectors with a roving commission casting a continuing jaundiced eye at airports World-wide. It won't happen - but at least you could tell me why, after SQ006, it wouldn't have been cost-effective.

[ExSimGuy]

All the "noise" seems to be aimed here (and in many other threads on the board) at SQ. Whilst CRM may (or may not) have been a significant contributor to the accident, Begique's post above certainly makes a lot of sense.

The (TV) news is reporting the absence of a "large white X" painted at the entry to the non-usable runway, but even if this had been present, with the crew looking for lighting markers, would they have seen it on such an awful night.

"Speed bumps" do wonders for waking up dozing motorists, and I would suggest that suitable rubber mouldings, with built-in "cats eye" reflectors, could be portable and easily deployed. Dirty great red strobe lights would also be very hard to miss as a 747 runs over them!

------------------
What goes around . . .
. . often lands better!

[SKYDRIFTER]

DERIVED FROM PRESENTED INFORMATION -

SQ-006


15:00:53 CA Light up.

15:00:54 FO Check.

15:01:12 CAM (Sound similar to that of starter switch in)

15:01:12 CA Fifty percent N-two.

15:01:14 FO Valve closed.

15:01:16 CA Starting Engine two.

15:01:18 MAINT Roger, start two.

15:01:18 FO OK, Starting two.

15:01:19 CA See if you can get…what's the latest weather. Can you write it
down What's the latest ... ATIS eh…

15:01:23 OBS OK, yah.

15:01:25 ATIS Taipei international Airport information "Tango." One four five
four, Zulu. Runway zero five left is in use. Runway zero six for departure only. Expect ILS
runway zero five left category two approach; wind zero two zero at three six gust five two,
visibility five hundred meters, runway zero five left RVR four hundred fifty meters, runway
zero six five hundred meters with heavy rain, cloud broken two hundred feet, overcast five
hundred feet, temperature two one; dew point two zero. QNH one zero zero one
Hectopascal. Departure frequency one two five point one. Caution - wind shear on runway
zero five left final. Due to radio interference, tower frequency change to one two nine point
three. Caution - taxiway November Sierra has been re-marked. Aircraft using November
Sierra, advise taxi slowly with caution. Taxiway November Papa behind Alpha one and
Alpha three closed. Runway zero five right between November four and November five
closed due to work in progress. Taxiway November four and November five still available.
Inform Taipei approach or tower initial contact you have"Tango."

15:01:29 CA Write up….write behind here.

15:01:29 CAM Write up.

15:01:30 OBS I got it.

15:01:33 CAM (Clicking sound -similar to the sound of chronometer resetting)

15:01:38 MAINT Number two N one rotation.

15:01:40 CA Thank you.

15:01:41 FO Oil pressure number two.

15:01:43 CX 2043 Ground Cathay two zero four three request the wind and RVR
of runway zero six.

15:01:49 CA Light up.

15:01:49 FO Check.

15:01:51 GND Cathay two zero four three runway zero six RVR five hundred
fifty meters and wind zero two zero at three eight gust five one.

15:02:04 CA Ok lah, this is better still, Fifty percent N two.

15:02:04 CAM (Sound similar to that of starter switch in)

15:02:06 CX 2043 Cathay two zero four three.

15:02:07 FO Valve closed.

15:02:09 CA Ok starting three.

15:02:11 MAINT Roger start three.

15:02:12 CA Zero two zero better for us.

15:02:13 FO Ya.

15:02:14 CA Starting three please.

15:02:16 CA So resolved already it become less.

15:02:21 CAM (Clicking sound -similar to the sound of chronometer resetting)

15:02:31 FO Oil pressure number three.

15:02:31 CAM (Clicking sound -similar to the sound of chronometer resetting)

15:02:33 CA Roger N-one.

15:02:38 MAINT Number three N one rotation and set the brake.

15:02:42 CA Confirm set parking brakes.

15:02:44 MAINT Yes.

15:02:46 CAM (Sound similar to that of parking brake being set)

15:02:47 CA OK light up.

15:02:48 CA Check, parking brake set.

15:02:49 MAINT Roger.

15:03:01 CAM (Sound similar to that of starter switch in)

15:03:01 CA Fifty percent N-two.

15:03:03 FO Valve closed.

15:03:04 CA Ya.

15:03:05 CA Starting four.

15:03:08 MAINT Roger, starting four.

15:03:09 CA OK, start first, four.

15:03:24 CAM (Clicking sound -similar to the sound of chronometer resetting)

15:03:27 FO None and oil pressure.

15:03:30 CA Fuel on.

15:03:34 MAINT Number four N one rotation.

15:03:35 CA Thank you.

15:03:37 CA Light up.

15:03:38 CA Check.

15:03:55 CA Zero two zero is better.

15:03:55 CAM (Sound similar to that of starter pressed switch in).

BREAK IN PRESENTED DATA

15:04:54 FO Point six.

15:04:56 CA OK, thanks.

15:04:57 CA That's the…OK…OK.

15:04:58 OBS This is the latest zero two zero three six gust fifty
two lah still within limit.

15:05:02 CA Yah, zero two zero better.

15:05:02 OBS Yah.

15:05:02 CA More, more on head wind side.

15:05:03 OBS The rest no significant change.

15:05:03 CA OK…

15:05:07 GND (Cathay 2043 - conversation with ground control)

15:05:45 CA OK, your side gone already, ah…

15:05:47 CA Is he there? OK, alright, OK, huh… gone away…

15:05:48 FO This guy, that guy out this side, on the right side.

15:05:50 CA OK, huh…

15:05:50 FO OK, wah "Terok" (terrible) man…

15:05:51 CA OK, lights…cabin going off.

15:05:52 CAM (Click)

15:05:53 FO OK.

15:05:55 RDO-2 Singapore six, request taxi.

15:05:57 GND Singapore six, taxi to runway zero-six via taxiway…
correction, runway zero-five left, via taxiway Sierra, West Cross, and November
Papa.

BREAK IN PRESENTED DATA

15:06:42 CA OK.

15:06:49 RDO (Dynasty four conversation with ground)

15:07:56 CAM (Sound similar to that of flap lever through the detent positions)

15:08:04 CA OK checking rudder er

15:08:06 CA Full left.

15:08:07 FO Full left.

15:08:08 CA Center.

15:08:09 FO Center.

15:08:10 CA OK, full right.

15:08:11 FO Full right.

15:08:12 CA Center.

15:08:13 FO Center.

15:08:14 FO My controls checks ah.

15:08:24 CA Hongkong is closed man, ha ha worse.

15:08:27 OBS Hongkong closed ah…

15:08:27 CA That' s what he said not accepting any…

15:08:29 FO I see.

15:08:30 CA I think some people might have diverted there lah I think.

15:08:40 FO Ok column coming back.

15:08:47 CA If the RVR five left was two hundred right just now we checked.

15:08:50 OBS RVR yah two hundred.

15:08:50 CA Correct, yah two hundred meters ah, ok lah.

15:08:54 CAM (Sound similar to that of seat motor)

15:08:55 CA Ok man before take off checklist.

15:08:56 FO Roger sir.

15:08:58 FO Before take off checks, flaps –

15:09:02 CA Twenty green.

15:09:03 FO Twenty green.

15:09:06 FO Flight control.

15:09:07 CA Check.

15:09:07 FO Check.

15:09:08 FO EPR and speeds.

15:09:09 CA Ok, EPR one point five two ah, Vee one, one forty two, Vee R
one five six and Vee two, one six nine set.

15:09:15 FO EPR one point five two ah, Vee one, one forty two, rotate one
five six and Vee two, one six nine.

15:09:19 RDO (Cathay 2043 conversation with ground control)

BREAK IN PRESENTED DATA

15:10:35 FO That's all the moisture.

15:10:41 FO Turning left skidding er turning right err skidding left two
seven zero.

15:10:42 OBS The weather radar will be all red ha ha.

15:10:43 CA OK, passing ah two eight zero now, ah needles tracking and
turn right skidding left now ah, past heading of about two…three hundred now
ah…

15:10:45 FO Yah, that's right ah…

15:10:56 CAM (Sound of clicks)

15:11:00 FO My speed excursion is more than the left side, because the
wind is coming from here.

15:11:03 CA Ah, yah…

BREAK IN PRESENTED DATA

15:12:01 FO Yah.

15:12:02 ATIS Taipei Chiang Kai Shek International airport Information
"Uniform," 1500 Zulu, runway zero-six for departure only, runway zero-five left for
Category Two approach and departure, wind zero two zero at three-six, gust five
six, visibility six hundred meters runway zero five RVR four hundred fifty meters
downward, runway six RVR five hundred fifty meters downward with heavy rain,
cloud broken two hundred feet overcast five hundred feet, temperature two-one,
dewpoint two-zero, QNH one zero zero one Hectopascal.


APPROXIMATELY 1 ½ MINUTES NOT DISPLAYED

15:13:25 FO Taipei Tower, good evening, Singapore six.

15:13:28 FO Singapore Six, good evening, Taipei Tower, hold short
runway zero-five left.

15:13:33 GND Hold short runway zero-five left, Singapore six.

15:113:38 TWR Singapore six, for information now surface wind zero two
zero at four, gust to four-three, say intention.

15:13:44 CA Gusting four-three, ah…

15:13:46 R-2 Thank you, Singapore six.

15:13:47 CA OK, OK; better…less.

15:13:48 OBS Less….less gust already.

15:13:54 CA Zero two zero, it's from left, lah…

15:13:56 OBS Two four; gust four three…

15:14:05 FO Zero two zero…

15:14:08 CA OK, this one will be here, ah…

15:14:18 CA Zero two zero…

15:14:20 OBS Yah, left, lah…

15:14:21 CA Go right, to the end of the runway, end of the runway, then
turn, OK.

15:14:31 OBS Quite a bit of aileron for the takeoff.

15:14:35 FO OK.

15:14:40 FO The next one.

15:14:41 FO The next one is 'November one.'

15:14:42 CA OK, second right.

15:14:44 FO Second right; that's right.

15:14:47 CA In Australia, to them, next one is this, first one, you know.

15:14:50 FO Next one this one.

15:15:51 CA Yah…ha ha.

15:14:52 CA Australian.

15:14:53 CA I think the best is to say 'second right, ah 'first right,' 'second
right,' ah…

15:14:55 FO Clearing that Satvoice…

15:14:58 CA Tell them that we are ready, lah…

15:15:02 R-2 Singapore six; ready.

15:15:08 R-2 Taxi into position and hold, Singapore Six.

15:15:12 FO I get them seated, ah…

15:15:12 CA OK, below the line, please.

15:15:15 FO Cabin crew to your takeoff station thanks.

15:15:20 CAM (Sound similar to door closing)

15:15:21 CAM (Sound of chime)

15:15:20 TWR Singapore six, Runway zero-five left, wind zero two zero an
eight, gust to five zero, cleared for takeoff.

15:15:30 RDO-2 Cleared for takeoff, Runway zero-five left, Singapore Six.

15:15:31 CA OK, man…

15:15:34 FO OK, checks below the line; Cabin Announcement complete.

15:15:37 FO Packs

15:15:38 CA OK, norm, eh…

15:15:39 FO Norm

15:15:40 FO Strobes on; landing lights all on.

15:15:44 FO Takeoff clearance.

15:15:45 CA Obtained, hah…

15:15:46 FO Obtained, Sir.

15:15:47 CA OK, thanks.

15:15:48 FO Before Takeoff checklist completed.

15:15:50 CAM Sound of click

15:15:50 FO OK, green lights are here.

15:15:52 CA It going to be very slippery, I am going to slow down a bit,
turn here.

15:15:53 FO Turning that…

15:16:07 FO And the PVD hasn't lined up, ah…

15:16:10 CA Yeah, we gotta line up first.

15:16:12 OBS We need forty-five degrees.

15:16:15 FO I see, excellent man…

15:16:16 CA Yah.

15:16:23 CA Not yet er, PVD huh, never mind, we can see the runway,
not so bad. OK, I am going to put it to high first. OK, ready eh, so, zero one zero
is from the left, lah OK.

15:16:27 FO OK.

15:16:30 CAM (Sound of windshield wipers going to HIGH speed)

15:16:31 FO Ready Sir, zero two zero check OK.

15:16:33 CA Left wing into aileron, left aileron into wind. Huh, OK. Cabin
reported, eh…

15:16:37 FO Yah, cabin is ready.

15:16:37 CA OK, thanks.

15:16:37 FO Yup, thanks.

15:16:43 FO OK, thrust – Ref, TOGA, TOGA.

15:16:43 FO Thrust – Ref, TOGA, TOGA.

15:16:44 CA OK, Thrust – Ref, TOGA, TOGA.

15:16:44 CAM (Sound of engines spooling up)

15:16:54 OBS Hold.

15:16:54 FO Hold.

END OF CVR PRESENTATION

[Gladiator]

Seems to me to be a clear cut case.

15:16:07 FO And the PVD hasn't lined up, ah…

15:16:23 CA Not yet er, PVD huh, never mind, we can see the runway, not so bad. OK, I am going to put it to high first. OK, ready eh, so, zero one zero is from the left, lah OK.

Here are the key words,

"CA Not yet er, PVD huh, never mind"

For those not familiar with PVD. It is Para Visual Display. This device was never certified by the FAA but used around the world. It is a very useful tool for low visibility takeoffs as well as RTOs. The equipment has the capability of takeoff and RTO in 00 visibility.

First you select the runway ILS frequency in the FMS. At about 45 degrees to runway centerline and PVD selected, a little window opens up on the glareshield. Inside the window is a yellow and black barber pole.

As you start to roll, no movement of the barber pole means centerline. If you drift left of centerline, the barber pole will spin to the right telling the pilot to kick right rudder and so forth.

In my days TPE 05L was not PVD certified, but nevertheless it is an excellent crosscheck instrument.

[WSSS]

Glads, I think the "never mind" comment made by the Captain referred to the fact that it was not an operational requirement to use it at the time.

But one must ask, though, in a cockpit resource management context, that when the PVD was indicating non-alignment with the centerline of 05L, given that the PVD is a reliable device, why was its indication ignored? CRM is more than cooperating with others in the cockpit.. it's using all resources that you have available to you to ensure the safe conduct of your flight.

Skydrifter, you must have the edited version of the CVR transcript. The downloadable version from the Aviation Saftey Council website has the full version.

[Gladiator]

True that the PVD was not operationaly required, however, if the crew intended in not using it as a crosscheck/backup, why did they load the ILS frequency into the FMS.

The point is that a tool was prepared for use as a reference, but it's replies were ingored. The very reply that could have saved the day.

An accident is never the contribution of one item, we all agree on this point. In my opinion the R/W markings are not an issue here. The crew would not have seen the white X from the starting point of 05R anyway, and since that portion was being used as a taxiway, no white X was required.

I my opinion the contributing factors are:

1- SIA's lack of proper air carrier culture, safety first, profits next.
2- The fear installed into the crewmembers by management. If you delay a flight, there will be hell to pay, promotions stalled, etc.
3- The F/O fears the Captain/bad or no CRM.
4- The Asian culture, "the supervisor is always right".
5- Crews are overworked, fatigue is rampant.
6- Crews are under paid, low morale.
7- SIA's famous attitude, "I am invincible".
8- Bad visibility.

SIA will do their best to blame someone else.

My employer has a fatigue policy. If you are not rested, you are off the flight with full pay. A simple oral explanation and end of the story.

[titan]

What I find difficult to understand is that this is a critical take-off, and yet the crew seem to be quite jovial about it all. The higher stress level and seriousness of the situation seems to escape them. The confusion over the first or second turn right is passed off with light hearted banter and amusement.

I don't see the light issue playing a major part here. The runway was NOTAMed off and a warning given on the ATIS. From the CVR the crew is well aware which runway they require and the fact that it is the second right.

There are many things in the transcript to be disturbed about.

[HIGHCONE]

Looking at previous discussions it is interesting that the issue is FINALLY getting narrowed to CRM. I'm surprised that the topic doesn't get more attention than it does.

I don't know the PVD device, I presume it's a heads-up display.

However, it sounds as though there was plenty of reason to ask CRM style questions. It also appears that Gladiator - among others - is quite correct on the effect of corporate, if not ethnic, culture.

Some previous thread alluded to the extreme priority given to a pilot's image. The implication was that often pilots die for their image. EA990 & the Silkair crash seem to emphasize that to a terrifying degree. Curious that no one seems to want to go near the self-image topic.

SQ006 seems to be another instance of the infamous 'immortality complex,' as well (It will always happen to the other guy; not to me,).

Previous exchanges seem to hit the issue dead-on with the position, "It isn't as much as WHAT happened, but HOW and WHY it happened." Seems that those exchanges bring in another powerful point of avoiding judgement, focusing on analysis.

This human-factors issue isn't going to cure itself. I'd say it's long overdue for serious attention. If management and the unions won't touch it, maybe the pilots need to self-educate.

If the concern over the U.S. carriers not issuing regulations to their pilots is true, a person can only imagine what else is being overlooked. The crew rest issue is another good example that the 'negligent oversight' issue isn't limited to CRM.

The Airline Safety Net website www.webpak.net/~skydream (http://www.webpak.net/~skydream) makes a good case for a lot of needed changes. That site really puts the actual reality of CRM in question. An FAA inspector friend says that he can't fault the allegations made, other than to say that some carriers have gone the extra mile, but not many. He didn't deny the FAA role.

Unless something radical happens at SQ, there might be a lot more crashes ahead. I don't mean to tamper with culture & tradition, but the left-seat 'royalty' thing just won't work.

[Insider107]

Rockhound

Thank you very much for your posting of 22 Feb which casts a more detailed light on the Tenerife disaster, mentioned firstly in Farside’s Article 2 on another thread and then in my recent posting of 16 Feb on this thread. I feel that I have to give you an equally detailed answer on this thread, even though the subject is overshadowed by comment following publication of the Taiwanese Safety Council’s first report on the SQ006 disaster. The following was penned whilst I’ve been away and out of reach of on-line facilities

I stand corrected on the actual dialogue which took place between the KLM captain and first officer and that between ATC and the KLM flight crew. I apologise for my inaccuracy and can only plead that I was writing/posting “on the hoof” and relying on memory of events which took place approximately a quarter of a century ago. Perhaps if you have a web site that contains CVR transcript information, you would serve us all well by providing it.

Notwithstanding, I do believe that you will find my recollection of all other circumstances which surrounded this disaster to be substantially correct and in particular I do believe that the conclusions which I drew in my original posting continue to stand, in light of the information disclosed in your posting.

If I may go through your posting from &lt;after KLM was lined up for take off&gt;, I hope that you will not consider me nit-picking to point out that you err on this point (easily done), as in fact the crew was merely cleared to “line up and wait” rather than “line up for take off” – two fundamentally different things!

Further, you will recall that the point I originally made was to the effect that “stress factors” of weather/NOTAM considerations plus company/FTL pressures compounding an already difficult day served to produce a state of mind in the captain whereby he convinced himself that he had the take off clearance he so badly wanted and probably also convinced his FO. Your writing &lt;Van Zanten (captain) apparently began advancing the throttles and released the brakes some 6 seconds before Meurs (first officer) finished reading back the clearance, ending with “we are now at takeoff”&gt; serves to neatly illustrate my point.

You mention that &lt;in short, there is no evidence, as far as I am aware, that Meurs (first officer) harboured any serious reservations that KLM had not received take off clearance&gt; perhaps should be put in the context of my first point, that the crew had been cleared to “line up and wait” and therefore had NOT received take off clearance. If I may tentatively suggest to you that we are discussing events which took place within an organisation that, at the time, was highly authoritarian and not overly given to the idea of junior crew members questioning exalted senior training captains, the first officer may have, in light of the captains actions in the 6 seconds prior to the first officer completing the ATC clearance read-back, similarly convinced himself that they had take off clearance and so therefore must have mistaken the original instruction to line up and wait – hence an initial reservation but overcome by a particular mind set. Let me please assure you that, after the long and trying day previously described, this is a thing easily done in the kind of culture KLM then was and SQ is now. If you are in any doubt as to the veracity of this proposition then perhaps you would care to check with any of the professionals you mention you defer to - I’m sure they will agree with me.

[SKYDRIFTER]

INSIDER 107 -

I can't find the reference, for the moment, but I seem to recall that there was a significant protest of sorts from both the copilot & flight engineer in the Pan Am / KLM collision. It's a detail worth researching, as there are valid parallels to SQ-006.

[muhdzailan]

In my opinion,the crash of a Singapore Airlines Boeing 747-400 Flight SQ006 in Taipei was caused by the taxiway lights that misguided the pilot of the ill-fated aircraft towards runway 5R that was closed due to maintainance.The aircraft should depart from runway 5L which was the designated runway.In fact some of the lights which lead to runway 5L were dim or not in working order.This might be the cause of the fatal crash that had killed 83 of 179 passengers onboard.The windspeed at the time of the crash was 28 knots and was within flight operational limits.The three pilots,CPT Foong Chee Kong,F/O Latiff Cyrano and F/O Ng Kheng Leng were well trained and disciplined pilots.

[This message has been edited by muhdzailan (edited 26 February 2001).]

[7times7]

I am sure many of you out there had experienced the "leans" or other spatial disorientation before. What was the best stimulus that re-erects you brain or semi-circular canals? VISUAL reference to the earth.

Aviation medicine studies indicates that our visual sense are the most powerful when we are trying to evaluate our present state of orientation, though it has its limitations and can play tricks on us too. The point is, it is the most POWERFUL sense compared to the rest we have.

I am not pointing to or mitigating for the crew why they seem to ignore the PVD cues. I think the visual cue were SO POWERFUL that it overrides everything, be it real or an illusion.

Moreover, I wonder what's the confidence level of the crew on the reliability of the PVD system, which may lead them to discard them easier, like the boy who cried wolf.


[This message has been edited by 7times7 (edited 26 February 2001).]

[muhdzailan]

The Last moments of Flight SQ 006

2315 hrs 02 sec
SQ 006 calls:"Singapore Six ready."

2315 hrs 22 sec
RCTP Tower:"Singapore Six,Runway Zero Five Left...Cleared for take-off."

2315 hrs 52 sec
Capt Foong Chee Kong:"It's going to be very slippery.I am going to slow down a bit,slow turn here."

2316 hrs 07 sec
F/O Latiff Cyrano:"And the PVD (Para-Visual-Display) hasn't lined up,ah."

2316 hrs 10 sec
Capt Foong Chee Kong:"Yeah,we gotta line up first."

2316 hrs 12 sec
F/O Ng Kheng Leng: "We need 45 degrees."

2316 hrs 23 sec
Capt Foong Chee Kong:"Not on yet,er,PVD,huh,never mind,we can see the runway,not so bad.OK,I am going to put it to high first.OK,ready eh,so Zero One Zero(Wind direction) is from the left,lah,OK."

2316 hrs 36 secs
Take-off roll commences

2317 hrs 13 secs
F/O Latiff Cyrano:"Vee one"

2317 hrs 16 secs
Capt Foong Chee Kong:"....something there!"

Later,sounds of impact was heard.

[WSSS]

7X7,

You've raised some good points there, and I'm sure many pilots early on in their IFR training have been told often enough, to believe their instruments and not their senses. .. I know.. this is easier said than done.

The factual report gives some information about the general confidence level on the reliability of the PVD amongst SIA pilots which I have quoted below;

<font face="Verdana, Arial, Helvetica" size="2">
1.18.6.6 PVD Reliability

Because the PVD is a reversionary (back-up) instrument, it needs to have
a high reliability. The reliability information is from several sources: SIA
747-400 pilots, other air carriers using the PVD, and the PVD manufacturer,
Smiths. Boeing itself does not maintain reliability information on this
instrument.

During several interviews with SIA pilots (five SIA Captains and one First
Officer, see Appendix 7-1, 7-2, 7-3, 7-6, 7-8, 7-12), the following information
was obtained: Except for one interviewee who had heard of some pilots’
having problems with the PVD, all the others were clear that the PVD is a
reliable system if the runway is appropriately certified for PVD departures or as
long as there is no shielding of the LLZ/ILS signal. They have not heard of
any failures of the system. Even the one exception could not specify the type
or nature of apparent problems with the PVD he had heard about.
When the investigation team contacted the air carrier who have
purchased the PVD option for their 747-400s or 767s, there were no reported failures of the PVD system (Appendix 7-32).

The PVD manufacturer, Smiths Industries, provided repair data for 13
PVD computer units which were returned to them in the period from January
1998 to November 2000. During that period, one PVD unit was returned
because it did not activate on takeoff. A second PVD was returned because it
tripped off during takeoff with EICAS and status messages displayed. The
remainder were returned for various status and maintenance messages,
including seven returned to incorporate an upgrade. Smiths Industries was
not able to find faults in any of the 13 returned units (Appendix 7-33).
</font>

...and I agree with Gladiator in that a little more attention to this device (and possibly even the PFD), could have saved the day.

[titan]

muhdzailan:
You have been sprung. Nice try.

[AEROVISION]

INSIDER 107 et al
Re: KLM/PanAm
For what happened during taxi prior to collision, go to:
http://aviation-safety.net/database/1977/770327-1htm
and for cvr transcript to:
safety.net/cvr/cvr_kl4805.htm

similarities yes. If you cant see,it pays to wait to make sure. We are in for a long exhange of views on this one.

[7times7]

thx WSSS,

quote
"the PVD is a reliable system if the runway
is appropriately certified for PVD departures or as long as there is no shielding of the LLZ/ILS signal"

The problem is very few airports are certified for PVD usage. Even for those certified, the airports need to be sanitized for that kind of ops, i.e.Cat III conditions.

For airports that are not certified, who is to know if the LLZ/ILS signals are good enough for the PVD system to be reliable. For example CAT 1 airports, the possibility of LLZ/ILS signals being shielded or reflected will render PVD displays erroneous, at best as a back up only, as mentioned in the report.

Then again you can only have so many other back ups but they are just that, back ups, not the authority for orientation of physical position.

If there is a conflict, the visual cues (with the earth, real or illusion) usually supercedes all the back up indications especially if you know that it is unrealiable in certain conditions, unless you have an authority to fall back on eg. the ADI when you get conflicting visual illusions just to draw a parallel.

In future with ADS-B or better gnd radars, that will be the authority for gnd orientation within its system limits of course.

In this accident, the back up PVD indications were discarded, I think, as unrealiable given the above background.

How many times when cruising at altitude, we can misjudge the passing traffic appearing visually to be below you, but actually above or vice versa. TCAS is the authority supposedly. Reminds me of recent JAL incident over Tokyo.

End of day, visual cues are very powerful, but you can be TOTALLY WRONG with it. We need full authority back up systems, crosschecking all the time.

Phew! :)

[bunyip]

The PVD requires that the LOC be tuned, and the PVD turned on. It makes more sense to simply check the Nav Display to see if the FMC position is located on the runway symbol. If it is not, then either the FMC position is wrong or the wrong runway is being used. This method does not require any specific action by the flight crew and can be used on any runway. It quickly becomes second nature. Keep it Simple.
Of course it only works if the airplane has GPS, which I assume the accident airplane did have.
And in case some of you remember the incorrect datum used at Taipei, that problem was fixed several years ago and the positions shown in the data base are accurate.

[Rockhound]

Insider,
I totally agree with the gist of your earlier posting re Tenerife. I was merely objecting to your claim that the KLM F/O (Meurs) strongly protested his captain's (van Zanten's) decision to take off. If indeed Meurs was satisfied they had takeoff clearance, it was probably because of van Zanten's actions and mindset. When Meurs requested clearance, they had already completed the turn on the runway to face in the direction of takeoff, so they were lined up for takeoff. Meurs hardly had the chance raise an objection, as van Zanten began the takeoff roll before Meurs had finished the readback of the route clearance. During the takeoff roll, two transmissions between the tower and Pan Am concerning Pan Am clearing the runway are audible in the KLM flight deck, prompting the KLM F/E to question if Pan Am is still on the runway. Van Zanten emphatically declares the runway is clear. The collision occurred some 15 seconds later.
My source is a photocopy of the official report of the investigation, as published in Aviation Week & ST of 1978. I note that Aerovision has provided a Website reference to the CVR transcript.
I can see some parallels between Tenerife and SQ006 but, unlike Gladiator, I remain to be convinced that SQ "cockpit culture" was a major factor contributing to the Taipei accident. How concerned was Choong's co-pilot, Cyrano, that they were apparently not on the runway centreline? I admit, however, that I've not been able to download the interview of Cyrano by the investigators.
Rockhound

[TE RANGI]

Rockhound is absolutely correct in the details he provides about the Tenerife disaster in '77. The KLM junior F/O never raised any doubts about their having a clearance for T/O. In fact he supported his Captains affirmation that the runway was clear when F/E Schreuder expressed his uncertainty on the matter. There's no doubt that the strong presence of senior Capt Van Zanten was a major factor here. (Details can also be found at http://www.airdisaster.com/special/special-pa1736.shtml ).

In the SQ-006 case the cockpit dynamics seem a little different, although a parallelism certainly exists. We all agree that the CRM concept should be extended to a management/pilot relationship as well.

The question is whether the Company/regional culture was an important contributing factor here. In other words, would the accident have happened in a similar environment if the airline had been another one, or may be from another part of the world?

Any safety experts around?

[This message has been edited by TE RANGI (edited 26 February 2001).]

[Gladiator]

muhdzailan,

Sounds like a piece out of the Straits Times.

[Lee]

Gladiator,

You mean the "****ty Times"?

[Lee]

Gladiator,

You mean the "****ty Times"?

[NC1701]

Can someone clarify?

15:15:50 FO OK, green lights are here.

What do the 'green lights' refer to and what are the implications .. if any?

[WSSS]

The green lights referred here would have been the taxiway lights leading into Rwy 05R.

Could the crew have assumed the "follow the greens" system in operation like at WSSS and therefore were not looking for further greens along taxiway N1??

[moschops]

What's interesting is that all three crew mentioned centreline lighting in their interviews with the investigators. But 05R has no centreline lights, bar the green taxiway lights.

[aviator_38]

WSSS on 28 February 2001 10:54 wrote:
" The green lights referred here would have been the taxiway lights leading into Rwy 05R.
Could the crew have assumed the "follow the greens" system in operation like at WSSS and therefore were not looking for further greens along taxiway N1?? "
____________________________________________

The Taiwanese report stated the following:
" 1.10.12 Taxiway Center Line Lights:

.....On straight sections of taxiways, the centerline lights are found to be spaced 30m apart, while taxiway centerline lights on curved segments are at 7.5m spacing......

For aircraft taxiing onward: .........
(b) towards Runway 05L, there are 4 taxiway center line lights are provided along the straight segment of Taxiway N1 up to the Runway 05L holding position. These taxiway center line lights are located at a distance of 30m, 55m and 116m respectively from the point of tangency (where the curved taxiway center line marking from Taxiway NP meets Taxiway N1).
During site survey(on Nov 4, 2000), it was noted that the first taxiway center line light after the point of tangency was unserviceable while the second light was less intense than the other lights. (See Figure 10-13) ...."

Furthermore,section 1.10.8 covering Taxiway Center Line Marking had this:

"Generally, yellow taxiway centerline markings of 20cm width are provided at CKS Airport. However, a segment of the straight portion of the taxiway center line marking on Taxiway N1 providing guidance in the direction of the entry point to Runway 05L was missing. This missing segment of the taxiway center line marking was located between the end of the curved portion providing lead-in guidance from Taxiway NP to Taxiway N1 and the end of the curved portion of the taxiway center line marking providing lead-in guidance from Runway 05R/23L to the northern part of Taxiway N1. Reference is made to Figure10-7 and10-8 and the figure shown in Figure 10-20. "

Does look like the taxiway-lightings and absence of proper markings may be one of the factors for the inadvertent transition onto 05R.

Cheers

[Rockhound]

I've now managed to plough through the bulk of the Taiwanese ASC report (although the Appendices have eluded me - can anyone tell me if these can be downloaded?) and cannot agree with Gladiator and others that this accident can be ascribed to SIA's corporate/cockpit culture, Singaporean or Asian attitudes, the failings of overworked and underpaid crews, etc. It seems to me that all three cockpit crewmembers were satisfied that they were on the correct runway (the fact that they were all wrong is something else). The captain was appropriately concerned by the weather but all three pilots agreed that conditions were within limits; this was subsequently confirmed by all concerned. All three crewmembers were well rested. All three were aware that the PVD indicated a discrepancy but, as I understand it, use of the PVD is not mandatory. This brings up the matter of the article in the Taipei Times of Feb 22 (to which InitRef drew attention), which alleged (even to the point of quoting him) that Cyrano had warned Choong that the ND indicated they were out of position but was interrupted by an overbearing captain. Surely the CVR and the interview with Cyrano show this is all complete and utter garbage.
Clearly, the crew erred grievously, with tragic results, but, surely, this accident could have happened at any airline. Or am I missing something?
Rockhound

[titan]

Rockhound:

15:14:40 FO The next one.

15:14:41 FO The next one is 'November one.'

15:14:42 CA OK, second right.

15:14:44 FO Second right; that's right.

15:14:47 CA In Australia, to them, next one is this, first one, you know.

15:14:50 FO Next one this one.

15:15:51 CA Yah…ha ha.

15:14:52 CA Australian.

15:14:53 CA I think the best is to say 'second right, ah 'first right,' 'second
right,' ah…


This is not the type of conversation I would have expected in such critical circumstances. As the crew thought they were on the correct runway then maybe it is because they weren't paying enough attention. Somehow I fail to see, given the CVR, how a u/s and dim taxiway light would have made any difference. They all knew that they required the second right and yet still took the first right.

Yes you are right in that this could have happened to any airline - if the crew wasnt paying attention. Maybe I stand alone, but I refuse to support pilots because they are "fellow pilots". I totally agree with others that the SIA culture has a role to play here. But where does the buck stop for FOs/SOs not having the courage to challenge their Captains? Where is the line drawn between "captain your heading bug is one degree out" and "captain, if you take-off we will all die"? It is THIS line that changes between airline to airline. Surely it is better to err towards the "picky" FO than one silenced with fear. Maybe this is also the reason why command training takes 8 months at SIA, because it takes this long to train the FOs to speak up and make decisions.

[aviator_38]

titan posted 28 February 2001 23:51
" Somehow I fail to see, given the CVR, how a u/s and dim taxiway light would have made any difference. They all knew that they required the second right and yet still took the first right."

Hi...that part of the CVR was when they were taxying down taxiway NP,and occured just before the aircraft came abeam of taxiway N2.The u/s and dim taxilights were on taxiway N1,whose yellow markings led directly to 05R,with the continuing section to 05L missing.


Cheers

[knackered]

titan, not like you to take things out of context!

Preaching about what you would or would not have done in the same circumstances is a very dangerous area for pilots to venture into. Holier than thou and all that.

Don't forget that at the home base for these guys the standard for taxi is "Follow the greens" and this appears to be what they've done. I don't think you can take the actions of the pilots in isolation from the airport conditions at the time, and I'm not referring to just the weather.

If you set up a situation where it can happen then someone is going to do it. If these guys hadn't then someone else would. Just a maater of time.

[Gladiator]

We can all be Monday morning quarterbacks. It all boils down to bad visibility (bad judgement) and the F/O's lack of assertiveness (company culture).

[TE RANGI]

I think Rockhound is correct in that the circumstances leading to SQ-006 accident were not unique to SIA or the Asia/Pac region. I couldn't be farther from SIN and yet I must admit that I could have easily made the same mistake.

We have a Capt that has a handful of a taxi. A heavily loaded 744, fierce winds, wet surface, rain, poor vis... You want to use the aircraft's momentum to coax it into a 90º turn on to the rwy, line it up correctly, all the while not wasting an inch of concrete. The twy is dark up ahead and you don't want to get into a dead end. And there's other concerns: How's the T/O going to be conducted in the gusty winds nearing the limit, slippery surface, windshear, what's the SID, and how you'll avoid the worst of the wx...It's all too easy to get lulled into the wrong runway by a curving path of green centerline lights.

Perhaps we as pilots should take this opportunity to demand a fresh, clearer, WORLDWIDE set of new regulations about surface movements/lights/markings and unified taxi procedures. Although conforming to ICAO standards, airports tend to develop their own microcosm of particular designs, markings, customs, style, procedures, LVPs...
and expect us pilots from all over the world to adapt to their idiosyncrasies,(CDG comes into mind) unduly increasing crew workload at critical periods and so mistakes are being made (No wonder the apalling number of rwy incursions).

But back to SQ-006. Insider hit one point in his thoughtful posts. Why the decision to launch in the first place when in view of the wx the flight could have been cancelled. A landing back at CKS should have been extremely difficult -beyond autoland limits, low ceiling, below CAT-I minima...- was there a suitable alternate in case of a dire emergency (think of SR-111)?. And there were also other airlines operating: CX and CAL are heard in the CVR.

Capt Kong was obviously in a hurry to set off. Sometimes the pressure (corporate or otherwise) is not conspicous, but it's there in the back of your mind. Here's a question for you SQ guys: What would have happened if the Capt had decided not to depart from Taipei?

My apologies for the long post.


[This message has been edited by TE RANGI (edited 01 March 2001).]

[This message has been edited by TE RANGI (edited 01 March 2001).]

[IGS]

Culture problem is certainly one of the major factors in the SQ6 case!!

[Lee]

Crew rest is another major factor in the SQ006 accident.

[Rockhound]

Hey, Gladiator, you're changing your tune. Now it's bad visibility first, SQ company culture second. I quote from your post of Feb 25:
I my opinion the contributing factors are:

1- SIA's lack of proper air carrier culture, safety first, profits next.
2- The fear installed into the crewmembers by management. If you delay a flight, there will be hell to pay, promotions stalled, etc.
3- The F/O fears the Captain/bad or no CRM.
4- The Asian culture, "the supervisor is always right".
5- Crews are overworked, fatigue is rampant.
6- Crews are under paid, low morale.
7- SIA's famous attitude, "I am invincible".
8- Bad visibility.

As for Titan's comment, I still don't see the evidence for a browbeaten F/O cowed into submission by an overbearing captain but, admittedly, I speak as a non-aviator, so may be way out in left field on this one.
Re TE RANGI's suggestion that the flight should have been cancelled due to weather, Capt Choong seems to have been concerned but overall pretty sanguine about the conditions and was he really in such a hurry to get going? (After all, he took the time to make a slow turn to line up for the T/O).
Finally, Lee's assertion that crew rest was a factor. I don't see that from the ASC report but, again, as a non-professional, I am open to correction.
And can anyone tell me if the Appendices of the ASC report are downloadable?

[Rockhound]

Apologies...I keep getting the SQ006 captain's name wrong. It's Foong Chee Kong, so he should be referred to as Capt Foong, right?
Rockhound

[SKYDRIFTER]

WIND FACTOR -

Of all the reasons to cancel the flignt was the wind factor. Having a momentary legal wind report doesn't diminish the high probability of encountering a fatal wind shear until being able to accelerate to approximately 250 knots. That's quite an exposure window.

The range of wind reports with no suggestion that the wind could be expected to either stabilize or improve for hours to come should have been considered - by the whole crew.

As the evacuation showed, the aerodynamic capabilities of the aircraft, crew and their luck won't overcome the non-controllability of the excape slides in high winds.

Not mentioned also is the propensity for the downwind engines compressor stalling in high crosswinds. Remember the SFO 747 incident that nearly took off the hilltop, as well as the Gatwick 747.

There should be no doubt that the crew would now tell us that given the same situation, they would wait out the weather. They are the experts.

[TE RANGI]

Lee:

Why is crew rest a major factor here?

[Gladiator]

Rockhound,

My list of factors does not have to be in any particular order.

Since you are not in aviation, may be an expansion of the factors is in order.

An accident as I previously mentioned is pairing of several events. Think of these events as pages with holes in them. Once all the holes line up you end up with an accident.

The list was carefully thought of. Something as simple as crew rest, which is puzzling to some can play an important role.

The rest issue is not, did he get enough sleep the night before? It is how has it been in the past year? Due to SIA's fixation on crew productivity they have lost focus on the bigger picture.

It is very easy to make a very serious mistake while suffering from chronic fatigue syndrome. A great number of crewmembers have chronic fatigue (I suffered from it while at SIA on the B747-400) which is very dangerous when mixed with a B747-400. SIA fails to recognize that such a syndrome exists.

Someone asked, what would have happened to the Captain of SQ006 had he made the decision not to go?

My opinion is, he would have been called into the office to explain why such a decision while the wind was within the go envelope.

Had this happened on the A-310, B-777 or A-340, that Captain would not be promoted to the B747-400 as well as many other petty torments.

My employer has a no-go policy as well as a fatigue policy. No explanation or paper work is required. If the Captain is not comfortable, the flight is delayed.

I just cannot imagine how one could have made a go decision in such a nasty condition.

We can discuss lights and notams all day. It all again comes down to not seeing where you are going.

[sia sniffer]

With regards the SQ6 crew rest query, I posted this back in early December.
http://www.pprune.org/ubb/NonCGI/Forum1/HTML/011351.html

Anyone noticed the amount of roster disruption since SQ6, then subsiquently the 3 man crew debacle? Way to go Gladiator!

[gaunty]

SKYDRIFTER and Gladiator

Spot on, it all comes down to professional command judgement.

Professional behaviour in my world says means "johnny on the spot" applying the advanced skills and experience with the authority bestowed by the enabling authority.

It of course requires that you can justify reasonable actions to your peers but they will always be conservative with any bias to perceived risk applied to the people lives with whom they are entrusted, not to massage some idiot ideologue managers ego.

If the system works otherwise, why appoint individual Captains in the first place.

The way it seems to operate in this organisation is that the Captains are in effect just senior FO's acting under the proxy command of the said ideologue sitting in an office in Singapore. It gives a whole new meaning to the title of Fleet Captain.

So until that is sorted lets call them Proxy Captains and hold the Fleet Manager responsible for ALL individual operations anywhere. If they ever had any ambitions for the opportunity to play God then here it is.

Having said all that I sincerely hope Farsides optimism and his comments to Insider107 at the beginning of this post is well founded. I too admire Insiders writing and posture.

I can speak with some authority on the "change" issues. One of the companies I am working for is nearly 100 years old and had survived that long due to an underlying technical excellence. However that had bred a form of arrogance and laziness in the management that had not recognised the express train bearing down on them whilst they were stalled on the level crossing. (In this context that express train was SQ006, it is immaterial in these terms as to who or what was responsible for SQ006, but it provides the opportunity for an orderly but wholesale rethink)
There is evidence that Qantas used QF1 so.
Worse the layers of time servers, ideologues and the sycohantic lesser abled that you accumulate over the years in these circumstances and risen through the ranks by politics rather than ability, had surrounded the leaders with a warm and fuzzy cocoon and they had gone to sleep. They were in fact now merely keeping the body warm. It was hard work, identifyng and sortng the good bits and ditching the junk. It has been three years and is as it should be a continuing work in progress.
If there were just 2 lessons to be learned from this exercise they would be.
1. It is possible that as an organisation you have been dead for some time and it is only sheer momentum that provides the illusion of continuing progress. The end in these circumstances comes very very swiftly.
2. The first and most fundamental step is to admit that this is so, communicate it directly to the staff, ask them to participate in the renewal and cut hard and deep where there is any continuing negative resistance.

Sounds like SQ have barely begun a similar process. I sincerely hope they make it.
With Insiders and Farsiders around it is possible that they can move on and become an international carrier as well respected by their peers, as by their undoubted passenger fans.

[0.88M]

Changes will happen in this company.But not the ones everyone hopes for to avoid another SQ 6.Some people still thinks there is no flaws, in their "mighty -LOFT" trainings.Hope the next SQ_ _ accident is 20years away.

[NC1701]

15:15:50 FO OK, green lights are here.

Does this suggest that the FO is assertive or passively waiting (in fear), for the captains commands? If indeed the FO was actively involved in navigating, is it possible that he too thought that they were on the correct runway and had no reservations about taking off .... as opposed to ...realising the captain's error but was too afraid to object because he would rather die in a fireball than to receive a stern rebuke. Is it possible that, 'fear of captain / asian cockpit culture', is not a factor here?

As a precaution though, all 'Asian' FOs should be reminded that there are worse things in life than being reprimanded by a captain ... like ... dying prematurely in a fireball leaving your wife and kids to fend for themselves.

I find the current discussions about CRM a little disturbing and perplexing.
Disturbing because it would appear that there are fatigued pilots who places self interest first before the safety of his crew and passengers. Disturbing because it seems that pilots are actually weighing in their minds, whether to attempt a risky takeoff or not, based on considerations for how the chances of his promotion will be affected.
I thought pilots were supposed to be a rare breed of individuals? It would appear that they are no different from the rest of us in that sometimes personal convictions take a back seat when it comes to climbing the corporate ladder.
Perplexing because the pilot doesn't seem to realise that the promotion will come to zilch if he dies as a result of of his 'valiant' effort.

In any case how valid is it to cite CRM for risky takeoffs? Who faces more pressure from his superiors? A military field captain or a commercial airline pilot? In crimes against humanity, does the defence of 'under pressure to perform' hold water? What is the price of a few hundred lives ... including the flight crews'? A missed promotion? An 'interrogation' from the superiors? Some paperwork?

Should be a small price to pay, ........ right?

[This message has been edited by NC1701 (edited 02 March 2001).]

[Insider107]

Rockhound

I have just discussed your postings of 28 Feb and 1 March with a very good friend of mine who is an ex-USMC flyer of great experience and very humble view. Having viewed these postings, at my urgent request, he has rapidly and, in my view, erroneously formed the opinion that you must either be “a civilian weenie wanabee out of his depth talking c**p, or an SQ management remf/puke, spinning misleading information to draw attention away from the main issues”. I have remonstrated with this rare display of emotion and have attempted to dissuade him of these quickly held views but, sad to say, he is adamant. Whilst I am not sure of the meaning of “remf/puke”, I certainly grasp the implication of “weenie” and am adept at filling in asterisks where required.

I have confirmed with him that, as soon as I have some “down time” and can get to a keyboard, I will produce what, whilst not being my magnum opus – I save that to a later day – will be a cogent and complete refutation of your views published to date.

Please bear with my presently hectic programme and I will post within a couple of days.

Kind regards. Insider107

[WSSS]

Rockhound,

You said;
<font face="Verdana, Arial, Helvetica" size="2">
All three were aware that the PVD indicated a discrepancy but, as I understand it, use of the PVD is not mandatory.
This brings up the matter of the article in the Taipei Times of Feb 22 (to which InitRef drew attention), which alleged (even to the point of quoting him) that Cyrano had warned Choong that the ND indicated they were out of position but was interrupted by an overbearing captain. Surely the CVR and the interview with Cyrano show this is all complete and utter garbage.
</font>

It was actually the F/O in the observer's seat who corrected the RHS F/O saying that the PVD will not be lined up until within 45 degrees of the centerline.

But why wasn't this followed up after the SQ 6 had lined up? .... Why didn't the F/O's raise this point again after the plane's heading was within 45 degrees of the centerline?

The Captain had quickly dismissed the use of the PVD as irrelevant since it was not an operational requirement although both F/O's showed at least some interest in the fact that the PVD indications were somehow not quite right.

...and the F/O's accepted the Captain's decision... without question.

I don't know, Rockhound, whether you have ever lived in Singapore, but here, you are taught from an early age to never ever question authority under any circumstances. When it comes to effective CRM, then this becomes a problem and must be addressed in the interest of air safety.

[This message has been edited by WSSS (edited 02 March 2001).]

[Rockhound]

Wow...am I flattered that the views of a dilettante like me on this forum are drawing a response, let alone being taken seriously! I would like to assure everyone that I tread here with great trepidation and never, in my wildest moments, truly believe that I am "Flight Deck Qualified". I repeat, I am not a pilot and you will all no doubt be happy to learn that I will never be one, as my eyesight is terrible. However, I do hope you will continue to allow me on to your flight decks for visits in-flight. (For the record, my two great dreams are to one day be allowed to sit in on (a) a takeoff in a heavy jet and (b) a Cat III autolanding in bad weather).
I would just like to respond to WSSS's and Insider's posts and then shut up (at least for a while).
WSSS,
My reference to the Taipei Times article was merely to point out that it was another example of irresponsible journalism and bore no relation to the CVR transcript in the accident report. It was not the ND that was the subject of discussion on the SQ006 flight deck but the PVD; the captain did not "cut off (the F/O) in mid-sentence"; and the captain was badly misquoted. And my reading of the CVR transcript still leads me to believe that F/O Cyrano was not overly concerned by the PVD indication. (Maybe the Appendix contains something of interest. Please, has ANYONE managed to download them?)
Insider,
Oh dear, I'm sorry to have upset your ex-Marine friend - quite unintentional, I assure you both. I may be a weenie but I'm not really a wannabe and I'm certainly not an SQ management remf/puke (but, like you, curious to find out what that is - perhaps you can email me privately). My entry under "Who?" is genuine and accurate.
I still don't see much of a parallel between the KLM Tenerife and SQ Taipei CRM but I look forward to reading your next posting.
Sorry, much too long a posting. I promise to lie low (for a while).
Rockhound

[7x7]

REMF - for many years now a term, not of endearment , by front line US military men for those who serve in uniform but far from the firing line. (REMF - Rear Echelon Mother F**ker.)

[geh065]

Someone told me that a newspaper said that the crew asked the tower 5 times whether they were on the right runway, and were told each time that they were. Sounds rather strange to me. Has anyone heard a similar story?

[TE RANGI]

Insider:

Let's not lose our composure. Rockhound is not that far off the ball (I wish I knew his trade as well as he knows ours). After all, the sound interchange of ideas is what a public forum is all about.

Having said this, I have to admit that you got the ball rolling in a most interesting flight safety issue, i.e. Is company (in this case SIA) and/or regional culture a major factor in the SQ-006 case? I understand the mindset that you discribe at the begining of this thread and the CVR proves the capt was on a rush to get going
(PVD wasn't lined up, but he could see the rwy not so bad...)

But what I don't understand is why the flight wasn't cancelled in the first place. My previous question went unanswered: What would have happened to the capt of SQ-006 had he elected not to go? Would he have been demoted/reprimanded/terminated/made his life a misery with bad rosters...what? What is it that makes you feel the management pressure so intense?

[This message has been edited by TE RANGI (edited 03 March 2001).]

[This message has been edited by TE RANGI (edited 03 March 2001).]

[AEROVISION]

Insider 107
I lost you here. When your marine friend came to the quick conclusion that Rockhounds postings were c**p you apparently vehemently
remonstrated with him as you thought he was erroneous. But, he stood firm and then you said, ok, I am now going to write a cogent and complete refutation on Rockhounds posts.
What happened? X-Ray vision?
Anyway, standing by for your revelations.

Back to the topic.
It seems to me that the discussion is concentrating on the SIA culture/ethnics issue, which could be a contributing factor in this accident.
What was the primary factor and, the secundary? Chain of thoughts;
Aircraft hit object. Why was object there.
How came aircraft on collision path with object. Why was object not visable for crew. And then comes the culture aspect.Why did capt. decide to leave the gate. etc. It is contributing, not primary.


[This message has been edited by AEROVISION (edited 03 March 2001).]

[titan]

Only when you have been a SO and FO at SIA will you truly understand how deep the loss of face mentality runs.
As on another SIA subject doing the rounds presently, SIA keep looking in different parts of the world for FOs because the western ones disturb their cockpit enviroment. Why? because they are prepared to speak up, albiet cautiously, and question the Captain and this is not the Singaporean way.
We become very comfortable in our warm enviroments as pilots, and it takes quite a bit of effort to project forward to a catastrophic outcome. So those that say that the crew would not knowingly take-off on the wrong runway are on the wrong track. The real point here is that when there is doubt the underlings side with the captain rather than with themselves. It was the non-actioning of the doubt that caused the accident.

[Insider107]

I’ve finally had chance to get to the keyboard, although I’m not sure when I will be able to make this posting. I’ve explained to Pprune Towers the exact nature of the circumstance that makes my present postings so sporadic - I would ask for your acceptance that the reason is genuine and overriding.
However, I had the unexpected opportunity to make my brief and hasty post of 2 March in which I revealed (in very much muted fashion) a friend’s reaction to Rockhound’s postings of 28 Feb and 1 March, which emerged earlier last week over the course of conversation at a common slip station. My view of the reaction was as stated and I did indeed argue that Rockhound could be the “genuine article” and as such, providing worthwhile debating points. Notwithstanding, following some thought, I decided to post the reaction on the twin basis that it serves us all well to realise that genuine emotion is generated by the apparent trivialisation of events which surround the SQ006 disaster – and I point out Rockhound’s trivialisation a little later - and similarly strong emotion is generated by the possibility of a “gloss over attempt” by SQ management, through the medium of phoney postings.

Te Rangi. Thanks for your note. Please be assured that my composure has been and remains completely intact. I agree entirely that Rockhound’s knowledge of our trade is laudatory (this detailed knowledge gave rise to my friend’s “wannabe” comment) and I agree absolutely with your view that “the sound interchange of ideas is what a public forum is all about”. Please see my note to Rockhound, below, most of which I roughed out a day or so before your posting. I hope also that Gladiator’s writing will demonstrate to you why the flight wasn’t cancelled in the first place and what would have happened to the captain subsequently - it is absolutely correct.

Aerostar. Thanks also for your post – contents noted. I similarly hope that my writings provide answers to your questions.

Rockhound

Thank you very much for your posting of 2 March in which you proffer your assurances that you are the “genuine article”. I certainly accept your bona fides and my American friend sends his regrets in respect of the intemperate expressions he used on first reading your postings and which expressions I subsequently relayed in my last posting. I now write in reply to these earlier postings of 28 Feb and 1 March in respect of your conclusions as to what did not cause the SQ006 disaster. May I say that as a member of the non-aviation public, you serve us all well by sparking both more debate and an increasingly forensic approach to our collective thinking. Similarly, if you had been a member of the SQ flt ops management/SQ PR department, artlessly posing as the former, then you would deserve equally to be thanked for assisting in the crystallisation of all our views and the ready articulation of them on this site. Therefore, please do not feel the need to “lie low” – you would not serve either the cause of free speech or that of aviation safety if you did so – please “keep ‘em coming” but also please heed my note at the end of this posting.

Before I move to answer your postings, may I say that the Taiwanese Aviation Safety Council Report is a “factual” report and no conclusions as to the cause of the crash are reached. We, however, are all trying to pre-empt this report and ascribe cause(s), using gleaned knowledge of the case and as much experience as we can muster. However I guess we will all have to wait for the potentially more contentious document that will be produced and available by year-end, which will state such causal conclusions and prove us individually right or wrong.

Next, I had intended writing a very detailed piece but reflection brought a realisation that I’ve already said everything in previous postings and that what I may have missed or not emphasised sufficiently, my estimable co-posters, Gladiator, Titan, Gaunty, Farside and Sia Sniffer have all filled in or emphasised. So, I will try to keep it short and rather than describe in detail, merely make reference to postings on given dates.

I hope that you will not be insulted if I say – in reverse order of your posting - that, (i) yes, you are “missing something” (ii) what has been said [albeit in a Taiwanese newspaper] is not, as you state, “complete and utter garbage” but merely the subject of unfortunate phraseology. Further, your glossy summing of “what seems to me that” is similarly in error. Allow me to elucidate.

I’m afraid that you miss the point entirely - “all three crewmembers were satisfied that they were on the correct runway” is not the case. First Officer Latif Cyrano stated that the PVD “indicated a discrepancy” and you then glibly dismiss the significance of this by saying that “but as I understand it, use of the PVD is not mandatory”. The point is that Cyrano noticed evidence to indicate that all was not well but did not pursue the point when the captain said that it did not matter – precisely because it was the captain who said it! He would, however, be harbouring his unspoken doubts on the subject, whilst events unfolded. This is a cultural issue that Gladiator and Titan have ceaselessly laboured and on which maybe I can expand later. Further, the third seat FO would similarly make no comment, following the captain’s judgement on the matter.

On the contrary, the captain appeared NOT to be “appropriately concerned with the weather”. The CVR transcript in fact demonstrated a remarkable levity amongst the crew in the face of a weather situation of the utmost gravity. If I may remind professional readers of conditions which prevailed on the night of 31 Oct 2000, by referring them to my original posting on this thread, they will be able to concur. For those non-professionals reading, please be assured that the conditions on the night were exceptional and worthy of the greatest respect by any operating crew.

I quote my first posting further:
“Apocryphal evidence indicates that the apron was flooded at the time and this would perhaps lead to the supposition that the runways may also have been in a similar condition, in light of the approaching typhoon front. Similarly the aircraft was reportedly strongly buffeted by high winds whilst still at the gate”.
I do believe that the CVR transcript bears out the crews’ appreciation of taxi conditions as the captain is heard to say words to the effect that “I’m taking it slowly as it is very slippery” – not wishing to slide off the taxiway, especially when turning onto the usually very slick runway end, rather than being “overall pretty sanguine about the conditions and was he really in such a hurry to get going”?
Next, “all three pilots agreed that conditions were within limits”. Please read:
“No overarching view of the situation would arise with this mind set, hence it would not be possible to consider that whilst technically within the cross wind limitations, prevailing gusts, low visibility, low cloud base, very heavy rain and a possibly flooded runway would lead to a take off in conditions somewhat different from the steady wind/good viz/dry runway conditions of test flying demonstrations”.
Do I really have to labour this point?
It may be worth mentioning that at this very time of the approaching typhoon front, Canadian Airlines, Eva Airways and Cathay Pacific all deemed it prudent to either cancel or place severe postponements on their flights, whilst only China Airlines – no arbiter of air safety I’m afraid, deemed the conditions suitable for continued flight operations.

Further, “all three crewmembers were well rested” is in error. The captain was one day short of his statutory rest period prior to reporting for SQ006 duty, although you could not be expected to know this (I’m surprised the ASC didn’t!) and I assume you missed my posting of a few days earlier to this effect. Further, Gladiator makes the point that SQ 744 crews have been stretched to the FTL limit of 28 day crew duty time for some time now (as are 777 crews) because of a serious pilot shortage (due to SQ’s antediluvian industrial practices/poor pay) and the cumulative effect of this heavy work pressure and constant time zone change has had and continues to have its adverse effect. Whilst on the subject, please also be assured that the present impasse over pay and conditions between ALPAS and SQ, which has been dragging on for nearly two and a half years is having an effect on most crews – yes, I know there is no evidence to suggest there was an effect on the SQ006 crew. The rancorous feeling amongst the SQ pilot body generated by a feeling of abuse and contempt of that body by the SQ management is producing the lowest morale amongst a pilot force that I have ever seen (35 years worth) and whilst I assume that long term data does not (yet) exist to provide a correlation between low morale of pilot force and susceptibility of a carrier to major accident, I think it would be a very brave man who would publicly state that no such correlation exists.

As to the actual incident as portrayed by the CVR, may I refer you again to my original posting in which I postulate the idea of there being “two thought processes which generate any flying decision made in the course of SQ operations”

1. Whatever happens, I must not take any action which will invite an admonitory/intimidatory phone call from the fleet management and which call will certainly be the culmination of a previously conducted, secret investigation involving the sustained interrogation of the FO(s) in an effort to establish inconsistency of story which could then lead to an adverse report being attached to a personal file/demotion without appeal or summary dismissal.

2. Under all circumstances, cover yourself by conducting operations absolutely within a highly legalistic interpretation of limitations and procedure without taking any overview or exercising any judgement, both of which will, necessarily, be subjective and hence open to fleet evaluation and criticism after any event.

I would suggest that perhaps a combination of the two thought processes prevailed on the night. The captain and crew were concerned with the weather and hence susceptible to the distraction that this would generate but masked this concern from each other (and perhaps themselves), in their desire to cause nil delay, with stylised SQ banter. They were however concerned to legalistically “cover themselves” and make sure that they were “within limits”. Hence mind set 2 also came into effect.

However, more ominously, if we completely disregard the above and the captain and crew indeed did not regard the prevailing weather as anything out of the ordinary, is this then not the most damning indictment possible against an SQ training philosophy that does not continually stress that operation in such adverse weather is to be treated with extreme caution, concurrent with the exercise of sound judgement? Indeed it is understood that the captain regaled his FO’s with details of an ANC take off “in far worse conditions”. Hmmm!

Unfortunately – you are again not to know this – such exercise of sound judgment is paid lip service in SQ. Crews are expected to depart and arrive on time and if not “we want to know the extremely good reason why not”. Gladiator and Titan – both experienced survivors of SQ, are entirely correct in their statements to this effect and their corollary view that such corporate stance places great psychological pressure on crews.

Similarly, their statements as to the mindset of local captains and first officers is absolutely accurate – as Titan says, however, you must have been in SQ to know exactly what this means. Therefore, I would ask you to accept as the complete truth that the Singaporean (yes I know the Straits Times said he was Malaysian) captain would never have dreamt of delaying the flight in case of sanction/adverse report from his reporting manager or even the FO (please again be assured this is perfectly possible – the system encompasses such reporting). Similarly the Singaporean FO - again you are not to know this – was fast tracked to stardom before the accident and NO WAY was he ever going to say anything which might generate even the slightest whiff of dissent that could then enter his non-accessible, secret squirrel personal file, maintained on all flight personnel. Such dissent would include demurral of the captain’s judgement to take off in the prevailing conditions. Hence the unfortunate Taiwanese press phraseology which I previously referred to, whilst inaccurately reporting that there was a heated CVR interchange between “overbearing” captain and a “subjugated” first officer on the subject, inadvertently but accurately reported the net effect on the flight of a much more muted and subtle interchange, that present day technology could only partially pick up.

Moving on, may I suggest that we are all in complete agreement that the accident happened because the crew lined up on the wrong runway and subsequently attempted a take off. The key question is then, why?

Now perhaps I understand that your suggestion as to “why” is that it was not because of any other reason than irregularities in the ground lighting system/taxiway markings (by default, the only other reason for the accident) that misled the pilots into such erroneous line up and subsequent catastrophic take off and, hence, “could have happened at any airline”. If I may say so, your leap of reasoning tritely discounts the possibility of any other cause for the accident than that this captain and crew (and by extension all captains and crews) were merely passive and uncomplaining users of a ground lighting system that hopefully may (or may not) have led them by the nose to the correct point on the airport for an intended take off, rather than them being wholly responsible, through the use of all available resources (charts, ATC instructions, internal aircraft systems, ground lighting systems, taxiway markings, familiarity with the airport, discussion between themselves, guidance by ground marshallers, common sense/airmanship) for the safe navigation of the aircraft on the ground to the correct take off position – in this case runway 05L. Such discounting, I can, however, understand as you were, hitherto, I believe, unaware of the national cultural/SQ culture dimensions affecting CRM, that my co-posters and I have now brought to your attention. I therefore maintain that the fact of their failure to line up on the correct runway, given that they are actively responsible (they most certainly were) for navigational accuracy, indicates that some distraction was present, to so prevent the correct line up on runway 05L. If we accept this, the key question then is “what was the distraction”?

My humble submission is that the extreme weather conditions, which the crew (perhaps subliminally) knew they should not have countenanced as suitable for take off, caused the fatal distraction at a time when they were grappling with a difficult ground navigation situation. If the crew had been operating in a culture/company more sympathetic to the exercise of good judgement/airmanship, they would firstly have not felt pressured to move off on schedule (please be assured that despite the “sanguine” tone of the CVR, they were) and secondly they would have felt relaxed about sensibly awaiting a weather improvement following frontal passage, when they would have been able to make a routine un-distracted take off from the correct runway. Please see my reference to the Kuching overrun accident in my first posting – If the crew (local) had held clear of the airport for 10-15 minutes before making an approach, they would have landed, un-distracted and safely, in clear weather and on a partially dry runway. They would, however, have been behind schedule on arrival – unbearable to contemplate! As it was, they landed distracted, on time, but half way down the runway in the middle of a local rain-storm and went off the end – see what we’re getting at?

To close, I’d like to make it crystal clear that I can imagine myself making catastrophic errors of the magnitude demonstrated by the SQ006 crew and I’m sure that any other thinking pilot feels the same. I’m also abundantly certain that rational pilots (of whom I count myself) will at all times strive to avoid such ghastly traps and will use, if unfettered by dogma/cultural constraints, all their experience, skill and airmanship to so avoid these traps. Hence, for these reasons of dogma/culture, I see the SQ006 trio just as much victims of circumstance as the passengers who were caught up in the fateful events of the night.

Finally, Rockhound, your less than temperate petty crowing to the effect “hey gladiator you're changing your tune. Now it's bad visibility first, SQ company culture second” is both insulting to an experienced, knowledgeable and courageous poster who is patiently attempting to give you solid facts, plus trivialising to a subject which I’m sure you will have finally noticed, professional airmen are now considering in deadly earnest.

[thegypsy]

You need to be in S.I.A. to understand about SQ6!!

[This message has been edited by PPRuNe Towers (edited 08 March 2001).]

[sia sniffer]

I can recall that during my initial training in SIA, that the paperwork is considered of extreme importance. I remember the heavy emphasis put on departing within 3 minutes of the scheduled off chocks time. We were continually reminded that 3 minutes is OK, lah, upto 15 minutes, then the Voyage Report would only make it as far as the director of flight ops office. However, to be over 15 minutes over departure time, your flight details would be sent to the chairman's desk, for further scrutiny. Pressure to depart on time? nah lah! We can do lah.

[Insider107]

I’ve finally had chance to get to the keyboard, although I’m not sure when I will be able to make this posting. I’ve explained to Pprune Towers the exact nature of the circumstance that makes my present postings so sporadic - I would ask for your acceptance that the reason is genuine and overriding.
However, I had the unexpected opportunity to make my brief and hasty post of 2 March in which I revealed (in very much muted fashion) a friend’s reaction to Rockhound’s postings of 28 Feb and 1 March, which emerged earlier last week over the course of conversation at a common slip station. My view of the reaction was as stated and I did indeed argue that Rockhound could be the “genuine article” and as such, providing worthwhile debating points. Notwithstanding, following some thought, I decided to post the reaction on the twin basis that it serves us all well to realise that genuine emotion is generated by the apparent trivialisation of events which surround the SQ006 disaster – and I point out Rockhound’s trivialisation a little later - and similarly strong emotion is generated by the possibility of a “gloss over attempt” by SQ management, through the medium of phoney postings.

Te Rangi. Thanks for your note. Please be assured that my composure has been and remains completely intact. I agree entirely that Rockhound’s knowledge of our trade is laudatory (this detailed knowledge gave rise to my friend’s “wannabe” comment) and I agree absolutely with your view that “the sound interchange of ideas is what a public forum is all about”. Please see my note to Rockhound, below, most of which I roughed out a day or so before your posting. I hope also that Gladiator’s writing will demonstrate to you why the flight wasn’t cancelled in the first place and what would have happened to the captain subsequently - it is absolutely correct.

Aerostar. Thanks also for your post – contents noted. I similarly hope that my writings provide answers to your questions.

Rockhound

Thank you very much for your posting of 2 March in which you proffer your assurances that you are the “genuine article”. I certainly accept your bona fides and my American friend sends his regrets in respect of the intemperate expressions he used on first reading your postings and which expressions I subsequently relayed in my last posting. I now write in reply to these earlier postings of 28 Feb and 1 March in respect of your conclusions as to what did not cause the SQ006 disaster. May I say that as a member of the non-aviation public, you serve us all well by sparking both more debate and an increasingly forensic approach to our collective thinking. Similarly, if you had been a member of the SQ flt ops management/SQ PR department, artlessly posing as the former, then you would deserve equally to be thanked for assisting in the crystallisation of all our views and the ready articulation of them on this site. Therefore, please do not feel the need to “lie low” – you would not serve either the cause of free speech or that of aviation safety if you did so – please “keep ‘em coming” but also please heed my note at the end of this posting.

Before I move to answer your postings, may I say that the Taiwanese Aviation Safety Council Report is a “factual” report and no conclusions as to the cause of the crash are reached. We, however, are all trying to pre-empt this report and ascribe cause(s), using gleaned knowledge of the case and as much experience as we can muster. However I guess we will all have to wait for the potentially more contentious document that will be produced and available by year-end, which will state such causal conclusions and prove us individually right or wrong.

Next, I had intended writing a very detailed piece but reflection brought a realisation that I’ve already said everything in previous postings and that what I may have missed or not emphasised sufficiently, my estimable co-posters, Gladiator, Titan, Gaunty, Farside and Sia Sniffer have all filled in or emphasised. So, I will try to keep it short and rather than describe in detail, merely make reference to postings on given dates.

I hope that you will not be insulted if I say – in reverse order of your posting - that, (i) yes, you are “missing something” (ii) what has been said [albeit in a Taiwanese newspaper] is not, as you state, “complete and utter garbage” but merely the subject of unfortunate phraseology. Further, your glossy summing of “what seems to me that” is similarly in error. Allow me to elucidate.

I’m afraid that you miss the point entirely - “all three crewmembers were satisfied that they were on the correct runway” is not the case. First Officer Latif Cyrano stated that the PVD “indicated a discrepancy” and you then glibly dismiss the significance of this by saying that “but as I understand it, use of the PVD is not mandatory”. The point is that Cyrano noticed evidence to indicate that all was not well but did not pursue the point when the captain said that it did not matter – precisely because it was the captain who said it! He would, however, be harbouring his unspoken doubts on the subject, whilst events unfolded. This is a cultural issue that Gladiator and Titan have ceaselessly laboured and on which maybe I can expand later. Further, the third seat FO would similarly make no comment, following the captain’s judgement on the matter.

On the contrary, the captain appeared NOT to be “appropriately concerned with the weather”. The CVR transcript in fact demonstrated a remarkable levity amongst the crew in the face of a weather situation of the utmost gravity. If I may remind professional readers of conditions which prevailed on the night of 31 Oct 2000, by referring them to my original posting on this thread, they will be able to concur. For those non-professionals reading, please be assured that the conditions on the night were exceptional and worthy of the greatest respect by any operating crew.

I quote my first posting further:
“Apocryphal evidence indicates that the apron was flooded at the time and this would perhaps lead to the supposition that the runways may also have been in a similar condition, in light of the approaching typhoon front. Similarly the aircraft was reportedly strongly buffeted by high winds whilst still at the gate”.
I do believe that the CVR transcript bears out the crews’ appreciation of taxi conditions as the captain is heard to say words to the effect that “I’m taking it slowly as it is very slippery” – not wishing to slide off the taxiway, especially when turning onto the usually very slick runway end, rather than being “overall pretty sanguine about the conditions and was he really in such a hurry to get going”?
Next, “all three pilots agreed that conditions were within limits”. Please read:
“No overarching view of the situation would arise with this mind set, hence it would not be possible to consider that whilst technically within the cross wind limitations, prevailing gusts, low visibility, low cloud base, very heavy rain and a possibly flooded runway would lead to a take off in conditions somewhat different from the steady wind/good viz/dry runway conditions of test flying demonstrations”.
Do I really have to labour this point?
It may be worth mentioning that at this very time of the approaching typhoon front, Canadian Airlines, Eva Airways and Cathay Pacific all deemed it prudent to either cancel or place severe postponements on their flights, whilst only China Airlines – no arbiter of air safety I’m afraid, deemed the conditions suitable for continued flight operations.

Further, “all three crewmembers were well rested” is in error. The captain was one day short of his statutory rest period prior to reporting for SQ006 duty, although you could not be expected to know this (I’m surprised the ASC didn’t!) and I assume you missed my posting of a few days earlier to this effect. Further, Gladiator makes the point that SQ 744 crews have been stretched to the FTL limit of 28 day crew duty time for some time now (as are 777 crews) because of a serious pilot shortage (due to SQ’s antediluvian industrial practices/poor pay) and the cumulative effect of this heavy work pressure and constant time zone change has had and continues to have its adverse effect. Whilst on the subject, please also be assured that the present impasse over pay and conditions between ALPAS and SQ, which has been dragging on for nearly two and a half years is having an effect on most crews – yes, I know there is no evidence to suggest there was an effect on the SQ006 crew. The rancorous feeling amongst the SQ pilot body generated by a feeling of abuse and contempt of that body by the SQ management is producing the lowest morale amongst a pilot force that I have ever seen (35 years worth) and whilst I assume that long term data does not (yet) exist to provide a correlation between low morale of pilot force and susceptibility of a carrier to major accident, I think it would be a very brave man who would publicly state that no such correlation exists.

As to the actual incident as portrayed by the CVR, may I refer you again to my original posting in which I postulate the idea of there being “two thought processes which generate any flying decision made in the course of SQ operations”

1. Whatever happens, I must not take any action which will invite an admonitory/intimidatory phone call from the fleet management and which call will certainly be the culmination of a previously conducted, secret investigation involving the sustained interrogation of the FO(s) in an effort to establish inconsistency of story which could then lead to an adverse report being attached to a personal file/demotion without appeal or summary dismissal.

2. Under all circumstances, cover yourself by conducting operations absolutely within a highly legalistic interpretation of limitations and procedure without taking any overview or exercising any judgement, both of which will, necessarily, be subjective and hence open to fleet evaluation and criticism after any event.

I would suggest that perhaps a combination of the two thought processes prevailed on the night. The captain and crew were concerned with the weather and hence susceptible to the distraction that this would generate but masked this concern from each other (and perhaps themselves), in their desire to cause nil delay, with stylised SQ banter. They were however concerned to legalistically “cover themselves” and make sure that they were “within limits”. Hence mind set 2 also came into effect.

However, more ominously, if we completely disregard the above and the captain and crew indeed did not regard the prevailing weather as anything out of the ordinary, is this then not the most damning indictment possible against an SQ training philosophy that does not continually stress that operation in such adverse weather is to be treated with extreme caution, concurrent with the exercise of sound judgement? Indeed it is understood that the captain regaled his FO’s with details of an ANC take off “in far worse conditions”. Hmmm!

Unfortunately – you are again not to know this – such exercise of sound judgment is paid lip service in SQ. Crews are expected to depart and arrive on time and if not “we want to know the extremely good reason why not”. Gladiator and Titan – both experienced survivors of SQ, are entirely correct in their statements to this effect and their corollary view that such corporate stance places great psychological pressure on crews.

Similarly, their statements as to the mindset of local captains and first officers is absolutely accurate – as Titan says, however, you must have been in SQ to know exactly what this means. Therefore, I would ask you to accept as the complete truth that the Singaporean (yes I know the Straits Times said he was Malaysian) captain would never have dreamt of delaying the flight in case of sanction/adverse report from his reporting manager or even the FO (please again be assured this is perfectly possible – the system encompasses such reporting). Similarly the Singaporean FO - again you are not to know this – was fast tracked to stardom before the accident and NO WAY was he ever going to say anything which might generate even the slightest whiff of dissent that could then enter his non-accessible, secret squirrel personal file, maintained on all flight personnel. Such dissent would include demurral of the captain’s judgement to take off in the prevailing conditions. Hence the unfortunate Taiwanese press phraseology which I previously referred to, whilst inaccurately reporting that there was a heated CVR interchange between “overbearing” captain and a “subjugated” first officer on the subject, inadvertently but accurately reported the net effect on the flight of a much more muted and subtle interchange, that present day technology could only partially pick up.

Moving on, may I suggest that we are all in complete agreement that the accident happened because the crew lined up on the wrong runway and subsequently attempted a take off. The key question is then, why?

Now perhaps I understand that your suggestion as to “why” is that it was not because of any other reason than irregularities in the ground lighting system/taxiway markings (by default, the only other reason for the accident) that misled the pilots into such erroneous line up and subsequent catastrophic take off and, hence, “could have happened at any airline”. If I may say so, your leap of reasoning tritely discounts the possibility of any other cause for the accident than that this captain and crew (and by extension all captains and crews) were merely passive and uncomplaining users of a ground lighting system that hopefully may (or may not) have led them by the nose to the correct point on the airport for an intended take off, rather than them being wholly responsible, through the use of all available resources (charts, ATC instructions, internal aircraft systems, ground lighting systems, taxiway markings, familiarity with the airport, discussion between themselves, guidance by ground marshallers, common sense/airmanship) for the safe navigation of the aircraft on the ground to the correct take off position – in this case runway 05L. Such discounting, I can, however, understand as you were, hitherto, I believe, unaware of the national cultural/SQ culture dimensions affecting CRM, that my co-posters and I have now brought to your attention. I therefore maintain that the fact of their failure to line up on the correct runway, given that they are actively responsible (they most certainly were) for navigational accuracy, indicates that some distraction was present, to so prevent the correct line up on runway 05L. If we accept this, the key question then is “what was the distraction”?

My humble submission is that the extreme weather conditions, which the crew (perhaps subliminally) knew they should not have countenanced as suitable for take off, caused the fatal distraction at a time when they were grappling with a difficult ground navigation situation. If the crew had been operating in a culture/company more sympathetic to the exercise of good judgement/airmanship, they would firstly have not felt pressured to move off on schedule (please be assured that despite the “sanguine” tone of the CVR, they were) and secondly they would have felt relaxed about sensibly awaiting a weather improvement following frontal passage, when they would have been able to make a routine un-distracted take off from the correct runway. Please see my reference to the Kuching overrun accident in my first posting – If the crew (local) had held clear of the airport for 10-15 minutes before making an approach, they would have landed, un-distracted and safely, in clear weather and on a partially dry runway. They would, however, have been behind schedule on arrival – unbearable to contemplate! As it was, they landed distracted, on time, but half way down the runway in the middle of a local rain-storm and went off the end – see what we’re getting at?

To close, I’d like to make it crystal clear that I can imagine myself making catastrophic errors of the magnitude demonstrated by the SQ006 crew and I’m sure that any other thinking pilot feels the same. I’m also abundantly certain that rational pilots (of whom I count myself) will at all times strive to avoid such ghastly traps and will use, if unfettered by dogma/cultural constraints, all their experience, skill and airmanship to so avoid these traps. Hence, for these reasons of dogma/culture, I see the SQ006 trio just as much victims of circumstance as the passengers who were caught up in the fateful events of the night.

Finally, Rockhound, your less than temperate petty crowing to the effect “hey gladiator you're changing your tune. Now it's bad visibility first, SQ company culture second” is both insulting to an experienced, knowledgeable and courageous poster who is patiently attempting to give you solid facts, plus trivialising to a subject which I’m sure you will have finally noticed, professional airmen are now considering in deadly earnest.

[boofhead]

All are concentrating on the culture as a reason for the accident, and blaming the decision to depart under the weather conditions as contributing. But IMHO neither was important compared to the real error, which was simply that of taking off on the wrong runway. The captain made the mistake, and the crew did not call him on it. SQ does not have the monopoly on mistakes, and neither does it have the only compliant crews.
Taking off and landing on the wrong runway is a constant danger and we all must guard against it. In this case, the airport documents show the layout clearly and there is no way a reasonable pilot would make this mistake if he took the time to study them. The taxiway does not lead to 05R; it leads to 05L. The pilot had to turn off the normal taxiway early to line up on 05R. The lights, runway markings, geometry and so on are not confusing, even in bad weather.
There has to be a different reason for the error, and if we concentrate on the distractions raised so far we will never find it out.
The weather reports were within company limits, and almost all pilots would have decided to go. It is unfair to second guess the pilots on this descision, and in fact the weather was not a factor (at least the rain and wind were not a factor, only the visibility had any effect, and that was not any worse than we see many times a month.)
And what about the reports that other pilots (CI?) saw the airplane line up and begin to takeoff on the wrong runway without saying anything to the crew concerned? Surely that deserves an answer.
Since this accident I have seen reports of at least one other landing on the wrong runway (in Europe) but it has not been the subject of debate here. Maybe it should. One airline I know about has issued a rule that the pilots are to call out the runway heading to each other when lining up as a preventive measure against the SQ accident, despite the fact that this would not have made a blind bit of difference under the conditions they had (both runways had the same heading); another example of twisted thinking.
Will we ever see truth here? I doubt it.

[SKYDRIFTER]

BLAME GAME -

May I suggest that judgement give way to the 'cooler' element of analysis. It is apparent that the human factor overcame logic in some cultural fashion. SIA doesn't have a monopoly on that.

In contrast is the submarine accident with the fishing vessel. At least one crewman knew something was wrong, but decided to downgrade the priority of his knowledge/suspicion, in favor of saving himself the problem personal 'hassle.' Not surprisingly, th4e same thing happened with the Vincennes A-300 shoot-down.

Learning to penetrate the human factor with both assertion on one side and respect on the other would go a long way toward saving lives.

With rare exception, we come back to the simplistic but powerful 'country' philosophy, "It just don't take long to fix it, but you're a long time dead."

In thousands of words we've all been saying essentially the same thing. Now is the time to put the obvious lessons into action. Most importantly is to share the cases where CRM has worked. For obvious reasons, good events are expected, not reported. While that's an accepted practice, it doesn't achieve anything.

Perhaps, the key is to formulate standard 'buzz' phrases such as, "I don't trust this; can we check this out?" If such phrases are appropriately respected as a matter of reflex, there should be a lot of lives and profits saved.

[SKYDRIFTER]

NOT JUST SIA & PILOTS -

FAA probes West Palm-bound jet's use of runway being snowplowed

The Associated Press
Web-posted: 12:24 p.m. Mar. 8, 2001

NEW YORK -- The Federal Aviation Administration said Thursday it is investigating how a Florida-bound jetliner used a Kennedy Airport runway that was being cleared of snow by five plows.
The airliner cleared the runway nearly 1,000 feet ahead of the plows on Tuesday afternoon.
FAA spokesman Jim Peters said the incident is classified as a "runway incursion." He said investigators will review how and why the snowplows were on the runway at the same time as a JetBlue Airbus 320 was taking off for West Palm Beach.
The investigation could take several months. Any penalties against the Port Authority of New York and New Jersey, which operates the airport, could range from an administrative warning letter to a fine.
"We are not commenting because of the ongoing FAA investigation," said Port Authority spokesman Greg Trevor.
Last October in Taiwan, a Los Angeles-bound Singapore Airlines jet plowed into concrete blocks and construction equipment while attempting to take off from a runway that was under repair. That accident killed 83 people.

[Rongotai]

I find it deeply frustrating that 22 years after the Air NZ Erebus disaster, and 12 years after the Air Ontario Dryden crash, there is still a large body of aviation professionals who do a huge disservice to the cause of aviation safety because they feel able to argue to the effect that SQ006 can be attributed to a terrible error by the crew and/or serious failures by the airport authorities, and that therefore the culture of SQ or of Singapore is not a legitimate subject for discussion. Even more distressing to me is the justifying argument that 'it can happen to anyone.'

Here are my reasons for being distressed by this:

1. Yes, it is true that there is a universal human predisposition to misinterpret sensory signals about what the 'real' situation is, and especially to distort visual signals into 'seeing' what one expects to see or hopes to see. Thus it is possible for any pilot to choose the wrong runway, descend into terrain, etc. etc.

2. It is also generally not disputed that the PROBABILITY of such misinterpretation is increased when there is poor visibility, loss of horizon, sector whiteout conditions, and so on. Few would dispute this because (a) it is common sense; and (b) the empirical evidence for it being true is overwhelming.

3. It is slightly less generally accepted that extreme physical conditions - such as those prevailing at Taipei on the night of SQ006 - place psychological stress on flight crew, and psychological stress itself increases the probability of making an error in interpreting the environment. This proposition is still common sense, and still supported overwhelmingly by empirical evidence. It seems that it is slightly less generally accepted because here some people begin to mount the argument that pilots are professionals who should be able to deal with stress without it impairing their performance or judgement. My response to that is 'nice idea, but totally disconnected from the real world.'

4. Once it is demonstrated and accepted that stress impairs judgement, and impaired judgement increases the probability of a critical event occurring, then it is reasonable to ask what factors cause stress in pilots and how they can be ameliorated.

5. It is not at all generally accepted that cultural factors - national or organisational, and management practices, can have the effect of increasing or decreasing stress on flight crew who work within them. Yet the empirical evidence that this is so is still overwhelming. So why is it that so many people want to dicount these factors in considering accident causation? Semi rhetorical question! The answer seems to be a deeply ingrained belief that technical training and technical competence can overcome the stress effects of cultural factors. To which I reply 'Nonsense. That can never be so.'

6. If my points to date are accepted, then it is entirely legitimate to question whether or not the organisational culture of SQ has the effect of increasing stress on its flight crew. If the answer is 'yes' then it follows that the airline is negligent if it fails to address cultural factors which serve to increase the probability of its flight crew experiencing avoidable stress and thus that be more prone to making errors.

7. I have no personal knowledge of whther or not this is the situation at SQ, but on the basis of the many cogent posts in this thread from amongst those that know the airline and its culture, my outsider position at present is that there is a prima facie case. Enough of a case for me, as an elite gold frequent flier card holder with a member airline of the Star Alliance, to avoid Singapore Airlines when I can conveniently do so in the meantime.

[Rockhound]

Insider,
Thank you for your posting. I appreciate your taking the trouble to respond to my comments and thank you particularly for your kind remarks; I also thank your American friend for his retraction (if I may call it that).
I would just like to respond briefly to some specific remarks you made in your last posting.
Firstly, I can only go by what I read in the technical and trade literature and by what I pick up from acquaintances in the aviation industry and from personal experience flying as a passenger on both scheduled and unscheduled services. You, on the other hand, as an experienced pilot, can also read between the lines, as it were, and in the case of SQ006, can speak with the authority of a company employee. What you say may all be true but I'm afraid you have not yet wholly convinced me.
Specifically:
1. You charge that I "glibly dismiss(ed)" the significance of F/O Cyrano's observation that the PVD was discrepant on the grounds that use of the PVD is not mandatory. Not so. My reading of the ASC report (CVR transcript and Secn 1.18.1.2 of the Flt Ops Group) indicated to me that (1) Capt Foong acknowledged the PVD was discrepant and (2) F/O Cyrano was satisfied (as was Capt Foong) that they were lined up on 05L, hence did not pursue the matter. This also led me to brand the Taipei Times article as "garbage" and I still hold that opinion. Now, the ASC report may not give the whole story - you clearly feel it doesn't. Again, you may well be right.
2. Weather conditions and the pressure to depart. This is obviously a very contentious issue (cf, e.g., boofhead's posting) but again, it seemed to me, from reading the ASC report, that Capt Foong WAS concerned by the conditions: he decided he, not his F/O, would do the take-off, urged the ground and air staff to take their time with flight preparations, continuously monitored the wx conditions (especially the winds), and taxied with extra care. My impression remains that, taking all this and his experience into account, Capt Foong felt comfortable that he could depart safely. Of course, how much his mindset and decisions were influenced by the SIA corporate culture is not for me to say (or know). You have to be able to read between the lines?
3. Crew rest. The crew may well have not been fully rested as per duty guidelines but do you really believe they used the wrong runway because they were tired? Again, maybe so.
Finally, I certainly did not intentionally trivialise any aspect of this tragic accident. If I have done so, I apologise unreservedly. I have been reading Gladiator's postings for more than a year and when I read his follow-up posting to the one wherein he listed seven factors relating to SIA/Singapore culture, practices, etc. ahead of the visibility factor, I could not resist taking him to task for what seemed to me a reversal. My choice of words was less than felicitous and I regret if I have caused offence. My sympathies are with the victims of this terrible accident, not only with the dead and injured passengers and their families but also with the surviving crew.
Rockhound

[Rongotai]

Rockhound demonstrates one of my main points from my previous posting. He writes:

3. Crew rest. The crew may well have not been fully rested as per duty guidelines but do you really believe they used the wrong runway because they were tired? Again, maybe so.

That attributes to Insider what he did not imply. If a crew is not fully rested then that is a contributory factor which acts as a probability multiplier that a misjudgement will occur. That does not suggest a simple cause and effect linear relationship (they made a mistake because they were tired).

Tiredness multiplies stress, bad weather multiplies stress on top of any tiredness multiplier. A culture of pressure to maintain on time departures multiplies the stress effect of tiredness which multiplies the stress effect of bad weather. And a deeply hierarchical culture multiplies the stress effects of all those and inserts a communications barrier to boot.

This all means that when SQ006 moved off the gate the crew were statistically many times more likley to make a misjudgement than if they did so in daylight, in good weather, fully rested and flying for an airline with a genuine cultural commitment to the principles of CRM (if the absence of this is, in fact, an SQ cultural characteristic).

By the way, airlines which espouse the principles of CRM in their manuals and training, but in fact act the opposite in their flight operations management practices, not only negate the effects of the training, but create a much more dangerous environment than if they didn't even pretend to espouse CRM.

[titan]

A couple points:

Fatigue is not a simple concept like "did the crew get enough time off". Fatigue is cumulative. SIA were quite happy to give their crews the mandatory 11? hour rest into places like Taipia and Seoul without any regard to the 2-3 hour travel time each way in bumper to bumper traffic, time to eat, to shower and also un-wind. Total sleep - maybe 5 hours. In 1995 a certain doctor M in Singapore was insisting that many of the Classic Captains that came to see him take "creative sick leave". Why? Because he recognised that they were suffering from cumulative fatigue, but of course he wasn't able to tell SIA that as it would jeopardise both his and the Captain's economic future. I believe he wasn't even able to tell his good friend Len in management either.

CRM is all about speaking up, and NO you won't often find direct signs of CRM problems by listening to the CVR!!! The CRM problem may be there in the form of silence, or words that do not reflect the true feelings of the speaker. CVRs do not pick up the real thoughts of the crew. What the CVR picked up in Taipai was that neither of the FOs challenged the Captain with "CAPTAIN YOU MUST LISTEN". I reiterate my comments at the time of the accident - I do not believe that all of the three fully qualified pilots on that flight deck were comfortable with their situation. This is certainly borne out by the PVD comments, but the FO refused to make a stand on the issue. To the unfamiliar this may seem minor, but to those that understand the SIA cockpit this is a big read warning light of a major CRM issue. So, who to blame:
1 the Captain? who was trained to be godly but was legally bound to operate safely
2 the FOs? who were trained to consider loss of face issues, but were legally bound to operate safely
3 Management for failing to manage and correct unsafe work practices?

[gaunty]

Rongotai
Thank you for crystalising the relevant issues in your very thoughtful post.
I have for some years taken the action you describe and have suggested to my colleagues and clients that they should consider the evidence and my reasons for doing so in their selection and use of carriers.
There have been more than a few occasions when travelling in a group where I have chosen to take a different route/airline to the same destination and suffered some light hearted ribbing about my paranoia and "hey we all got here". I sincerely hope that they will continue to be able to do so.
And isn't that the problem in the perception.
You are always at risk whilst you are in motion. But on a personal level we try to increase our statistical chances of staying alive on the roads by choosing the mode, method and manner of our driving, why not load the stats in your favour in the air, especially when you do not have any personal or direct control over the operation.

There are many very clever passengers out there running very large organisations that have the same safety and legal responsibilities as airlines (mining is one industry with even more draconian sanctions for misbehaviour) who are captive to the perception that equipment, marketing hype and cabin service excellence, (the 1st class seating they enjoy at discount prices should be a red flag here) is a reflection of what goes on behind the cockpit door.

"If they are that big and succesful then they must be doing something right"
Is both true and at the same time dangerously false, as you point out in regard to the pretense v practise of CRM.

The carcasses of once "big" companies lying around the world are legion, whose post mortem results were "cultural intransigence" or "hubris".
Who would have dreamed that Pan Am would die or that TWA is about to be engulfed.
I and several others in the post have commended the study of amongst others, the Homeric writings and traditions which describe the human condition as it was then and now. It's trite but true that those who fail to learn from the lessons of history are bound to repeat them.
It is not fashionable in the modern education system to educate beyond what is necessary to get a sufficiently high score to gain entry to the highest paid professions. The classical part of a real education is nowadays either trivialised, unknown or debased as a waste of time in the race to visible social and financial success. The lessons already learn't, often a great cost, so long ago and now supplied free, are never applied and so it goes.
All cultures have potentially fatal flaws, it is how they deal with and learn from them that separates long term successes from relative flashes' in the pan.

"whom the gods would destroy they first blind with hubris" should be carved in stone at the entrance to every organisation.
This of course requires that people have the education to understand what it really means.

I suspect it is little understood in this context.

[boofhead]

There were two parts to the problem; the first was the pilot's decision to line up on the wrong runway, the second was the lack of warning from the people who could have warned him. This includes the other crew on board and the crews of the other airplanes taxiing behind them. Again, nobody seems to feel that the latter guys had any responsibility. Wonder why that is?
The accident would not have occured if the original mistake had not been made, and it would not have happened if the CRM had been better.
The first cause is the one that needs attention, since it is the only one that can be fixed. The recent US Navy Submarine accident shows that the circumstances of this accident are not unique to SQ. The same culture can be found in many airlines, not just those in Asia either.
The crew did not speak up because they too were not concerned, and did not see the error. They would not have just sat there knowing that the captain was about to put their lives in jeopardy. Sure they would have kept silence if they could see it was a procedural error, maybe to embarrass the captain or with some other devious plan in mind, but not to the point of definite danger to their own lives. So they did not know they were about to take off on the wrong runway, so they did not say anything.
But the original error, lining up on the wrong runway, was a simple mistake and caused by the spoon feeding the pilots get all through their flying career. They are not encouraged to think, or use discretion. Whenever there is an incident, the company comes up with a new rule to cover it, and if the pilot follows the rules, they can never repeat the incident. In the Western culture, and particularly as it was practiced in the past, pilots were trusted more, and given more freedom to exercise their judgement. In this way they developed an ability to anticipate problems and reduce risk.
In Asia, and also becoming a problem in the Western airlines, the rules and regulations have replaced judgement. I can see why this is happening, since the airline administrators are fearful of the damage a pilot can do with a mistake, but it will never work. No pilot can remember all the rules, and will not be able to apply the correct rule to the situation in every case. Only one small mistake can cause the loss of the airplane and all on board, and relying on memory of regulations is hopeless.
I would rather be a passenger on an airplane flown by an experienced, older pilot who has made his own mistakes and learned to recognise hazards, than a younger guy who has come through the new airline culture.
The B744 as it is equipped by SQ has the PVD and GPS. The PVD is not suitable to confirm the runway, since there are many reasons why it may be inaccurate. The GPS, though, gives a clear unambiguous indication of the airplane position, and the Nav Display will show the airplane and the runway relationship. If the takeoff is made on the wrong runway this will be immediately obvious. The pilots will also have the airport plan view on Jep, and finally will have the runway markings and lighting to confirm the runway. None of these were missing on this accident site, and could have been used.
They obviously were ignored, by all the pilots on this airplane. That is the root cause of the accident and that is what must be addressed.
I think you will find, if all the facts are presented, that the reason for the error is that the crew were concentrating on rules and regulations, and not on what we used to call in the "good" old days, Airmanship.

[Tosh26]

I’ve been reading the ongoing debate with great interest. The accidents mentioned appear to have the following in common:

KLM – Tenerife – Culture that stifled the expression of doubt by the FO/Flt Eng.
Air NZ – Antarctica – Culture that stifled the expression of doubt by the FO/Flt Eng.
SIA – Taipei – Culture that stifled the expression of doubt by FO’s.

An accident which has not been so far mentioned was the B737-200 in to the Potomac River, Washington DC:

Air Florida – Washington DC – Culture that stifled the expression of doubt by the FO.

I seem to remember that all these airlines also used to be aggressively “on-time”

Skydrifter mentions an incident which happened the other day at La Guardia, involving a JetBlue A320. Could this brand new start-up have the same culture?

While SIA is apparently not alone in allegedly having this kind of culture surely this fact does not invalidate the contention of some contributors that the SIA culture was at least partly to blame for the accident and should be examined closely with a view to changing it if necessary?

Keep it up guys, I don’t think I’ve seen such a quality debate on pprune for a long time now!

[Captain Mercurius]

Gentleman,

It is a very nice thread, indeed of high quality information.

SIA spent thousands of dollars in a very good quality CRM program, but they do not use it!

The management administrative technique is the long distance one, in other words the aircraft is commanded by someone seating in his desk in the fourth floor.

One of the major factors putting pressure on pilot's it is the aggressive policy of three minutes of delay, after this period of time the Captain MUST explain why the flight departed "late".

There are cases that technical crews are on their way from another aircraft, and the Ground dispatch officer in co-ordination with Chief Steward can start boarding the passengers!

And of course it is expected that the crew MUST move the flight on time, unless… will be captain's delay.

We all can appreciate the impression the passengers will have, seating in the aircraft and suddenly the crew walks in…

Passengers will have the impression they are late, and crew in turn will feel pressurised to rush their procedures to depart on the company's scheduled time!

The second major factor, in my view, is the aggressive fuel control policy, and every captain knows that if he orders any amount of fuel above the minimum given by the system, he has to write a full report explaining and proving why he did so.

As far I concern it is a simple conclusion.

What company in this world will release a flight through a heavy thunderstorm, to land, and depart on time, minutes before a well know WX report stating that a Typhoon was going to hit Taipei on full strength?

Maybe, a simple action, rescheduling that flight could prevent this accident…

Safe flying to all.

Mercurius

[NC1701]

After following this thread for abt a week, i must confessed i'm utterly confused now. Hence i would like to pose a few questions:

1) Were the pilots judgment wrong/unwise when they proceeded with the flight?
What were their chance of a successful takeoff in the prevalent weather conditions, if they were on the correct runway? 50% 80%, 95%, 99% or 99.9%?

2) The airlines which cancelled their flights, were they scheduled to take off before or after SQ006? When was the decision to cancel made?
I really would be obliged if someone with the facts can post the answer to this question.

3) Is bad CRM or the lack of Good CRM a necessary condition for this particular accident to occur? ie. could the same error be made by a crew/airline with state of the art, perfect CRM practices, but with all other contributing factors remaining unchanged?

4) Is bad CRM of the lack of good CRM a sufficient condition for this particular accident to occur? ie. do crews/airlines with what might be generally accepted as bad CRM generally end up on the wrong runway, under the same weather conditions but with all other contributing factors not present?

5) Is CRM the main factor in this accident?


May i humbly, and without the intention of being contentious make a few points here.

It is my belief that the crew intended to use the PVD only as an aid for takeoff as they may have anticipated the view of the runway to be not as clear as they would have liked. As it turned out this aid was unnecessary as the view of the runway was 'not so bad' and was concurred by all. It is easy to say now after the facts, why the crew did not pay more attention to the PVD not lighting up. Being on the wrong runway is but only one of the many reasons to explain the PVD's failure to light up. When everything that was seen by the crew point to the 'correct' runway in front of them, it is very unlikely that this thought, &lt;PVD not lit = wrong runway&gt; would occur to them. It is moot to discuss whether the co-pilots had any reservations taking off without the PVD since the cause of the accident was taking off from the wrong runway and not poor visibility per se. The more appropriate point is, were the co-pilots aware that they were on the wrong runway when the PVD failed to light up. If the co-pilots had this thought it would be inexplicable for him to remain quiet just so as to avoid personal hassle. If indeed it is the case, it is not bad CRM but insane. I agree that an overbearing can be intimidating but where do you draw the line? Surely no one is suggesting having 3 captains as the solution. So up to a point, if co-pilots think something is terribly wrong, they must raise the alarm as it is their professional duty. Or am i still missing the point?

However, i agree that CRM might have a role in the sense that if they had waited for a minute or so to check, it might (and i stress might here for it is not a given), occur to them that PVD not lit = wrong runway, eventhough the view from the cockpit is 'normal'.

Another point which i think should not be overlooked is the fact that there is only one operational runway. It could have reinforced the crews' notion that they were on the correct runway, when they saw a lighted runway, which appeared normal, in front of them, even to the point of confirming with the control tower, without once seeing any '05L' markings.

[Rockhound]

In regard to CRM and the question of the crew's attitude toward the PVD discrepancy, boofhead and NC1701 have hit the nail on the head, as I attempted to do in my postings. In my last posting I wrongly ascribed Secn 1.18.1.2 to the Flight Operations Group of the ASC report; it is actually in the Human Factors Group. If accurate, this summary of the investigators' interview of F/O Cyrano indicates unequivocally that he thought they were lined up on 05L and saw no reason to object to Capt Foong's decision to disregard the PVD.
Surely this is a critical point with respect to CRM, with which Insider 107, Gladiator and Titan, among others, take issue. Can we not resolve it?
Incidentally, has SQ006 led to any changes in procedures using the PVD and Nav Display to confirm runway alignment at SQ or other airlines?
Rockhound
Rockhound

[gaunty]

Capt Dan Maurino head of Human Factors for ICAO wrote a fascinating article for our Oz Flight Safety mag.
Cuppla headlines:
"operational personnel develop informal and spontaneous group practices that circumvent poor equipment design, clumsy procedures or policies incompatible with operational realities(my italics), all of which complicate operational tasks."

or what he describes as normalised deviance.
He goes on
"Precisely because they are normal, neither these practises not their downsides will be noted by incident reporting systems.
This problem is compounded by the fact that the most willing reporters may not fully appreciate what events should be reported. If you are continuously exposed to substandard managerial practises, poor working conditions (my bold) or flawed equipment, you might have difficulty working out what problems are reportable."

Again

"Operational errors do not reside in the person as conventional safety knowledge would have us believe. They reside within task and situational factors, emerging as the consequence of mismanaging compromises between safety and production"

Sound familiar in the context of this discussion?????

I would commend the full text to you and accompanying articles, go here.
http://www.casa.gov.au/airsafe/fsa/download/01jan/28-41.pdf

[Rockhound]

Tosh26 continues to propagate the belief, now unfortunately ingrained, that "the KLM 'Tenerife' cockpit culture...stifled the expression of doubt by the FO/Flt Eng". If he were to refer to my earlier postings in this thread, in which I reviewed the relevant parts of the CVR transcript from the KLM 747, he would realise the "KLM cockpit culture", as revealed at Tenerife in 1977, at least, cannot be boiled down to the simple phrase he uses. What we KNOW is that the Tenerife tower did not issue a take-off clearance to KLM (i.e. they did not utter the words "cleared to take-off" or words to that effect). What we can INFER (with a large measure of certainty) was that the KLM captain (the PF) was convinced he had T/O clearance. There is NO EVIDENCE that the F/O harboured doubts on this score. (He may well have but hardly had the opportunity to voice them). We KNOW that the F/E had his doubts that the runway was clear but he only expressed them when the aircraft was well into its T/O roll, to a captain at the controls who was convinced he had T/O clearance (i.e. convinced the runway was clear). The captain did not "stifle" the F/E. By declaring the runway was clear, he merely voiced his conviction. The ultimate cause of Tenerife was surely the captain's decision to take off. Tragically, neither of the other two crewmembers, as far as we know, pointed out to the captain, early in, or before, the take-off roll, that T/O clearance had not been issued. We will never know why they didn't. Was it because they, like the captain, thought they HAD been cleared for T/O? Personally, I think that's quite possible ...but, who knows? But, no matter what, the tragedy of Tenerife lies in the failure of the system (CRM?) to catch the error (take-off without clearance).
Did Taipei happen because all three cockpit crew of SQ006 were satisfied they were on the right runway? For what it's worth, I think so. But the ultimate cause was the turn on to the wrong runway. Once again, the system failed and the error was not caught...again, with tragic results.
Perhaps, contrary to my earlier opinion, there is a close parallelism between Tenerife and Taipei, but not for the reasons favoured by Insider, Gladiator, and others.
Rockhound

[titan]

Rockhound:
I think you seem to be missing part of the point here about the CRM. If the Captain is treated with such infallable regard, then when another crew member has doubt, that doubt tends to get transformed into doubt apon their own ability rather than the original problem. The FO says that he believed he was on the right runway - well of course he did!! We are all in agreeance on that, but it is the fact that the Captain dismissed his concern and then "the Captain is always right" mentality took over to fix their position securely on the correct runway in the FOs head.

[boofhead]

Rockhound, Gaunty etc are on the right track. Accidents did not happen due to pilot error more frequently in the days before CRM, and in the days when the captain's opinion was the only one considered. That is because we had CRM in fact, but called it Teamwork and Airmanship. CRM is not a new invention.
The root cause of the SQ accident is the management style of Regulating Safety. They (and many other airlines) try to anticipate all the possible errors that the crews might make and write rules and regulations to cover their own backsides. The intention is not to help the crew handle the problems, but to be able to say after the event that the accident/incident must have happened because the crew did not follow the rules!
After a time under this regime, backed up by a strict punishment culture, crews lose the ability to think for themselves (if they ever had that ability). Their judgement dissolves in a fear of criticism and they learn that all they have to do is to follow the rules and they will stay out of trouble. Great, if the rules cover all eventualities, and if they can manage to remember the right rule at the right time.
Experience shows that this is unlikely.
An example from SQ procedures:
Two B744 airplanes on approach, and ATC clears them to make straight-ins. They are a little high and fast but both captains decide to accept the clearance. One is flown by a foreign pilot, who raises the speed brake and as the speed falls, puts down the flap at the schedule speeds. If he needs more drag he drops the gear. When he has F10 he puts the speedbrake back down. A normal approach and landing is flown.
The second is flown by a local who does not know any other way to fly than what he has been taught by SQ. He uses the speed brake only until he reaches the max speed for the flap, then he puts it back down and selects flap. He uses the maximum speed schedule, and the flap load relief is in constant operation. Initially the airplane goes even higher on profile, but when he has F30 (blown up to F25 because of the speed) they start to come down faster. The approach is not stable and they go below the glideslope (WOOP WOOP) but manage to stabilise at around 500 feet for a normal landing.
For their own reason, SQ forbids the use of speed brake with flap, so guess who is on the carpet the next week (dobbed in by his FO), and threatened with dissmissal if he does it again?
Has anything been done to prevent a similar accident in SQ or any other airline? Anybody out there?

[gaunty]

boofhead
Precisely put.
Erm we didn't share the same paents?? coz thats what they called me too :)

[Rongotai]

In my view Dan Maurino is THE voice to listen to in this matter.

I want to draw out two themes around one word. the word is 'probability'.

1. We can think much more clearly about accident causation if we start thinking that certain conditions or actions make an accident MORE LIKELY, rather than by asking if those conditions or actions CAUSE accidents. This is because it allows us to think more clearly about multiple causation and the way in which errors or misjudgements tend to compound on each other in order to produce critical incidents. Thus we can say that good CRM practices make it 'less likely' that a particular set of circumstances will lead a flight crew into making a poor decision. I made the point in an earlier post that:

CRM in training, CRM in management practices = greatest contribution to reducing probability of error

NO CRM in training, NO CRM in managment practices = significant contributor to poor decision making

CRM in training, no CRM in management practices = very large contributor to poor decision making.

2. It is all very well to look at the flight deck behaviour of the SQ006 crew or the KLM Teneriffe crew, or whoever else, and say it is irrational for a F/O to NOT challenge what s/he believes to be an unsafe situation. But - As Maurino himself has often pointed out - we all make such irrational decisions all the time because we all indulge in frequency gambling. We do it when, for example, we walk against the 'Don't Walk' red light - after all, so far we have never been hit by a car.

Frequency gambling - an unavoidable, indeed necessary, function of human cognition - is one of the everyday cognitive strategies which CRM is designed to neutralise in the interests of air safety. What is similar about Taipei and Teneriffe is that in both cases there was reason to suspect that there might be obstructions on the runway, but no visual evidence that this was so. In both cases the NATURAL and HUMAN response of an F/O is to frequency gamble - 'this guy is an experienced pilot who is still alive. He is more epxerienced than I am, and he also has rank over me. So......'.

This happens every day on every flight deck. It happens more often on flight decks of an authoritarian (or respect for one's elders) flight deck. And it happens less often on a CRM flight deck. We all gamble on the fact that these pathological behaviours do not often produce critical incidents.

But, in retrospect of Teneriffe, or Erebus, or Taipei, we always say 'how stupid, so it couldn't have happened, and if it did, it's down to individual stupidity.' This is what lets airline management off the hook time after time after time.

If most airlines ran their aeroplanes like they run their people we would all be in danger of bits of metal falling on our heads from the sky all the time.

[Streamline]

Maybe a little bit of track here but still within the context of the assesment of liability as discussed in the SQ 006 incident.

If an airline has a codeshare contract with an US based carrier, to what extend does that make them liable in the US ?

[smith]

boofhead,

Stop making up stories. You are obviously not a 744 driver. You don't need the speedbrake to slow down a 744 for flaps extension. It's 744, not a glider or Mooney.



[This message has been edited by smith (edited 11 March 2001).]

[Midnight Rambler]

Smith, are you a 744 driver? Do you know how slippery it is? I'd definitely use speedbrake if I was high and fast and wanting to get down.

[titan]

I think the SIA speed brake ideal came about because of two separate reasons.

The first was because the 747 Classic wasn't permitted to have the speedbrake used with flaps extended due to the static loading through the flap gap on the trailing edge flaps, and also because of the associated buffeting on the tailplane by the inboard panels. I believe the 744 doesn't have this limitation.

The second reason was because it was "unprofessional". Maybe somebody should have given Mr Boeing SIA management's views during the design stages. Obviously Boeing have got it wrong again :] By frowning on the use of speed brake it also gave great point scoring opportunities during the Loss of Face game.

I am also of the opinion that if the act of flying becomes so resticted by rules then it reduces the ability to think outside the box when a life threatening situation occurs. The optimum is a happy medium that disallows the cowboys and promotes situational thinking. A point to ponder, though, is that a heavy weighting of rules also allows low experienced pilots to function as operating crew ..... and that is fine until something goes wrong.

[Tosh26]

Hold your horses Rockhound, I don’t “continue to propagate the belief” etc etc. I merely wrote that “the accidents mentioned appeared to have the following in common”.

Maybe I should have said “along with other common features of the individual company cultures involved in the following accidents, that of stifling the expression(s) of doubt by the FO/FE is noteworthy”.

I guess you might like to consider that KLM took urgent steps to investigate and then radically change its culture post Tenerife – see Farside. Air NZ caused a national uproar with its operational methods plus company attitudes and was the subject of a judicial inquiry post Erebus, following which it took good care to dramatically alter its culture. Air Florida went out of business before it too could examine itself and conclude that a culture change was overdue. If your interested, I’ll confirm that SIA is now looking very carefully at its own culture (though it won’t admit it) and change is in the air, led by Lt Gen Bey.

You seem very confident that cultural influences leading to silence at critical times by FO’s and FE’s have no bearing on the Taipei crash. If only this was true. If I can throw my 2 cents in. When I left the air force for airline flying, I was pretty clueless for the first few years about the job itself and then how to handle “difficult” captains or “difficult” common perceptions. I can remember three or four occasions in these early (bad old) days when I allowed myself to be convinced that the captain was right and I was the half-wit who didn’t know what he was doing. I was brought up with a couple of real jolts when I realised I was right and it was the captain who was the half-wit and we had just got away by the skin of our teeth, from disaster (in the days before CHIRPS). Please be advised that it can happen and that a company culture has a MAJOR influence on how captains behave but more so on how subordinate crew-members behave in these critical situations. I know this as I’ve been in companies with both “good” and “bad” cultures!
Maybe the CVR can’t give the true picture as it isn’t configured to read the mind of the FO/FE. I guess when technology gets that far we’ll have a clearer idea of events leading up to crashes.

You seem to be to be a pretty erudite kind of guy on the basis of your postings that I’ve read and you are real forthright in expressing your certainties. Do you have a particular professional capacity that allows your ease of expression? I notice that you are not a pilot. I guess we’d all be interested to know where you’re coming from.

Rgds Tosh26

[Gladiator]

As of 6 months ago SIA was not code sharing with UA. Star Alliance and milage share, yes, code share, no.

If SIA does indeed code share with a US airline, then yes there is liability. It needs to be brought to the attention of the proper unions in detail.

[smith]

Midnight Rambler:

Yes, I do use speed brake when I need to get down fast but not under the circumstances that boofhead described. No, I don't use the speedbrake to slow down a 744 for flaps extension. I use the speedbrake for high speed descent because it kills the lift on wing and keeps the airspeed below the red line. Go talk to the QFI at the flying club if you have forgotten how to slow down a plane for flaps extension.

Sincerely,

Smith

[boofhead]

You're an abrasive little chap, aren't you? I'll bet you'd fit right in to the SQ culture.

[smith]

boofhead:

This is an annoymous forum and people do live out their fantasies here behind their alias. Making up stories like yours do nothing to promote safety and prevent similar accidents/incidents from happening again. SQ or not.

Smith

[boofhead]

Annoymous forum is it? Whatever that is, I won't argue. My little example is not made up, it is true.
This thread is meant to be related to SQ6, not How to Fly. I would suggest you post your comments on Tech Log, under the heading "How Boeing Asked ME to Re-Write the B744 Normal Procedures". I would be glad to debate you there.

[Midnight Rambler]

Look, smith, your method may be correct but it is not the only correct method. High and fast and wanting to get down is a place I would want to use the speedbrake. It is there for a purpose and I would choose to use it then. My CHOICE.

As boofhead says, your attitude, which is reminiscent of the philosophy of some real old dinosaurs I've flown with ( "Thou shalt only use speedbrake when all else fails and at the cost of your professional demeanour") smacks of superiority and has no place in a modern cockpit.

I was beginning to think this speedbrake thing was an irrelevant side-issue, but you seem to have made an illustrative point.

Also, inasmuch as you may think I am hiding behind my alias to express my fantasies, I have flown the 747 for 11 years and the 744 for 8 of those. I must have had it wrong all that time.

[Rockhound]

Tosh,
Thank you for your kind words but please believe me when I say that I hold very few certainties. Indeed, I find it difficult enough to gather simple facts (if there are such things). And I certainly don't feel confident that cockpit culture played little part in the SQ006 accident. I joined this particular discussion because Insider 107 alleged that at Tenerife the KLM captain took off despite the protests of his F/O and then proceeded to draw an analogy with the SQ006 crew in respect of the PVD indication. I still believe that Capt Foong fully appreciated F/O Cyrano's warning that the PVD was anomalous but that the concerns of both of them were overridden by the visual cues that indicated to them both that they were on the correct runway. Nothing that Insider, Gladiator, Titan, etc. have subsequently posted has caused me to change my belief. As to the role of other factors relating to SIA corporate/cockpit culture, practices, policy, etc. in this accident, e.g. pressure to take off in the face of an approaching typhoon, insufficient crew rest, and the like, I've formed some opinions but these are based on even thinner qualifications and subject to change without notice. After all, I'm just a pax who loves to fly and takes a keen interest in aviation - and considers it a privilige to be able to participate in discussions among airmen on PPRuNe.
Rockhound

[EasyGo-Lucky?]

The PVD was on because the ILS frequency had been set into the FMS NavRad page. Was the ILS inserted because the SID required it to be tracked outbound, as in runway 06 at TPE? The ILS deviation indications would automatically be shown on the PFD once the ILS was tuned, and the ND would have shown the aircraft right of the runway. The localiser would have shown a left deviation as we know, but wouldn't this raise questions since it was possibly required for SID tracking. The B744 standby AI should also have had the ILS selected as a backup, but was it? There are 3 indications indicating that you are not aligned with the localiser, and 1 that you are not aligned with the runway, all of them right infront of you. Why the PVD was solely noted is disturbing, and why did no-one check the other 3 indications when the PVD showed a discrepancy?

[This message has been edited by EasyGo-Lucky? (edited 14 March 2001).]

[Gladiator]

All are valid points. Rockhound either does not understand the point regarding the PVD, or he or she understands it but is trying to divert attention. I think it is the latter.

It is very simple. Not withstanding the LOC tracking required for the SID (that would have also acted as a backup since SIA's SOP requires LNAV), why would one insert the ILS frequency if the intent was not to utilize it, at least as a backup. OK so the PVD was not required (TPE not certified), however the visibility is very very low, are you not going to use a resource, a good resource, available to you?

Hello, CRM, Resource Management!

The Captain's statement, "never mind, I can see the runway", was a clear 'Flying 101' mistake, not even misjudgement.

What is the first thing you do in low visibility? Trust your instruments. The decision to go was a misjudgement, thereafter he clearly made mistakes by,

a) Brushed aside a resource that he intended to use (having entered the 05L ILS frequency).
b) Brushed aside the F/O's input.
c) Ignored the PVD.
d) Ignored the ND (runway not ligned up).

I see nothing else but negligance. Now I am not picking on the Captain, however, bad judgement and serious mistakes indicate either,

a) A weak Captain.
b) Other factors such as pressure, company culture, fatigue, etc.

What Rockhound does not appreciate is that we are/were the insiders, whistleblowers, etc. If we do not/did not tell you, then who would? You would have never known the other elements.

When I attended the CRM courses at SIA, how come there were no local Captains attending the course? Too good? Too perfect? Master ability? If attend, lose face? What was it? Cost too much?

I never got a straight answer for the above question. Any locals care to clear this question?

[Rongotai]

Have I understood Gladiator right? Was it a fact that CRM courses were run at SIA, but that attendance was up to individuals?

If that is correct then the creation of CRM awareness amongst SOME flight crew, but not others, almost certainly created a situation which is worse than if no CRM courses were held at all.

[EasyGo-Lucky?]

CRM or ARM courses as they are known at SIA were not voluntary. The courses were of no benefit whatsoever though, just an excuse for a few days in Manila/Bangkok at the Companys expense. The only ones who did benefit were those who designed or ran the course. There are individuals who require urgent CRM training but with the current crew shortage I'm sure the Company could not justify the loss of productivity.

[gaunty]

I too would be fascinated to hear the answer to Rongotais' question on Gladiators comment from anyone else involved.

It would have been the very essence of the exercise to have the locals in the same room as the expats.

Otherwise why bother?

[Rockhound]

I really didn't want to throw another two cents in, as I've already said my piece more than once, but I cannot let Gladiator's last posting go by unchallenged.
Gladiator, I believe I do fully understand the efficacy of the PVD - thanks in large measure, by the way, to your explanation of it earlier on this thread. And why would I want to "divert attention" from it???!
However, what I most strongly protest is your assertion that Capt Foong "brushed aside" F/O Cyrano's observation (warning, if you like) concerning the PVD. From the CVR transcript (times are UCT):
1516:07 CM2: And the PVD hasn't lined up
1516:10 CM1: Yeah we gotta line up first
1516:12 CM3: We need 45 degrees
1516:23 CM1: Not on yet er PVD huh never mind we can see the runway, not so bad.
So 16 seconds had elapsed after Cyrano drew attention to the PVD indication (and 12 seconds after the relief pilot's comment on the PVD) when Foong acknowledged the PVD discrepancy and voiced his decision to ignore it. This hardly constitutes "brushing aside" an objection and he certainly didn't cut Cyrano off in mid-sentence, as the Taipei Times article had it.
For what it's worth (not much, I know), I don't take issue with the rest of Gladiator's posting.
Rockhound
PS to Glad: I am a he (if it were otherwise, I suppose I would have called myself Rockbitch).

[Insider107]

There have been some great posts recently and I’d like to comment on some of them

Boofhead

Re: your post of 8 March. Yes, “the real error was taking off on the wrong runway. The captain made the mistake and the crew did not call him on it”. Please see my reference to “why” being the key question in the debated (mine was in fact “why” did the crew line up on the wrong runway and subsequently attempt a take off? - the implication being why did no one say anything). You imply that the crew was just negligent in ensuring use of correct runway - “there is no way a reasonable pilot would make this mistake if he took the time to study them [the taxi charts]”. However, I do not believe that we are discussing a negligent crew.
If I may say so, I think your statement to the effect “the weather reports were within company limits and almost all pilots would have decided to go” reveals the narrowest of assessment criteria in the formulation of your judgements (please read my initial post at the beginning of this thread - you’ve no need to agree with it) and without going into details of your writers actions/inactions over the years, a sweeping presumption of the judgement of your professional peers. We are not second guessing the crew on the decision to go in the prevailing weather conditions, merely saying that any causal anxiety/stress produced by its severity was a factor leading up to the accident and that if there had not been cultural/SQ cultural pressure on the crew to proceed in such conditions, then this anxiety stress factor would not have been present (because they wouldn’t have gone). Final word on your post of 8 March is - yes, I think we will see the truth, if only because the survivors/relatives have filed suit in a California court and there is no way SQ can duck that.
Re your post of 9 March. "The accident would not have occurred if the original mistakes had not been made and it would not have happened if the CRM had been better". Yes, of course the FO's would not have just sat there knowing their lives were in jeapody. Your proposition that pilots are spoon fed and rule bound throughout their careers and hence do not think, was perhaps relevant at this critical time and that they were concentrating on the rules and regulations to the exclusion of good old fashioned airmanship. This is contained in my original posting, when I postulated "mindset 2". Once lined up, as no one else said anything, each individual assumed the others were happy and so said nothing about any residual doubt that may have been in their minds - a combination of human psychology and SQ culture that CRM is designed to break and which, yes could happen in other airlines but did happen in SQ through, amongst other things, lack of effective CRM culture/training and which, hence makes SQ firmly responsible for the acccident.

Skydrifter

As usual I like your posts (not just because we seem to be generally in agreement). “In thousands of words we’ve all been saying essentially the same thing. Now is the time to put the obvious lessons into action. Most importantly is to share the cases where CRM has worked”.

Rongotai

I believe you are right on the nail. May I quote you here rather than refer readers to a preceding post? It will make it so much easier to relate to the contents of this post.

1. Yes, it is true that there is a universal human predisposition to misinterpret sensory signals about what the 'real' situation is, and especially to distort visual signals into 'seeing' what one expects to see or hopes to see. Thus it is possible for any pilot to choose the wrong runway, descend into terrain, etc. etc.
2. It is also generally not disputed that the PROBABILITY of such misinterpretation is increased when there is poor visibility, loss of horizon, sector whiteout conditions, and so on. Few would dispute this because (a) it is common sense; and (b) the empirical evidence for it being true is overwhelming.
3. It is slightly less generally accepted that extreme physical conditions - such as those prevailing at Taipei on the night of SQ006 - place psychological stress on flight crew, and psychological stress itself increases the probability of making an error in interpreting the environment. This proposition is still common sense, and still supported overwhelmingly by empirical evidence. It seems that it is slightly less generally accepted because here some people begin to mount the argument that pilots are professionals who should be able to deal with stress without it impairing their performance or judgement. My response to that is 'nice idea, but totally disconnected from the real world.'
4. Once it is demonstrated and accepted that stress impairs judgement, and impaired judgement increases the probability of a critical event occurring, then it is reasonable to ask what factors cause stress in pilots and how they can be ameliorated.
5. It is not at all generally accepted that cultural factors - national or organisational, and management practices, can have the effect of increasing or decreasing stress on flight crew who work within them. Yet the empirical evidence that this is so is still overwhelming. So why is it that so many people want to discount these factors in considering accident causation? Semi rhetorical question! The answer seems to be a deeply ingrained belief that technical training and technical competence can overcome the stress effects of cultural factors. To which I reply 'Nonsense. That can never be so.'
6. If my points to date are accepted, then it is entirely legitimate to question whether or not the organisational culture of SQ has the effect of increasing stress on its flight crew. If the answer is 'yes' then it follows that the airline is negligent if it fails to address cultural factors which serve to increase the probability of its flight crew experiencing avoidable stress and thus that be more prone to making errors.

Precisely put and shows that there was no one absolute accident cause but a series of events or circumstances which, when combined, led up to the accident.

Rockhound

Thanks for your postings of 8/9 March both of which I found very well thought out and which caused me to think at length for answers. I am sorry that you remain of the view that the accident cannot be "ascribed to SIA corporate/cockpit culture, Singaporean or Asian attitudes, the failings of overworked and underpaid crews etc." (your post of 28 Feb 2001). Perhaps I might again try to convince you that myself and others might be on the right track in respect of the cause(s) of the SQ006 disaster?
I think the point that I may have been trying to get over was to the effect that whilst “Captain Foong acknowledged the PVD was discrepant and FO Cyrano was satisfied that they were lined up on 05L, hence did not pursue the matter” was not to say that the FO was happy with the situation (or could express such happiness on the CVR) in that, it is entirely possible (even probable) that he would have been thinking along the lines of “OK why is it discrepant - usually its pretty reliable and why does the ND not show us on 05L? Oh, OK, maybe it’s a map shift - the captain seems happy enough and we are lined up on the correct runway after all”. Further, I think that he was distracted by events leading up to that point and perhaps did not (a) wish to lose face by questioning and being shown to be wrong (b) wish to counter the SQ chain of command by questioning the captain’s competence in safely conducting the flight (at this stage by getting the aircraft to the correct runway). In this latter respect, if he did so question, he would not expect to be berated by an overbearing captain but would instead fear further lose of face and the possibility of a PQ report back to fleet, that could definitely affect career prospects.
Gaunty’s posting of 9 March, quoting Captain Dan Maurino, Head of Human Factors, ICAO and Rongotai’s post, also of 10 March, expanding Captain Maurino’s views perhaps provides a further, relevant, CRM dimension to the disaster.
On the question of weather conditions prior to departure - simply put Captain Foong was inevitably the recipient of one of either two pressures that were going to cause severe stress to him. Firstly “do I delay and subsequently field the inevitable ‘phone call from the fleet management which will cause me great stress later on” or alternatively “do I go despite the weather being atrocious and me being worried about it and it causing me great stress right now but I’ll have it behind me once I’ve taken off and climbing”. It’s one or the other I’m afraid. The third alternative, which I’ve suggested previously, is that SQ’s training is deficient in that sufficient attention has not been focused on operation in extreme weather conditions.

Gaunty

Both very nice postings of 9 March. Perhaps as a side issue, although I think it may be germane if consideration is given to a thesis of multi-cause of the SQ006 accident, is the hubris (we have both written on this subject before) of the taxiing crew prior to turning onto 05R, as revealed by the CVR and posted by Titan on 28 Feb. They all seemed to be having a very good laugh at the expense of the Aussies and strongly implying that the Aussie logic in respect of next right/second right was in error. It is of the most tragic irony that the crew applied their own logic as to which was next right before turning off the taxiway (ie second right) but the Aussie logic for their next right turn (onto the wrong runway 05R), when, using their stated logic, they should have taken the second right onto the correct runway, 05L. Could it be that some form of stress provided the distraction and hence the fatal error or do the words “whom the gods would destroy they first blind with hubris”, apply?

Titan

Exactly put when you make "a couple of points". Rockhound please re-read. All readers may be interested to note that a highly respected and experienced aviation medicine practitioner could not communicate the fatigue situation to his personal friend, the now invisible SQ Director of Flight Training. Demonstration of SQ management receptiveness/open-mindedness?

Finally, some time ago, I completed a particular manufacturer’s course that contained, amongst the technical/flight sim training, a section devoted to “human factors/crew resource management”. I recall going through the usual classroom exercises that I know we are all familiar with and which are designed to demonstrate how our minds work in various situations. Following this, a non-aviation behavioural psychologist made a powerful presentation to the effect that events leading to an accident can be considered as links in a chain, which, if unbroken either by design or by good fortune, must inevitably lead to the accident which such a chain of circumstances predicates. The telling points brought out were that: (a) if at any stage a link of the chain was broken, then the accident would not happen (b) the individual links in the chain could be made up of innocuous, seemingly irrelevant and hence easily overlooked items/events (c) it was possible for airline managements, in an “overview” position, to be able to identify such links and so eradicate them before any event and it was similarly possible for flight crews to identify such links “on the day” and so “break the chain” of events on a particular flight, which otherwise would lead up to an accident.
These processes, however, required a strong commitment to the principles of CRM by management (who were going to spend the money) plus trust and openness between management and flight crews and the same relationship features between the crewmembers themselves.
Without repeating ad nauseum the collective invective against SQ management, I would offer my own view that the present SQ flt ops management (M de V and cronies) has not (a) any real concept of what it’s about and (b) are not interested anyway, as to implement a full CRM programme would cost money. Plus the flight crews have absolutely ZERO trust in the present management, nor between themselves, as, during the 19 year de Vaz tenure, a system of secret reporting on other crew memebers by selected (usually FO) spies has spread like a blight.
World class airline? Pull away the glossy cover and you'll see the rat's nest of bungling, ineptitude, amateurism, conyism, hypocrisy and vindictive spite which has made the organisation what it is today.

[Tosh26]

Yes, come to think of it, the ARM courses I've been on did not feature any local captains, only FO's.
I've also asked around today, since reading gladiator's last post and no ex-pat I've spoken with can recall ever being on a course with a local captain!
Coincidence? Maybe they are all perfect as gladiator says.

[Farside]

It is interesting to note that Singapore Airlines is conducting a safety survey with Dr. Helmreich an accomplished and well known guru in the field of CRM/Risk Management. This should be the first sign of a positive change in safety awareness in the company. However why would one select a team responsible for formulating the survey ,which only excists of local captains and totally excludes expat crews from over a dozen different countries and airlines, to include BA, Swissair, Quantas, and other flag carriers. A perfect example of zero CRM, not using resources ready available in the company. Or could this be another example of the xenophobic attitudes here in general. Remember:” You have to ask the right questions to get the right answers”.

[Streamline]

I have heard this story about tuning a ILS as a backup for lat guidance before.

If required to fly the SID it's OK.

But some airlines use it during the ground roll.

Imagine, with a RVR of 125 m they look outside at the lights, below 125m they start to look inside at the LOC deviations.

I call these guy's dangerous and I hope it is not SOP at SIA.

------------------
Smooth Trimmer

[Sick Squid]

Streamline,

Used correctly a PVD is an excellent tool in low visibility take-offs, I think 75m is the lowest my mob operate to on suitably equipped aircraft.

The idea is that as the visual segment decreases due to variations in the fog, your eyes naturally track down to catch the next runway light. This then brings the PVD into the scan, and its deviation (or lack of it) will help you keep to the centreline.

As the visual improves, your eyes transit naturally up and away from the PVD. Used correctly, it is not dangerous and quite natural after the first few (simulator!) attempts.

£6

[sia sniffer]

Its quite interesting to note that I made a post about the short cummings of SIA's CRM training just prior to the SQ6 incident.

To reiterate, SIA traditionally has two CRM courses (officially called ARM by SIA). Conducted, designed and taught by an American professor of dubious distinction, it personified one mans appreciation of Aircrew Resource management.

As a new first officer in SIA, you would be rostered 5 days in an Asian city, away from Singapore, to study the merits of becoming ARMed (as SIA would like to call it). But just incase anyone was to think that the merits of CRM could be fully appreciated,ie candidness of opinion, SIA would always insure that a management pilot was to accompany the participants at all times.The inexorable eyes of the fourth floor were always present.

A second ARM course would normally be rostered within about two years of the first.
The course was conducted by the same Professor, hankering to his own personal theories of CRM. After all, he was a professor.

After completion of your second CRM course, you as a three/four year "seniority" first officer, were considered fully "ARMed", and therefore would be able to cope with any of the decidely none CRM behaviour of the local captains you would inevitably fly with.

From this time on, as an F/O, no more CRM training would be given or expected. It could be quite easily to spend the rest of your time in SQ and never be reinforced in the aspects of CRM. Consequently there are never any local captains participating in CRM training.

I believe last year SIA introduced ARM 3, but of course, run by the same Professor and including all his idiosyncrasies.

And the reason that the courses were not conducted in Singapore? Well it allows many of the participants to escape the emancipation of their wifes/girlfriends, to be free to indulge in an fiest of massage parlours and prostitutes, all under the adoring gaze of the one and only professor Perv.

To have walked the walk, one can talk the talk, isn't this right guys?

[SKYDRIFTER]

History - again

There can be no doubt as to the CRM failures, the issue is the WHY of it.

In the USA, CRM is a mandatory training course, however, the FAA simply won't impose CRM in the cockpit and that leaves management free to treat it as a mandatory joke. I prefer to believe that most airlines treat the CRM issue very seriously at all levels, however, that is questionable.

If that same treatment of CRM is true in the ICAO environment, the failure is clearly understood. Obviously, that needs to change.

The damning factor is the human factors. The captain had to be thinking in terms of his accountability to management, who takes safety for granted, where they do not take the loss of revenue for granted - for any reason - safety be damned.

The typical pilot psychology very often leads pilots into a denial mode with a clear threat in their face. That's the historic force behind the science of CRM.

Now, a major effort needs to be made to examine specific accidents (most) and break that link of the chain. The philosophy, "There are no dumb questions" has to be embraced with professional respect, as opposed to embellishing an ego with a discounting response.

In the last 4 years, all the major incidents & accidents in the USA (with rare exception) have a major CRM breach, yet there is no significant response to the obvious problem.

Management and the aviation authorities will probably continue to ignore CRM. As a minimum, crews need to develope an autonomous and dynamic attitude toward CRM & treat its use as a professional and masculine deed, as opposed to dying to protect one's self-image and the company schedule.

God bless forums such as this! We won't get this type of information out of management.

[titan]

A related post is at
http://www.pprune.org/ubb/NonCGI/Forum1/HTML/012895-2.html
and just to be fair, another fine example of the subject of non-load shedding would be the Swissair fire.

I too was ARMed twice. I too was never allowed the privelege of ARMing with local captains but was given the privlege of the watchful eye of the management spy at all phases of the training. Yes, I know you can all see the irony, but maybe you are wallowing as to the reasoning behind why SIA went to all the trouble to produce a CRM sytem and then not utilise it properly. Simple ...... the ARM course company that was contracted to provide this expensive service was owned by Maurice, Lenny? and the Professor. You see, in the real world 85% of fraud is committed not by employees as per the popular belief, but by management. The most usual form this takes is to form a contracting company and use your power to ensure that YOUR personal company gets the contract, a contract that is normally grossly over-priced and doesnt go to tender. The question must be asked, therefore, how can such blatant corruption go unpunished? Maybe the answer is because it is the NORM and if a lower card is "taken out" then the whole edifice will topple.
I never cease to be amazed at how people get promoted into management and suddenly become super humans with super intelligence and look down apon their once colleagues as unsophisticated morons. I suppose any political system will suffice here as an example.

[nose-cabin]

Cockpit Resource Management- Communication in Anxiety and Stress situations.
Anytime we go to work we can expect the worst problems to present themselves usually more than one at a time.
Very bad weather, low fuel, over shoot, technical problem, diversion etc.
To the experienced pilot this is no big deal but think of less experienced crew in this situation

Communication with pilots and crew in a non- normal or emergency draws upon a core of group communication skills.
These skills are learned rather than a fixed attribute of a personality that a pilot does or does not have.
They are developed through a combination of experiential learning that involves practice, expert comment and supportive guidance (instructor tutorials) and the acquisition of theoretical and research based knowledge about communication. Once developed, competent communication can be reflected in many individual styles.

Communication process in an aviation emergency may be conceptualised under the headings of crew- pilot and flight attendants factors (for example individual differences in personality and intelligence and socio-demographic variables such as age, gender, class, ethnicity), situational factors (for example high arousal, fear, anxiety, fatigue, depression, pain, noise, body position, feeling helpless) and Captain factors for example work pressure, fatigue, perceived status, confidence states and personal style.
All of these factors will eventually be considered, but I shall now focus on the crew factor of the effects of anxiety and stress on communication.

Anxiety is a complex concept and many factors affect the nervous system.
There are three approaches to assessment,
1 Subjective Level -self-report represents the subjective experience of the individual. Crew can assess their personal physical aspects such as muscle tension, trembling, choking, and dizziness. And physiological features such as apprehension and fear. Wide individual differences exist in the levels of anxiety and people experience and or report. There is a difference between trait anxiety which is personality based on a day-to-day basis and across the state anxiety level which refers to an immediate level of fearful arousal experience in a particular situation. Therefore the effect of anxiety depend on a) the individuals predisposition to trait anxiety, b) appraisal of the immediate situation c) previous experience.

Anxiety can very rapidly become a condition response to particular situations.

It is possible for someone who is normally calm, and who is proud of this, to experience a high-level of state anxiety and stress in a threatening situation.

2) Physiological approaches to anxiety focus on parameters such as heart rate, blood pressure, respiration rate, skin condition.

3) Behavioural approaches observe tremor, sweating, rapid speech, and high pitch of voice, cold hands, and avoidance behaviour.

Measurements according to these various approaches do not always correlate very highly for a person with high physiological and behavioural indications might for various reasons report only below subjective levels.
.
Anxiety and stress is relevant to communication in this case in three important ways.
1) Laboratory studies have shown that anxiety can have deleterious cognitive effects such as reduction in capacity to sustain attention, process information, and to learn and recall information. Performance can be reduced because task irrelevant thoughts associated with the anxiety reduce the availability of working memory. Anxiety may also increase the amount of effort required to keep performance at a level comparable to more typical low anxiety conditions. These effects could reduce the crews' capacity to understand and recall information conveyed by the Captain, and hence reduce their capacity to understand and to comply effectively with the Captains instructions, and to follow standard operating procedures.
2) High anxiety can be extremely distressing to crew and should be alleviated as far as possible.
3) The potential for developing condition anxiety responses to emergency situations should be recognized and avoided.

Management of crew anxiety and stress is a necessary component of effective Cockpit Resource Management.
Common sources of anxiety include feelings of helplessness, inability to accept support, fear of expressing genuine fear. Anxiety often accentuates crewmembers characteristic styles of functioning.
Three particular communication skills apply
1) Empathy with and recognition of crews' anxiety.
2) Provision of realistic assurance, rather than false assurance or stark reality confrontations.
3) Verbal and nonverbal behaviour that reflects the care which is crew focused and expert.

This is not addressed in most information on CRM I have read to date.

[gaunty]

nose cabin
So tell us something we don't know.

Forgive me if it is not so but the language of your post suggests a self serving SQ management agenda.

[SKYDRIFTER]

NOSE CABIN -

Good posting on the 'close-in' aspects of the human factors. Beyond the basics of CRM, the personal experience and impact on crew interactions is a major factor in getting a team to pull together, or possibly having to eliminate a team member due to incapacitation. The crew has to be whole.

I remember seening a news-reel clip of a 737 landing with the left main gear retracted. They forgot to disarm the auto-speed brakes & snapped the left wing down on thouchdown. When the aircraft came to a stop, the captain bolted through his side window & ran away before a cabin door could be opened. Thus, the close-in experiences you describe apply to all.

The name of the game is awareness in yourself & others as to the potential effects of stress & for everybody to solve that problem as well. A partial or completely incapacitated crew member can turn into a passenger quickly.

No "crew;" no CRM.

[gaunty]

nose cabin
Sorry if I was a bit short there.
What you say is true and underlies the whole concept, but is it not the recognition of these criterion/symptons that is the essence of CRM.
If this is so, then would not a predisposition or cultural leaning to a "righteous attitude" render this recognition unlikely.

[Streamline]

Sick Squid

PVD OK

Loc Dangerous

------------------
Smooth Trimmer

[Sick Squid]

Ahhh, sorry mate. RTFQ.... you weren't criticising PVD's. My mistake...

However, the LOC is still a useful tool in low vis for making sure you are either a/ on the correct runway or b/ not aligned on the edge lights.

But I agree, it should not be used for guidance during the t/o roll in low vis under any circumstances.

£6

[boofhead]

The PVD in this case is a red herring. It is used only under low vis conditions as an aid to maintaining the runway centerline. It is not, and nor was it designed for use in identifying the runway.
There is no requirement to use the LOC for tracking on 05L so it need not be on, and if it is, it would be the 23R LOC that would be used, so the PVD would be in reverse sense. If the PVD is required to be used, there are a number of checks that need to be carried out on the system. Including confirmation that the ILS is operating correctly and the signal is protected. If these checks are not carried out, the PVD is a toy only.
It is not unusual for the PVD to give incorrect information, since the usual errors affecting the ILS also affect the PVD.
It is not uncommon for the PVD display to be absent or wrong as the airplane lines up, due to LOC errors, especially under the weather conditions and navaid reliability at Taipei. In order to verify that the PVD is right (this is NOT the same as verifying the runway is correct) it would be necessary to re-check the ILS tuning, listen to the ident, contact the Tower for them to check the ILS monitor, etc. All way too long for the situation, so the pilots would simply discount the PVD and ignore it. I can imagine that the Captain would be annoyed that the FO was waffling on about the PVD when he would have been better employed helping him to find and confirm the runway identification. In the same manner that Boeing recommends not using the FMC at lower levels on Approach, but to use basic information instead.
And:
If the airplane had no GPS then the ND would be of no use in identifying the runway. The position error can be considerable as the runway is approached. When the TOGA switch is pushed the FMC position is moved to the beginning of the runway display anyway.
The only aid that can be reliably used to confirm the runway identification (not to make the ident, but to CONFIRM it) is the GPS.
If this airplane had GPS that is. Anyone know?
It is always the crew responsibility to takeoff and land on the correct runway, and no amount of PVD, LOC, GPS etc can take that away. In the same way that having a Green light does not absolve a motor car driver from making sure the intersection is clear.

[SKYDRIFTER]

LEGAL / POLITICAL PROBLEM -

The underlying issue is that a case for the PVD being pertinent can be made under the "...reasonable standard of care" precedents.

The core issue is whether or not the pilots get targeted in the legal crosshairs. If so, we may be certain that the PVD will become a supporting issue, enabling management to escape liability.

Again, the issue for pilots needs to be productive analysis, not holier-than-thou judgment of the pilots.

[Insider107]

In furtherance of the great debate, I thought readers might be interested in material recently produced by the SQ Operational Safety Interest Group (OSIG). The point being that what is now surfacing, at the instigation of Lt Gen LG Bey, can be seen as the cancer that has been growing in SQ for many years and OSIG’s probing as initial cathartic action long overdue. Similarly, doubt can now also be laid to rest in the minds of the sceptics who may in the past have questioned the accuracy and veracity of postings in respect of both flight ops management style and CRM (or lack of it) in SQ.

OSIG was set up under the chairmanship of Executive Vice President Technical (EVPT) Lt Gen Bey, to meet approximately every two months – first meeting held on 8 December 2000, second meeting on 12 January 2001. The Group exists to review operational safety issues and then to pass recommendations to Flight Operations (Management) plus publish safety information for pilots. OSIG stresses that the initiative was planned before the SQ006 tragedy and is not a reaction to that event. As those are Lt Gen Bey’s words, I believe them. If they had come from any other source within the flt ops “management” then I would not.

In respect of recommendations going upwards to this present “management”, of course, this remains highly problematical, for your writer has never seen a more closed minded, defensive, prevaricating, evasive, cost obsessed group of tired old timers, masquerading as knowing what they are doing, than the present bunch. If, however, the aim is to pass recommendations for positive action to the new management, presently comprising Lt Gen Bey and shortly (1 July 2001) to include Maj Gen Raymond Ng as SVPFO designate, then the future does indeed look brighter, with the prospect of two very high calibre intellects directing technical events. I personally have optimism for an era eventually free of de Vaz and crew – but until such happy time we will lurch in the familiar slough of cynicism, confusion and despondency know so well and for so long, by so many.

OSIG quickly decided to split into focus groups to concentrate efforts in sectors considered important and so produce detailed and authoritative recommendations. These groups comprise:

MAN – Human Factors, CRM, Training
MACHINE – Aircraft & other equipment
MEDIUM – Airports, Weather & ATC
MANAGEMENT – FCC, Safety Dept Org, Investigation process and analysis.
MISSION – COP’s (crew operating patterns), Crewing, Fatigue
INFORMATION TECHNOLOGY – Info dissemination/collection within pilot body.

All extremely laudatory stuff, desperately needed and producing some very intelligent recommendations! I was unfortunately away on the relevant dates in December and January but would otherwise have been delighted to make an input – I do in fact look forward to making future contributions. SQ pilots, meanwhile, do not hold your collective breath whilst awaiting recommendation implementation by the present bunch!

Perhaps I could draw attention to appropriate material under the MANAGEMENT and MISSION banners? SQ readers can read the rest in the OSIG Newsletter of 1 March 2001.

MANAGEMENT. The chairman of this focus group reviewed the current climate that exists within flight operations as perceived by company pilots.

“The group felt that morale was low and the atmosphere stagnant. Broad based thinking was stifled by the system and this contributed to a divide between pilots and company. It is suggested, however, [that] the group wanted to improve the system rather than censure individuals or departments, that is “to play the ball rather than the man”. By so doing it is hoped that a sense of pride in the division will encourage active involvement by all pilots [in OSIG], which will benefit everyone and the company in the long run”.

“The group felt that the prevailing culture in flight operations was punitive rather than corrective. Many [of the management] believed that blind adherence to Company Policies and Procedures would ensure operational safety. This did not take human factors into consideration. A further perception was that flt ops management was intolerant of criticism, resulting in loss of two-way flow of information and [so] flight crew withholding information and suggestions”.

“The focus group see[s] it as an urgent need to rebuild the confidence of SIA pilots in the flt ops management to remove the “us” and “them” culture. Flight crew feedback and criticism should not be seen as always “anti company” unless saving money”.

“The group felt that the present culture was instilled in new pilots right from their arrival in the Singapore Flying College. Many cadets report being collectively told that their status was “the lowest form of life”. The damage to achievement of good CRM in the future can only be imagined!”

“The Performance Appraisal System (PAS) has generated much mistrust and misapprehension, such that it is considered a Demerit System. Annual appraisal interviews do not happen and pilots are left to conclude that “no news is good news”. Of those appraisal interviews that have been held, many were unsatisfactory in that they focused on minor aspects of an individual’s performance rather than overall potential. Leaving the pilot confused about the appraisal. Administrative changes to appraisal procedures have not been adequately explained. In some cases, First Officers have been bypassed for command without having been informed in advance that their performance was not up to standard. There is no formal structure for remedial training to allow such pilots to achieve the target standard. Some Senior First Officers choose not to accept sectors for fear of jeopardising their command prospects in case of making an error. Etc etc”.

“Voyage Reports are a tremendous source of feedback to management but there is a feeling that it is a waste of time. Replies, although requested, are seldom sent and experience has left pilots wondering if their feedback was appreciated at all. Etc etc”.

“The company anonymous reporting system has been unsuccessful, bringing an average of 5 reports per year only. ALPAS introduced a parallel system, PPOS, which has received considerably more reports and produced much useful feedback to line pilots. The question that must be asked is “why are pilots willing to share information with their pilots’ association but not with their flight ops division?”

“The company’s Flight Safety Bulletin mostly consists of articles from other publications and seems to carefully avoid any analysis of incidents within our own sphere of operations. It seems that this information is kept within the confines of a select few and any information which is disseminated, avoids any mention of human factor aspects”.

“Although our Training Department is well equipped with advanced modern technology, we have failed to keep pace in the human elements. Little effort is expended on instructor training and standardisation. None of the recommendations of the August 2000 Instructor Symposium have been implemented and no report has reached the instructors. Our CRM training has fallen behind the industry and relies solely on one individual lecturer”.

“There is a perception that the Management considers operational safety to consist of meting out punishment to those involved in incidents. This is a very reactive attitude and a more visionary and proactive approach is required. Many well motivated individuals have found the best policy is silent resignation and this message is passed by word of mouth to new arrivals as the best way to survive in SIA”.

“The method of appointing managers does not necessarily ensure the best man gets the job. Once appointed little or no training is given and managers rarely attend aviation related courses or seminars, locally or internationally. As a result, we lag behind other companies in the industry. The appointment of Principal Officers of the Pilots’ Association into management posts without a reasonable cooling off period is unethical”.

“The company has played on the goodwill of its pilots to avoid cancelling services by requesting volunteers to work on what would be days off. There is little goodwill in the other direction however, when it comes to making requests for specific days off or COPs by pilots. Leave has frequently to be carried over to subsequent years, as it cannot be fitted in due to pressure of work”.

MISSION. The chairman of this focus group summarised the findings/recommendations:

“The group feels that it is important that inexperienced on type crews should not be rostered together. Other companies use systems to identify inexperienced crews and to ensure that they are not paired for flights”

“The group also expressed concern about First Officers handling at early stages after check out. At present, we rely on the commander’s judgement but should we publish lower limits for inexperienced First Officers and perhaps introduce a categorisation system. New pilots would progress through the system with experience and competence. It is also the feeling of the group that all First Officers with only cadet flying should progress through the A310 or short haul fleet [Silk Air?] prior to posting to long haul or ‘electric jets’”.

“The company has recognised that there is a problem with Three Pilot Crews (1 x Captain, 2 x FO’s) now that CAAS has removed the approval for First Officers to occupy the LHS. Any block time in excess of 10:30 (ie duty time over 12 hours) will have Augmented Crews (2 x Captains, 1 x FO). This will be implemented as soon as practicable and included in the Northern Summer COP’s”.

“Much concern has been expressed about Standby Duty. Many Authorities require the reduction of FDP according to the preceding period spent on Standby. At present it is possible to have, for example, an 18-hour standby, 2 hours off, followed by another 18-hour standby and then be called for a 15 hour FDP. B744 crews are rostered split Standby periods at line stations [down route] followed by lengthy FDP’s. Is this safe?”

“Although many of the concerns voiced to the focus group are “Lifestyle” and essentially “Industrial” matters, they affect Morale. LOW MORALE IS A SAFETY PROBLEM. Within this context, Leave is seen as very important. The group recommends that once leave has been allocated, it should be sacrosanct and not subject to cancellation. Similarly, leave should not be imposed on the younger members of the pilot community, such that their whole allocation for a year is lost to them just because the training system cannot cope with them at a particular time”.

Outside readers are invited to form their own opinion of SQ as “the world’s best airline etc” and in doing so, should remember that mature and well-respected members of the airline have collated the above material in a very public manner and at the behest of a most senior officer of the company. It is not scurrilous “on the fly” anonymous posting material which some misinformed readers may assume certain pprune postings to be. It bears all the hallmarks of accuracy and veracity that, indeed, are in the finest traditions of pprune.

Unfortunately the OSIG recommendations will receive scant regard at present, for Lt Gen Bey does not yet have full control of the Flight Operations Division and it is still “steady as she goes” with the present corrupt and worn out crew. What, however, could be a more publicly damning indictment (yes the same wording has been used before) of them than the above officially sanctioned material, which underscore the years of arrogant stupidity, complacency, mendacity, evasion and intimidation perpetrated by a group driven by egomania, personal instability and an insatiable drive for personal financial gain?

Finally, as yet another example of their institutionalised mindset, we need look no further than the evidence relayed to me by two trusted colleagues on another fleet, who recently attended their own fleet meeting last week, chaired by the relevant CP and briefly attended for a “dialogue session” by the famous SVPFO, Maurice de Vaz. After one captain detailed an 11hr:30min, FCO-SIN, Three Pilot Crew flight he had recently completed and during which he had attained zero rest and had only been able to leave the LHS for brief “nature” breaks, the question was asked of our Dear Leader, Maurice, “do you think this is safe?” After much prevarication and the effects of a demonstrably, increasingly restive audience, he was eventually nailed down to admitting that it “costs money to train FO’s to occupy the LHS in the cruise and it is expensive to crew flights on an Augmented basis”. When asked how he would feel if a flight crashed on approach and landing and the cause could be attributed to crew fatigue, he just shrugged! He then hurriedly left, citing an 18.00hrs dinner engagement! The CP then confirmed to the meeting that the fleet had started rostering relevant flights on an Augmented basis but the pilots present confirmed in turn that they had not yet experienced this change of policy. Finally, an ALPAS member took the CP to task to the effect that SQ had a signed agreement with the Association, in force from 1 Jan 2001, whereby SQ would roster all former Three Man Crew COP’s forthwith as Augmented Crew flights. The CP was caught out lying when he denied the existence of any such agreement. He then refused to answer further questions, closed the meeting summarily and stalked out!

Watch this space.

[Anotherpost75]

It looks as if the likely content of the “missing” 14 minutes on the SQ006 CVR indicates two things. Firstly, the fact that the “local” crew was allegedly severely slating SIA flight ops management directly/SIA in general at a particularly critical stage of the flight is indicative of very poor morale/anxiety, which people may or may not believe affects aviation safety. Secondly it goes some way towards explaining the antipathy felt by senior management towards the crew, having read the highly personal and defamatory remarks directed at particular senior individuals and may further have prompted a desire to fire them asap, to extract personal revenge.
Sensitive egos? What do you think?

[Gladiator]

Bravo Insider. The truth will prevail.

Reformasi.

[EasyGo-Lucky?]

Again, well said Insider.

I do wonder though if any of this action, or the inadequecies of Flight Ops management, would ever have come to light were it not for the SQ6 crash.

Does this now mean that I can cancel my life insurance that I was obliged, more like bullied, into buying from the wife of the Chief Pilot for Training?

[thegypsy]

INSIDER107 Well said. I do not however share your optimism with regard to the two ex generals. They are a product of careful selection from birth almost to follow the party line as laid down by LKY and they will have been brain washed from day 1.Their military background will always I suspect show through in their dealings with us pilots.They have probably been brought in to ensure even tighter discipline and to get us rebellious pilots back in line! They are both of the school that believes that all mistakes have tobe punished! {Being SIA that means financially Fof course as well as other ways} All these recent CRM OSIG etc etc are just window dressing to try and convince the regulatory authorities in USA and UK and elsewhere that something is being done ,those of us in SIA know that attitudes have not changed one iota. Why have the CAAS allowed SIA for example to have 747 Captains who are owed 3 years leave!!!??? It is an absolute disgrace.Fatigue,low morale,arguments over the CA which are a permanent source of irritation affects our not being able to concentrate wholly on the job. If indeed SQ6 crew were slating the company at some stage that just proves the point.Forced leave ,cancelled leave,illegal standby duties as most would see it all make for an unsafe operation.Radical steps need to taken which can only come from outside theSingapore sphere of influence because no one in Singapore has been allowed to think an original thought yet alone express it.

[Gladiator]

thegypsy has an excellent point. A year from now, all may feel that life was better under DeVaz.

If a Captain or any other crewmember is owed three years leave, he should be taken off of flying duty immediately.

SIA pilots (one's will the necessary courage) should write to the FAA, NTSB and ICAO, and complain about SIA's unsafe operations.

Remember Singapore government's corporate culture, if I can't exploit you, I don't want you.

Reformasi.

[1 of many]

Read with interest Insider

If the management response isn't just mouth music, I would call that a result. Sadly, only time will tell.

The 'read-across' to just about all other airlines is stark.

Perhaps that unfortunate incident and its backdrop will become the stuff of CRM teaching just like the Kegworth 737.

You have my respect (for what that's worth), well done, I hope it works out for you.

To quote the old adage 'Evil happens because good men . . . etc'

[gaunty]

I don't always agree with Gladiator and I am by nature an upbeat person but I suspect he may be right on it.

Pity, because we all have the seeds of our own destruction within us, the trick is being able to recognise it.

The die is cast, the results will not be visible for a little while.

[SKYDRIFTER]

JUST AN IDEA -

As whorish as U.S. politics can be, there is the possibility that a letter campaign to the new Secretary of Transportation (Mineta) might result in an international pressure on SIA.

It's worth a try.

[titan]

Publicity is the only thing that SIA will ever understand. Their entire business is based on smoke and mirrors to decieve people that their airline is safer and better than all others. It is a marvel and a credit to the power of modern advertising.
You won't get into the international media by complaining about not having holidays for three years. The only headline that will wake up a passenger from his Singapore Girl wet-dream is SAFETY. Encyclpodedia salesmen invented the line years ago ... "you mean your children aren't worth $4 a week?!", well try this one "you mean your life is not worth an extra $100 on your ticket". This works!!! I know because I have used it for five years now and converted hundreds of people over to other carriers, namely Qantas. It is most effective on cockpit visitors who then go out like Disciples to spread the word.

I am doing my part, if you are sincerely concerned, then you do yours too.

[Gladiator]

Skydrifter,

In reference to the letter campaign, please research the appropriate addresses for the interested authorities.

Reformasi.

[Farside]

It is really sad, but I have to agree with almost everything stated in this long thread, especially the well worded and thought out writings of Insider107.
If somebody were to ask me what the present state of affairs is in Singapore Airline’s Flt Ops department between the pilots and management, I would compare it with a couple who had been married for a long time, and finally, due to the absence of the three main components of a good marriage, were now in the divorce court battling an ugly fight, with only the lawyers talking, and the partners trying to do as much damage to each other as possible. In short a very sorry state of affairs.
What are these three components?

a) Communication
b) Trust
c) Respect

In the absence of any one, or all, of the above mentioned components any marriage, friendship , business relation or employment contract is doomed to fail.
The fact that we as pilots over the last two years had numerous meetings and negotiations with management, resulting in nothing else but a big zero, only confirms that we are unable to communicate with each other . The tone, and the way in which both sides were reporting, in the form of newsflashes and letters from the desk of the EVP, on the outcome of these critical meetings showed that not only were we not able to communicate, but we did not trust or respect each other either.
Too much damage has been done and I don’t think that the present situation will get better if there is no dramatic change in the present status quo. But if we are open to change and have a fresh, but critical outlook on the new “forces” in Flt Ops management, give them a little bit more time, and if all sides are willing to take some sort of responsibility for the predicament we are in right now, there might be a simmer of hope that we get out of the divorce court, start to communicate and rediscover some new form of respect and trust. I might be an idiot, but I still get a kick out of V1 and Rotate, and can live with the 13 hours of boredom in between, if they could be filled with a conversation other than CA ,CA ,CA .

[Rongotai]

Farside has triggered a new level of understanding for me. When those of us who are engaged in cross-cultural research in organisations think about Singapore, we tend to define what is distinctive about Singapore companies as being that they function on

vertical loyalty (with 'absolute' as the default value)

horizontal trust (with 'unconsciously assumed' as the default value)

What this thread has described is the apparent breakdown of both those values in Singapore Airlines. Vertical loyalty is not only not absolute but hardly there at all - if some of the comments by SIA employees are evidence.

Horizontal trust is also clearly badly wounded, especially in the field of cross cultural relationships on flight decks.

When fundamental values can no longer be relied on, distraction, demoralisation and the breakdown of standard operating procedures inevitably follows (counter to normal assumptions about SOP's being culturally neutral, the reverse is the case -SOP's are fundamentally dependent on cultural congruity in those who use them).

When you superimpose upon this a substantial portion of the workforce whose fundamental values are profoundly different from the prevailing culture (in most Western cultures - and especially in OZ, NZ, US and Canada - loyalty is rarely blindly given, and trust is won rather than assumed) then the systemic contradictions and stresses become truly frightening.

This leads me to wonder about the prognosis. It is going to be extremely difficult for managers who are deeply embedded in the two Singapore norms I have listed to provide the right kind of leadership to deal with the problem - and especially when there is a significant portion of the workforce which does not subscribe to those values, and even despises them. Equally it is highly unlikely that non-Singapore assistance can win any credibility at all with the Singapore workforce - some of whom appear to despise western values.

This is not to say it is impossible - just very difficult. Whoever succeeds will be able to approach the issues with their own cultural baggage well under control. There are such people, but conventional recruiting processes tend to weed them out rather than short list them.

What SIA needs is to be able to turn away from its 'Singaporeness' and concentrate on its organisational culture. But in trying to do this it will find itself faced with the same issue which made things so difficult for Air NZ after Erebus - it carries not only the flag but an iconic manifestation of Singapore national identity.

The tragic paradox for the airline is, therefore, that the very act of hanging grimly to its symbolic cultural role runs the strongest risk of destroying precisely those positive characteristics which made it worthy of its iconic status in the first place.

[gaunty]

Rongotai
So elegantly and succintly put.

They would not be the first nation state to find themselves in this dilemma. History ancient and modern is littered with them and the monumental remnants of their once existence. One need not look far.

[Farside]

Thank you Rongotai for your very well written reaction. I have to agree with you that the task ahead of us is going to be very difficult, but hopefully not impossible. We have to look ahead with a certain level of optimism, since our present path is only leading to a very destructive future with no hope if improvement whatsoever. I also realize that there are many different and negative forces among both sides of the table , but I still hope that at the end common sense will prevail. But then again I could be totally wrong, and the enormous inertia of the negative force might destroy what could be one of the best jobs around. Only time will learn, and that is just the commodity we are very short of.

[Insider107]

Anotherpost75

Yes I believe that the CVR transcript of the “other 14 minutes” went to SQ CEO Dr Cheong and then right up the government line to the very top. As far as I can gather from the local FO’s I speak with, some of whom are very well connected, the collective, unpublished response to the sentiments expressed on the CVR tape has been extremely frosty and seen as yet another example of “ungrateful, prima-donna” pilots following their own selfish agenda, with no idea of “the big picture”. Readers, I’m sure, by reflecting on the combined input to this and other SQ related threads, will be able to divine the erroneous nature of the latest example of what could possibly be introduced as a national sport – that of jumping to wrong conclusions. The pilots of SQ are a highly professional, intelligent and concerned group who realize two fundamental facts and are trying with the most limited leverage available to them, to make effective adjustments:
1, They are now and have been over the years, consistently used, abused and undervalued.
2. The airline they fly for has a profoundly flawed attitude towards flight safety and is concerned only with marketing hype and bottom line profit.

Gypsy

Thank you for your well expressed post. I agree with you entirely that things could go the way you forecast. I perhaps force myself to be optimistic about the near future and my remaining time in SQ, for the alternative picture that you paint is bleak in the extreme and clearly sets the scene for further catastrophe. When I think of your collage, I’m utterly depressed and consumed by a despondency and perplexity that SQ seems unable to get the message that any airline management’s relationship with the very flight crews that make it all happen on the day, is of the most subtle, complex and fundamental nature, requiring the constant nurture of respect and trust between the parties – acknowledgements to Farside. Only then can communication be effective, morale buoyant, with safety and efficiency proceeding hand in hand. I remain of the view that Lt Gen Bey understands the interplay of this relationship and will eschew any thoughts of authoritarian action towards an independent minded professional group. Perhaps events on and subsequent to the IAC hearing of 11 April 2001 will reveal all?

[titan]

Will SIA become the PanAm of Asia?

[twitchy]

With great difficulty I was able to go on 3 weeks holidays with no newspapers or the internet. After resuming my work I realised, how much I had missed about SIA.
Farside and Insider107, thanks a lot for your wonderful postings.

Hey I never read anything here about the so called confidential "SAFETY ATTITUDE SURVEY".
I don't feel any body can give true picture out there. I wanted to complete the questionnaire but could not digest the facts and was amazed that the SIA AND Dr. Robert L Helmreich wants to know now the following:
1. The management in Flt. Ops. Div. listens to us and cares about our concerns.
2. I feel comfortable going to chief pilot to discuss the problems.
3. Working here is like being part of a large family.
4. Management will never compromise safety concerns for profitability.
5. Pilots moral is high.
6. Pilots trust Senior Management in SIA.
7. Meritocracy has to prevail in promotion.
8. Appraisals are conducted fairy.
9. I am always aware of where I stand in promotional exercises.

The purpose of last page could not be understood in a confidetial survey that also conducted by "Leepublic of Singapore's National Airline.
I wonder the management definitely knows the answers to all the above questions, why do they want to waste their and our time. Whom are they trying to fool. Does SIA want University of Texas to give them a Masters degree acknowledging that every thing is alright within the greatest and safest airline of the world. Any comments please......

[Lee]

Twitchy,

That's a good one "Leepublic of Singapore".

Can I be the Senior President or CEO of the Leepublic of Sinapore National Airlines, since I'm really a Lee.

Fate, has it that my Great, great, great, great, great, great, great, great, great, great Grandfather was the inventor of the rocket (remember, the Chinese invented the rockets, gunpowder and paper) and he became the head of the National Space and Aviation Adminstration (NASA) of China. So, I think, I deserve to qualify for the post - on the grounds of meritocracy and Singapore is a tiny red dot, didn't PM Goh say so?

[twitchy]

Dear Lee,
Yes certainly you can be the CEO of the greatest Airline provided you have all the great qualities required. At first you can start with learning how to SQrew the local pilot community, how to pay less and get more work etc. etc.etc
Do you still aspire to be one....
me certainly never.

[twitchy]

Come on friends
in last three days no comments on the Safety Attitude Survey points at all..........

[old-timer]

sounds like I should cancel my SQ tickets ?

[Insider107]

Following the SQ006 imbroglio and the subsequent interim Taiwanese report on the catastrophe, one of the many luminaries who have disappeared below the radar horizon is the Great Freddie, aka The Barman and latterly grouped with his 777 acolytes under the disrespectful pseudonym, Freddie and The Dreamers, in tribute to the collective optimism of this 777 team of ETOPS aspirants.

SQ readers have quickly recognised that the seeds of the next “SQ006” have long ago been planted in the fertile ground of the SQ B777 ETOPS patch and 777 line pilot serfs have become increasingly worried by the lack of ETOPS knowledge displayed by the team, the unwillingness of the team to tap into the vast ETOPS experience of the ex-pat pilots, the dearth of evidence pointing towards the establishment of an ETOPS dispatch/flight watch department and the blatant manipulation/falsification of engine failure/shutdown events since introduction of the SQ 777 aircraft into service, so as to maintain statistical integrity of this fleet’s ETOPS approval, granted by CAAS.

Your writer notes with great interest, not to say incredulity, the trumpeting in the latest edition of the SQ in-flight rag, Silver Kris, that the airline intends to operate the new 777ER on the SIN-AMS-ORD route from 1 August 2001 and the SIN-SEL-YVR route from 1 September 2001. This presupposes, of course, that a new CA, permitting 777 operation beyond the present 4200nm agreement, is in force – on present track record, this should not be taken as a given – and similarly presupposes that ETOPS clearance beyond the present fraudulent 120 mins, to an even more fraudulent 180 mins will be granted by that time.

Pilots experienced on both routes will remember that the North Atlantic winter holds some interesting weather conundrums in respect of Tracks available and Suitable Airports with TAFS above ETOPS minima, requiring something above the present highly questionable 120 mins approval, to safely and consistently operate. Similarly, the winter North Pacific routes eastbound, taking advantage of the strongest jets, are somewhat more than 120 mins at single engine speed, from Tokyo, Petropavlovsk, Shemya, Cold Bay and Anchorage. Notwithstanding the foregoing, all this is intended to be operated by a brand new fleet equipped with the new marque RR Trent 829, which, whilst no doubt a very fine engine, is at the start of its development life and will demonstrate exactly the same behaviour which the present marque of engine on the shorter range 777 versions is currently manifesting, to show SQ, if the company would stop fiddling the figures, that it is still at the temperamental early stage of its life!

Perhaps, however, all will become possible in the time honoured SQ tradition of lifting and then selectively re-writing the existing FAA/UK CAA rules, to circumvent the tedious, costly and presently unattainable provisions of the ETOPS rules of these Authorities and metamorphosise them into something with a little marketing pizzaz, flt ops cost cutting gloss and represention to CAAS with the usual “you know it makes sense, sign here” spiel.

Sigh!!

[SKYDRIFTER]

INSIDER -

Great illustration; worth monitoring, for sure.

The SIA ETOPS certification makes for a great barometer of international aviation politics. I'm betting it will end up another formula for disaster. The icing issue should be sufficient to produce the first catastrophe.

The B-737 has serious control problems with an iced-up horizontal stabilizer during a go-around. I wonder what's true with the B-777.

[Hung Like A Horse]

With the advent of a possible return to Oz via employment with SIA Mauritius doing the now infamous Brisbane and/or Perth services, I have read with interest the posts on Pprune that have anything to do with SIA.
For a time there, I thought that a few of the original agitators were just that, agitators. Now I’m starting to think otherwise because the consistency of the threads, their repeated appearance and the clarity with which some are written, not to mention the official nature of the reference below, brings forward the possibility that the main contributions are not the rantings of a dispossessed few.
Referring to page 12 of the SQ006 post, specifically Insider107’s 22 March 0800 epistle, there seems to be a genuinely damning section that harks directly from SIA management meetings, titled “MANAGEMENT – FCC, Safety Dept Org, Investigation process and analysis”.
In the above post, outsiders are invited to make a comment on the status of SIA as the world’s best airline.
Okay, but I might start with another area of SIA’s operations that I have first hand knowledge and experience of, about which specifically relates to the prospect of SIA being the world’s best airline simply because it is in the realm of customer service.
Readers with inside knowledge, pardon the pun 107, might like to determine whether my siblings’ experience that I will refer to indicates confirmation of a corporate dilemma at SIA, one of lying, and that the Flt Ops side of things is not alone in being slated as fertile ground for another aviation disaster.
On on.
A family member visited us recently, coming from an airport where snow threatened an on-time SIA departure. When the decision came from the airport authorities to close the airport due to snow, the passengers were stranded. The SIA counter staff insisted that the roads to the hotels were also closed, rendering SIA’s attempts at meeting their IATA obligations to accommodate the stranded passengers impossible.
The First Class passengers, however, were to travel on a different road.
Yet as luck would have it, they were seen to be exiting stage left by some of the monetarily challenged SIA passengers. Thus, the demands went out by a few of the better informed peasantry stock that they too be afforded access to the open roads, and a nice warm bed in a hotel.
Oh, and would the SIA staff stop their bare faced lying.
Lots of huffing and puffing saw the main SIA representative storm off in a flap, unable to hide from the lie.
With a 15-hour wait until the storm would pass, boxes of sleeping bags mysteriously arrived at the SIA counter. When the serfs inquired if the sleeping bags were going to be handed out, the SIA staff reverted to mantra like utterances that that was not what the bags were for, but if passengers of SIA would like to use them they were welcome. Passengers of other airlines were not invited along to the little pyjama party.
This is unembellished truth.
Therefore, regarding the prospect of SIA being the world’s best airline, I am of the opinion that anything is possible in this world but there is this annoying little concept of probability involved, which basically stops 50 virgins knocking on my door just as I wake up every morning.
These days, it would seem that the probability of SIA being the world’s best airline is lower than the probability of the 50 virgins at my door, and I posit that few it in any other way.
So what is it about SQ?
I always THOUGHT it was the world’s best airline, truly, just like I always thought it was a safe operation in the pointy end of the plane and that the initial agitators to the SIA name were just that, agitators.
Having lobbed in to Singapore recently on a turn-around, I rang an erstwhile colleague of 9 years vintage, to see how he was getting on at SIA.
He was almost in tears of frustration on the phone.
Not good, especially from a pilot.
If an airline treats customers like SIA did to our visitor and her equally financially constrained economy class passengers, that airline is in need of serious help.
If the airline hides the assertion that the SIA cabin staff made it to the airport boundary fence at Taipei before the passengers following the crash, they are in denial.
If an airline promised their (pilot and other) employees monetary entitlements and is not paying those entitlements, they are cheats.
If, if, if…
As an outsider, it is hard to glean a true composite of the internal dynamics of a company and Pprune, the odd phone call and one flight’s dilemma does not make for a strong case for exactly what the hell it is with SIA.
Most often, when such a difficult exposition is required, teams of people from a management-consulting firm like KPMG Peat Marwick, Deloitte Touche Tomatsu or any number of similarly world class firms will come in, ask the hard questions and present the considered opinion of seasoned professionals who spend a career investigating the world’s industries, not just aviation, with respect to just where problems lie and how to fix them.
For me though, SIA just isn't the world’s best airline, but it clearly was, once.
If I was a Singaporean, I’d be pretty damned angry at the people who have been at the helm whilst this sea change has taken place.
Meantime, SIA poses a problem.
Just ask the pilots.

[Tosh26]

Hung Like A Horse

I think it was titan who started a thread in January 2001 on the subject of the above flight - SQ11. Maybe you would like to check out the following: SQ11-How did they ever get that service award? (http://www.pprune.org/ubb/NonCGI/Forum51/HTML/000146.html)

Tosh, it was actually Firewall who started the post earlier. I transferred it down to Passengers and SLF as it didn't fit the remit of Rumour or News, and your earlier link was to Titans attempted resurrection of the thread on R and N, which I shut down and commented on with the reasons for closure.

I've updated your posted link to the original thread, which is stil alive and well, if untended and in need of watering down in Passengers and SLF. Hope you don't mind; I feel it has more relevance if a link leads to something people can comment on other than a thread which is closed. Here's Titans closed one SQ11-The lies continue (http://www.pprune.org/ubb/NonCGI/Forum1/HTML/012369.html) as well just to remove any charge of censorship... it is identical to the above.

Sick Squid
Rumours and News moderator



[This message has been edited by Sick Squid (edited 10 April 2001).]

[Hung Like A Horse]

Thanks, I had a look.
It happened, my sister was to be on the plane, ending up on another the next day.
They are not the world's best airline.
They're dreamin'.

[Tosh26]

Sick Squid

Not a problem. I must have missed Firewall’s thread when I was trawling for details of an event I knew had been posted some time ago. I’ll look more closely in future.
Regards to all at The Towers.


[This message has been edited by Tosh26 (edited 11 April 2001).]

[Murrelet]

CBS' 48 hours will soon be showing a report on SIA 006, including footage and interviews. Probable air date is 26 April.

[VH DSJ]

So what has become of the SQ 006 pilots? Are they back on the line?

[Wiley]

Like 'Hung like a Horse', I've always suspected that 'Titan' and 'Gladiator' might have had a not too hidden agenda in their pursuit of SQ. However, I was in Singapore last week, and had arranged to see a friend who works for SQ. He couldn't make it - he'd been called out for a flight. But he wasn't complaining, because he'd worked out that the only way he could get any leave was to fly until he 'max-ed out' on his flying hours for the year - which he was very close to achieving.

It will be interesting to see how and where SQ finds crews for the 14 new 777's soon to join their fleet. You can't help but wonder if something approaching the following scenario hasn't been touted around a Singapore boardroom. (If it has, it might explain the seemingly suicidal tendencies among AN senior managers in their mishandling of their 767 fleet maintenance.)

Let's see... SQ own a big slice of ANZ, who own AN, and SQ own a big slice of Virgin Atlantic, who are run by the same man who owns Virgin Blue, whose staff, (including pilots), come far, far more cheaply than the very well paid AN pilots and the very long term AN engineering and ground staff. How do we (literally) kill two birds with one stone? - ie, get cheap 777 BONDED pilots for our Australia basings AND get to run a domestic operation within Australia far, far more cheaply than we currently are using Ansett?

Just because you're paranoid doesn't mean the b*****'s aren't after you.

[gaunty]

Wiley old bird
Interesting scenario, but IMHO more like wishful thinking on SQ part. I don't believe they would or could get a domestic AOC in their own right, perhaps Virgin Blue would be the Trojan horse though.
Ozzers and our Government might be silly but they're not stupid.
If you saw Lee talking about (patronsing) OZ on ABCs 100 years the other night we don't need or want it.

Now about that Singtel van parked outside :rolleyes:

[Spad]

Gaunty, I think the hypothetical domestic operation Wiley was referring to was Virgin Blue rather than a 'new' SQ Australian domestic airline. But on the other hand, with the curremt Oz/Kiwi air agreement, it could just as easily be AirNZ, could't it?

Interesting to see, if that second scenario were to come to pass, whether the 'suits' in AirNZ have given any thought to any possible backlash by the Oz travelling public to flying with a Kiwi (or 'forrin') airline. Nah, on past performance, knock ten bucks off the price QF and Virgin are offering and they'd flock to fly with Air Botswegia or Aeroflot.

I tend to agree with Wiley. I think there's a more than even chance the SQ/AirNZ 'suits' are trying to divest themselves of their high cost employees within Ansett by gutting the airline and starting "anew". If it's true, it'll be interesting to see if the Libs let them get away with it with an election looming.

[gaunty]

Spad

You're probably right, although the Oz public might be happy?? to let Vegemite and other suchlike Oz icons go to overseas ownership, there is deep in our psyche a serous suspicion about our transport systems.

We were after all transported here, and the depth of isolation in the local geography of our country and its isolation from the rest of the world is deeply embedded. The recent global conflicts and the threats therefrom ares still in living memory. Transport is like no other country our very lifeblood, it will not be sold easily.

The amount of heat in the current aviation arguments is a pretty good indication.

Virgin Blue yes, we have a cultural affinity there, but SQ, Air NZ nup won't play.
Neither will any organisational suits caught playing funny buggers with Ansett.

All safety issues aside, Ansett can only survive as Ansett. A Claytons version will not. Especially when we have 3 home grown alternatives.

I've said it before Ozmates love the underdog but are equally adept at covering their bets.

[Anotherpost75]

I read Insider107’s piece on the SIA approach to ETOPS for their 777 fleet and it prompted me to root around in my archives that go back a number of years to when I first started ETOPS flying. I reproduce extracts from the following ICAO Information Leaflet, which, whilst not having the compliance weight of legislation, under ICAO rules, requires a non-complying carrier to inform ICAO, the relevant Regulatory Authority plus it’s code share partners of such non-compliance.

Information Leaflet No. 20 (International Civil Aviation Organisation)
Temporary Guidance Material for Extended Range Operation with
Two-Engine Aeroplanes ETOPS Certification and Operation

1 July 1995 (revised)

j. Additional Criteria for Operations above 120 minutes and up to
180 minutes

Each operator requesting Approval to conduct extended range
operations beyond 120 minutes should have approximately 12 consecutive
months of operational inservice experience with the specified ETOPS
configured airframe/engine combination in the conduct of 120 minute
operations. The amount of service experience may be increased or
decreased after a review of operator's experience taking into account
all factors including the number of sectors. Prior to approval, the
operator's capability to conduct operations and implement effective
ETOPS programmes in accordance with the criteria detailed in paragraph
10 will be examined. The record of the operator in conducting its 120
minute programme will be considered when granting Approvals beyond 120
minutes diversion time. These operators should also demonstrate the
additional capabilities discussed in this paragraph. Approval will be
given on a case-by-case basis for an increase to their area of
operation beyond 120 minutes. The area of operation will be defined by
a maximum diversion time of 180 minutes to an adequate airport at
approved one-engine inoperative cruise speed. The release limitation
will be a maximum diversion time of 180 minutes to a suitable airport
at the approved one-engine-inoperative speed.

11 Continuing Surveillance

The fleet average In Flight Shut Down (IFSD) rate for the
specified airframe/engine combination will continue to be monitored in
accordance with Appendices 1 and 4. As with all other operations, the
appropriate Authority should also monitor all aspects of the extended
range operation that it has authorised to ensure that the levels of
reliability achieved in extended range operations remain at the
necessary levels as provided in Appendix 1, and that the operation
continues to be conducted safely. In the event that an acceptable
level of reliability is not maintained, if significant adverse trends
exist, or if significant deficiencies are detected in the type design
or the conduct of the ETOPS operation, then the appropriate Authority
should initiate a special evaluation, impose operational restrictions,
if necessary, and stipulate corrective action for the operator to
adopt in order to resolve the problems in a timely manner. The
appropriate Authority should alert the Certification Authority when a
special evaluation is initiated (and provide for their participation).

Appendix 1 - Propulsion System Reliability Assessment

ASSESSMENT PROCESS

To establish whether a particular airframe/engine combination has
satisfied the propulsion systems reliability requirements for extended
range operation, an assessment will be made by the Authority using all
pertinent propulsion system data. To accomplish the assessment the
Authority will need world fleet data, and data from various sources
(the operator, the engine manufacturer and the aeroplane manufacturer)
which should be extensive enough and of sufficient maturity to enable
the Authority to assess with a high level of confidence using
engineering and operational judgement and standard statistical methods
where appropriate that the risk of total power loss from independent
causes is sufficiently low. The Authority will state whether or not
the current propulsion system reliability of a particular
airframe/engine combination satisfies the relevant criteria. Included
in the statement, if the operation is approved, will be the engine
build standard, propulsion system configuration, operating condition
and limitations required to qualify the propulsion system as suitable
for extended range operation.

If an approved engine CMP is maintained by the responsible engine
Authority and is duly referenced on the engine Type Certificate Data
Sheet then this shall be made available to the Authority conducting
the aeroplane propulsion system reliability assessment. Such a CMP
shall be produced taking into account all the requirements of
paragraphs 8 and 9 and should be incorporated or referenced in the
aeroplane CMP.

a. Service Experience

When considering the acceptability of a propulsion system for
extended range operation, maturity should be assessed not only in term
of total fleet hours and fleet leader time over a calendar time, but
also on the extent to which test data and design experience can be
used as an alternative.

There are two extremes in the ETOPS process with respect to
maturity; one is the demonstration of a stable reliability by the
accumulation of service experience and the other is by an agreed
design and test program between the manufacturers and authorities. The
extent to which a propulsion system is a derivative of previous
ETOPS-rated systems is also a factor of the level of maturity.

There is justification for the view that modern propulsion systems
achieve a stable reliability level by 100,000 hours for new type and
50,000 hours for derivatives. 3000 to 4000 hours is considered to be
the necessary time in service for a specific unit to indicate problem
areas.

Normally, the service experience will be:

(1) For new propulsion systems: 100,000 hours and 12 months
service. Where experience on another aeroplane is applicable, a
significant portion of the 100,000 hours should normally be obtained
on the candidate aeroplane.

(2) For derivative propulsion systems: 50,000 hours and 12 months
service. These values may vary according to the degree of commonality.
To this end in determining the derivative status of a propulsion
system, consideration should be given to technical criteria referring
to the commonality with previous ETOPS-rated engines. Prime areas of
concern include: Etc, etc…….

It seems that with the introduction of the brand new 777ER with the new engine derivative described, SIA is not in compliance with the above.

Doubtless SIA will therefore be informing all interested parties of their non-compliance.

Sorry for the length of this lot!!!

[Gladiator]

Anotherpost75,

Please provide in detail specific area where SIA is in breach of ICAO minimum safety standards in regards to ETOPS operations.

I will forward the material to the person in charge at ICAO. After the 3-pilot crew saga, the guys at ICAO will listen.

SIA/CAAS will bend any regulation for more profit. It is up to us to act as watchdogs, the life you save may be your own family.

SIA can run but can't hide.

[thegypsy]

Using Learmonth as alternate for Perth with inadequate fuel to hold until someone gets out of bed and switch everything on!!! This has now been corrected but not without a lot of Voyage reports. Basically SIA do not understand ETOPS!!

[Anotherpost75]

Gladiator

Sure - I'll get some more information when I next meet my SQ buddies

[In the slot]

Hey Gladiator
Got any engineering documents from Alskan which ICAO and the FAA might be interested in, not to mention the relatives of the unfortunate passengers.
Fly safe to you all, wherever you may be.

[SKYDRIFTER]

IN THE SLOT -

Following Ak-261, the FAA has arranged for Alaska to do their own certification, etc. (But you're not supposed to know that.)

Flying is disproportionately safe. After all these years, something is finally being done about that. It may not be called progress, but it's damn sure profitable.

[Gladiator]

In the slot,

It is Alaska Airlines, not Alaskan.

ICAO is not in charge of Alaska Airlines, FAA is. With all it's shortcomings, they do a better job than CAAS's oversight of SIA.

I will follow up the ETOPS issue with ICAO, FAA, and NTSB.

The life I save may be you wife and kids.

[Insider107]

Disquiet continues amongst SQ 777 pilots against a backdrop of Company efforts to secure 180-minute ETOPS approval from Civil Aviation Authority Singapore (CAAS), or at least, retain its present fraudulent 120-minute approval. Word leaking from CAAS, however, is that SQ will not get 180 approval in the foreseeable future and that one more airborne Trent failure/shutdown will see withdrawal of 120 approval – seems a realization of overriding and fundamental responsibility is at last taking over in the Authority.

The policy of “discouraging needless in-flight shutdowns”, therefore continues with a vengeance and this same policy may be contributing to engine damage throughout the 777 fleet. A curiously unpublicized but significant event took place earlier in the year, prior to a 777 departure from SEL, when, during taxi out, the EICAS warned of a No2 Engine Vibration. This engine was shut down but during taxi return to the ramp No1 engine then lost significant power when higher than normal thrust was selected during the heavy weight single engine taxi. Subsequent boroscope examination of No2 engine revealed extensive internal mechanical damage, requiring engine removal and return to RR. No1 engine was diagnosed as sustaining a transient FADEC fault!

How many times in the past had the No2 engine been brought back to in-flight idle, rather than been “unnecessarily” shut down and how much cumulative damage did this “policy” contribute? I guess we will never know as the above (and many similar events) will never appear in the SQ Safety Digest – the pages being filled with the much more interesting and important events relating to other carriers!

Further, neither of these concurrent engine malfunctions entered the ETOPS statistics, as they were ground events! Perhaps it would be preferable from a statistical point of view that this sequence of events took place when just airborne? The mind boggles at the potential of this double engine malfunction situation!

One of the other contributors to this thread recently kindly produced extracts from the ICAO ETOPS Information Leaflet (IL) of 1996 to illustrate a point that he/she was making at the time. I seem to remember that there is a section of this IL dealing with the statistical evaluation of engine reliability for determining ETOPS approval and that it determines such reliability as better than double engine failure every 10-8 hours. Can anyone who has the IL confirm this?

The above double engine event, if it had taken place in an airborne situation, would seem to represent a statistical failure performance worse than the 10-8 deemed acceptable by ICAO and would seem a very shaky basis on which to proceed with an extension programme beyond the present 120 ETOPS approval, rather than the pursuit of a joint programme with RR, keeping the pilots fully informed, to eradicate the manifest current crop of engine deficiencies.

As usual, SQ tries to hide everything from the very pilots who could possibly assist in its efforts to overcome the present difficulties and who certainly have to deal with the situations that arise on the day. Rather it relies on diktat and subterfuge to force pilot compliance and regulatory approval, which, if eventually granted, will, under present circumstances, explode in SQ’s face as another SQ006 fiasco.

Finally, the Confucian regime running SQ might like to consider its own programme of accelerated evolution, when it might finally emerge, blinking into the sunlight of modern corporate management philosophy and methodology, to quickly realize that all the airline’s pilots consider the 777 a very fine airplane, the RR Trent an equally fine engine of choice and the overall acquisition programme an admirable example of commercial savvy and negotiating effectiveness. Treat us with respect, communicate with us, take us into your confidence and we will all do our damdest to make things work out for you!

[SKYDRIFTER]

INSIDER -

Great account. Nice to know how the scams work.

[crl]

Insider 107,
Excellent posting AGAIN, you had concluded well in your last paragraph. Really wish some of those 4th floor XOXXHXXDs get to read your comments....
Cheers,
CRL

[Whiskery]

What makes you think they don't?

[crl]

They are still behaving like BXXXHXXD I guess? What makes you think they do? Am I responding to ONE now?

[Anotherpost75]

My buddies tell me that the rumour in Singapore now is that the last two SIA A340's that were due to fly from the Toulouse production line straight to Boeing, Seattle, as part of the SIA/Boeing deal to remarket the A340 fleet and replace with B777's are now being delivered to Singapore for revenue service.

Is this because SIA is having big trouble with ETOPS approval for the 777 or has the deal with Boeing fallen through? Would either explanation mean that the A340's will be staying?

Anyone know what's happening?

[TE RANGI]

Can anyone confirm whether the crew members of SQ006 have been reinstated to flying status?
Are they facing any legal actions?

[Goofyfoot]

Apparently nothing has been heard of the crew,from the company or ALPAS.Very disturbing!

[EasyGo-Lucky?]

This year 7 A340s will be withdrawn from the SIA fleet. The only official line heard regarding retaining any of the aircraft is related to the late delivery now of the A340-500 in 2002. It may affect the numbers removed next year but the 7 this year have already been placed by Boeing, with 3 going to Cathay for their new HKG-JFK service.

I'm not sure where the B777 info is originating from but certainly not from the Fleet Management. At the recent fleet meeting ETOPS was now not seen as a problem, the aircrafts down time, maintenance costs and reliability are the best amongst the SIA fleets. Worldwide, on the B777, the RR engine has the lowest IFSD whilst GE has the highest. SIA certainly are giving the impression that they are extremely pleased with the aircraft. I actually do operate the type for SIA and you hear of very few problems, except usually from those of other fleets who are apparently more in the know.

[This message has been edited by EasyGo-Lucky? (edited 10 May 2001).]

[In the slot]

Hello gents.
Any TRUE info. on the needless in-flight shutdown of an engine with a perceived fire?
Was there an EICAS warning, engine parameters out of tolerence, illumination of the fuel switch or engine fire switches??
It's almost too embarrassing to ask!
Did the observing crew all look through the same window? If so, surely by looking through as many windows as possible and hence from as many reflective angles as possible, the "fire illusion" would not remain consistant enough to fool the onlookers? I assume there were no cockpit warnings, nor change of flight characteristics. Is there a checklist for COMMON SENSE in the QRH?
If this were to happen on the 777, kiss ETOPS goodbye!

[valhalla]

Insider 107

Be very careful how much information you post as peolple are alredy guessing to your identity. :)
I would hate for another honest and reliable person to be axed for speaking the truth and warning others of a bull$hit company practice. ;)

------------------
Keep Safe

[addinfurnightem]

In The Slot - first, not all engine fires or fires in the engine area will be detected by the fire wire, MOST will but not all, Sod's Law.
Second, would you continue with half the pax thinking you had ignored what they saw as valid warnings of a fire? "Don't worry Ladies and Gents, it only LOOKS like a fire"!
In the aftermath of SQ6 prudence was surely the order of the day?

[twitchy]

4 day ago there was a 777 AOG in Bali, required an engine change. I hope this was not another IFSD, another nail in the coffin of 180 mn. ETOPS. Good luck guys.

[star gold]

That A/C in Bali was SQ235 BNE-SIN 09May01, a 772. Was IFSD and divert to Bali.

[gaunty]

So it's only a matter of time before an even bigger wake up call.

Except the next one will be the coup de grace.

Boeing and Rolls need to be right on top of this, lest they too pay a very high price.

I sincerely hope not.

[twitchy]

Gaunty,
You bet, worst seems to be coming true.
Regards

[0.88M]

Wonder what would LG think once the 777 loses it's 120 ETOPS? The 340's will definitly be retained and futher extend it's service. No end to the 777 IFSD.

[burnoff]

SQ235 is actually SIN-BNE.
Heard that the aircraft spent 3 sunny days in Bali with an engine change.
The much hoped-for 180 minutes ETOPS can be kissed goodbye now.
Holding on to the current 120 minutes ETOPS would be a damn good saving grace.
Crossing the Pacific on B777 with 120 minutes ETOPS this winter would be very interesting with the constant visit of Mr. blizzard at Shemya, Cold Bay etc.

[7times7]

Any one knows what is the allowed IFSD rate for 120 or 180 min ETOPs?

[star gold]

Burnoff, you're correct about the flight number. The flight was SQ236 BNE-SIN.

[burnoff]

stargold,
From what I know, it is SQ235 SIN-BNE.
Another aircraft was then dispatched to Bali to pick up the pax and onward to BNE.
Then again, SIA never dissiminate any info of this nature to its employees, leaving us to shoot in the dark.

[highcirrus]

7times7

Is this the ICAO IL stuff you are referring to?

Quote:

Appendix 1.

Propulsion systems approved for extended range operation must be
sufficiently reliable to assure that defined safety targets are
achieved.

A review of information for modern fixed wing jet powered aircraft
over a recent six year period shows that the rate of fatal accidents
for all causes is in the order of 0.3 x 10-6 per flying hour. The
reliability of aeroplane types approved for extended range operation
should be such that they achieve at least as good an accident record
as equivalent technology equipment. The overall target of 0.3 x 10-8
per flying hour has therefore been chosen as the all-causes safety
target.

When considering safety targets, an accepted practice is to
allocate appropriate portions of the total to the various potential
contributing factors. By applying this practice to the overall target
of 0.3 x 10-6 per flying hour, in the proportions previously
considered appropriate, the probability of a catastrophic accident due
to complete loss of thrust from independent causes must be no worse
than 0.3 x 10-8 per flying hour.

Propulsion system related accidents may result from independent
cause events but, based on historical evidence, result primarily from
events such as uncontained engine failure events, common cause events,
engine failure plus crew error events, human error related events and
other. The majority of these factors are not specifically exclusive to
ETOPS.

Using an expression developed by ICAO, (ref AN-WP/5593 dated
15/2/84) for the calculation of engine in-flight shutdown rate,
together with the above safety objective and accident statistics, a
relationship between target engine in-flight shutdown rate for all
independent causes and maximum diversion time has been derived. This
is shown in Figure 1.

In order that type design approval may be granted for extended
operation range, it will be necessary to satisfy the Authority that
after application of the corrective actions identified during the
engineering assessment (see Appendix 1, paragraph 1d.), the target
engine in-flight shutdown rates will be achieved. This will provide
assurance that the probability objective for loss of all thrust due to
independent causes will be met.

Unquote.

Seems to me that the last paragraph is pretty pertinent

[7times7]

Thanks cirrus.

Anyone with any info on the overall IFSD rate of all Trent 800 B777 operators combined. For that matter PW and GE.

.88, do you have any figures for SQ B777 IFSD rate? I sense you are an interested party for the SQ B777 to lose ETOPS. :)

[Tosh26]

Have readers noticed any reports in the Straits Times, of B777 flight SQ 235, SIN-BNE, which recently diverted to DPS following an in-flight shut down? If so, perhaps they could direct me to the appropriate edition.

I normally do not have any great difficulty in spotting interesting and relevant pieces in the ST, such as comprised the three-day press feeding frenzy which followed the Egypt Air B777 tail pipe fire at Changi, approximately eighteen months ago.


[This message has been edited by Tosh26 (edited 16 May 2001).]

[star gold]

Burnoff / Tosh26

It wasn't SQ235 SIN-BNE, I was on that flight and we definitely didn't go to Bali. The airside arrivals monitor in Changi terminal 2 was showing SQ236 due 0030 on the 10th, schedule time is 2050 ish. (not much good for all those flight connections). I had been planning to go to SIN on that flight, but had travelled up earlier.

I realise this is off topic a bit but Qantas in BNE damaged 9VSRG the newest 772 the other night when they removed the cleaner's steps without closing the door (2L) first.

[Tosh26]

star gold

I’m just a little confused here. Perhaps you can clear things up?

You say on 13 May 2001 “That A/C in Bali was SQ235 BNE-SIN 09May01, a 772. Was IFSD and divert to Bali.”
Then on 14 May 2001 you say “Burnoff, you're correct about the flight number. The flight was SQ236 BNE-SIN.”
On 16 May 2001 you finally say “It wasn't SQ235 SIN-BNE, I was on that flight and we definitely didn't go to Bali.”

If you were on flight SQ235 and that wasn’t the flight in question on 9 May 2001, why, in your post of 13 May 2001, did you say it was this flight number?

Can I confirm that you know the event definitely took place and on which sector and that we merely have a misunderstanding over flight numbers?

regards

[star gold]

Tosh26,

Sorry for the confusion, I got the flight number incorrect in my first post. I should have said SQ236 BNE-SIN. When I said to Burnoff he was correct, that was in the sense that I had made an error with the flight number.

I wasn't on the diverted flight, but the diversion and the nature of it were confirmed to me by 2 separate sources afterwards.

[0.88M]

Latest from 4th Floor : there is enough IFSD to rattle ol'Bey. 120 ETOPS is definitly in jeapordy. CP777 isn't too concerned since he'll be out of job soon. I'm not too keen on 777 losing certification as it is a great bird to fly. comments?

[thegypsy]

0.88M Just restrict your nice bird to short haul sectors theres a good chap and don't clog up our long haul routes in your slow nice bird.

[0.88M]

Would love to "duke"
But don't think ol'Bey would too happy though. As for me i'm confortable with .88m

[Insider107]

Following the SQ236 BNE-SIN IFSD event – the latest in a long running series – a number of very hard questions are now being asked both by the SQ Board arcana and the upper reaches of Civil Aviation Authority Singapore (CAAS). A distillation of this intense clamour generates convergence by both sides on one key interrogative – can the shortly to be delivered Trent 892 engined B777ER be released to service on the intended ETOPS routes, AMS-ORD on 1 August 2001 and ICN-YVR on 1 September 2001?

On the SQ side, greatest feeling is stoked by thought of the potential loss of face involved with what the Board and Flt Ops Establishment will see as a serious climb down from a trumpeted first of a brand new route (AMS-ORD) operated by a brand new aeroplane plus a tacit acknowledgement that their blithely confident Pacific ETOPS aspirations may be somewhat premature. The standard SQ witch hunt for the driving force B777 acquisition culprit will now be discretely taking place behind closed doors and immolation may be identified by regretful acceptance of an early retirement request. The Great Freddie seems to be the most likely candidate – the two recently elevated SEVPT’s being too senior and too nimble of foot to find themselves without a chair when the music stops.

On the CAAS side, the hand in glove ”special relationship” with SQ is now under serious strain following loss of all hope of 180 minute approval and the evaporation of a statistical case for continued 120 minute approval. Intense pressure will be felt at CAAS from the SQ CEO/SEVPT’s and polite ’phone calls from the highest levels of government will be fielded, the import of which will be the ”continued confidence in the Authority’s ability to do what is right for the Nation” – significantly not ”what is right for the innocent travelling public”.

All, of course, taking place under a Singapore press blackout, neatly brought to attention on this thread by Tosh26’s adroit posting of 16 May 2001.

Both vessels have all hands on deck braced for the very next 777 IFSD, shortly to take place.

Whilst not using this thread to extol the virtues of modern, western style corporate governance – I defer this task to SM Lee, who regularly uses the World Economic Forum at Davos, Switzerland, for this purpose – I would suggest that perhaps SQ, CAAS and the Singapore Government may serve themselves better by not keeping silent and not taking the strain of the situation on themselves but, rather, generating publicity and holding the collective feet of Boeing/RR firmly to the fire and forcing a solution from both manufacturers – in the finest tradition of corporate North America. Not only will they be doing the right thing to ensure the highest safety standards/practices of the airline that the world travelling public has a right to expect but they will be catalytic in expediting the full development of the 777/Trent 892 combination to its true worth.

Finally, whilst intimating philosophy change, it is instructive to remember the Lufthansa approach to ETOPS, as instigated by the airline’s Supervisory Board of the time and in marked contrast to the lemming like and ubiquitous airline unquestioning acceptance by most airlines of the exhortations of juvenile marketing gurus and seductive bottom line promises of wizened airline cost accountants – both groups proudly confessing ignorance/disinterest in flight ops matters as irrelevant to the scheme of things – abetted by the Boeing ETOPS commercial saviour siren songs of the 757/767 marques and probably the 777 production run.

Lufthansa’s exhaustive twelve month study demonstrated a less than convincing cost benefit case for twin operation and an overwhelming safety, operational reliability, marketing and customer confidence case for long-haul, over-water operations using 3/4 engine aircraft. In the event, the airline chose the A340 for the ”long thin” routes, in preference to the Boeing twin alternatives. Is there perhaps an important underlying message here?


[This message has been edited by Insider107 (edited 26 May 2001).]

[John Barnes]

"Finally, whilst intimating philosophy change, it is instructive to remember the Lufthansa approach to ETOPS, as instigated by the airline’s Supervisory Board of the time and in marked contrast the lemming like and ubiquitous airline unquestioning acceptance of the exhortations of juvenile marketing gurus and seductive bottom line promises of wizened airline cost accountants – both groups proudly confessing ignorance/disinterest in flight ops matters as irrelevant to the scheme of things – abetted by the Boeing ETOPS commercial saviour siren songs of the 757/767 marques and probably the 777 production run."

Wholy Magholy Insider I lost you there could you please repeat this in English, we simple drivers do understand, because I don't want to miss a thing of your always very good write ups! ( no Joke!!!!)
Thanks for the trouble!

[titan]

John Barnes:

"Wholy Magholy"

..... I lost you there could you please repeat this in English, we simple drivers do understand, because I don't want to miss a thing of your always very good write ups! ( Joke!!!!)
Thanks for the trouble!

Titan

[gaunty]

I think what Insider was saying was that Lufthansa listened to but did not accept the Boeing 777 sales pitch out of hand, did the home work, decided the product was not yet sufficiently mature and went for the A340.

Insider is absolutely correct in the proposition that SQ, CAAS and the Singapore Govt are about to be tested on whether they are prepared to bet the company and their Nations reputation in the name of hubris or act like the responsible people they would have us believe they are.

[John Barnes]

So far Insider has been correct on all his very well written exposes. I suggest, and again this is no joke, that Insider looks very seriously to the present management possibilities offered in SQ. It is exactly his type of person with his experience and shown clear insight in the present problems in SQ that is needed to get us on track to a brighter future. So far the military option has made no real progress and you wonder what is going to happen later this year with all the changes on the fourth floor. Since the expats represent a large percentage of the working force they need a representation on management level. As I said before it should be someone with Insiders capabilities. ( And I promise to buy a Webster!)

[7times7]

Insider,
you mentioned a series of shutdown of the SQ B777. How many do you know at hand since the start of operations in 1997? Is the IFSD rate worst off than other operators, say Emirates, Cathay, MAS, Thai or BA. Some of them had been operating TransAtlantic for quite some time with the B777. Any different with SQ? Just curious. I know the PW B777 had been operationg TransPacific. Anyone knows of Trent B777 operating transpacific.

Of course according to RR, the IFSD rate of SQ B777 is identical to the worldwide fleet and well within the etops criteria.

Insider, do you know the SQ B777 IFSD, if it is within certification limits even after the recent shutdown. 5 shutdowns in &gt;4 years is it outside the limit? Maybe I should say over the hours flown.

I sense quite a hangup and interest on SQ getting their 180 etops. How's the other operators doing? Just curious. What do you guys feel about China Southern 180 etops flight to USA. How can SQ learn from them, for that matter UA, AA etc.?

Following news from Bloomberg.

Singapore Air May Face Range Restrictions for Boeing 777 Fleet

By Andrzej Jeziorski

Singapore, May 23 (Bloomberg) -- Singapore Airlines Ltd. may face
difficulties getting long-range certification for its Boeing Co. 777 fleet
after an in-flight shutdown of one of the two Rolls- Royce Plc engines
earlier this month.

The jetliner en route to Brisbane, Australia, on May 9 was forced to land
in Bali, Indonesia, on a single engine when its other Trent 800 engine had
to be turned off after overheating and losing oil pressure, said airline
spokesman Innes Willox.

The incident was the fifth shutdown of a Trent engine during a Singapore
Airlines 777 flight since the Boeing aircraft entered service with the
carrier in May 1997, said Rolls-Royce, the second- largest jet engine
maker, adding that three of these were "engine- related.''

Singapore Airlines is in the process of replacing its Airbus Industrie
A340s with the twin-engine 777s for use mostly on long- range routes. The
Civil Aviation Authority of Singapore is now considering an upgrade of the
777's certification to allow the carrier to fly the jet on transpacific
routes that go further from emergency diversion airports than now
permitted.

"We are looking at many factors, including training, engineering support
and operational procedures,'' said Albert Tjoeng, the public relations
manager for the island's industry regulator, declining to comment
specifically on whether the shutdowns will affect the certification for
longer-range flights.

SIA Engineering, along with partners Rolls-Royce and Hong Kong Aero Engine
Services Ltd., is opening a new Trent engine maintenance facility in
Singapore today. The facility is to be operated by a venture called
Singapore Aero Engine Services Ltd.

Questions Raised

Boeing and Airbus, the largest jetmakers, differ over the design of their
long-range jets, with Boeing promoting the cost and maintenance benefits of
the 777s two-engine design, while Airbus stresses the additional safety of
its four-engine A340.

The shutdown-rate "would certainly be enough to raise some questions in the
(Singapore) aviation authority's mind,'' said Ian Thomas, senior consultant
at the Centre for Asia-Pacific Aviation in Australia.

Rolls-Royce said Singapore Airline's engine performance is comparable with
operations elsewhere.

The in-flight shutdown rate of the carrier's 777 fleet in the seven months
to the end of April this year, shortly before the Bali incident, was
"identical to the worldwide fleet,'' said James Acheson-Gray, director at
Grayling Group, which represents Rolls-Royce, in an e-mailed comment.

The engine meets the extended range criteria with "significant margins,''
Acheson-Gray said.

The incidents are "nothing to be alarmed about,'' said William Tan, chief
executive of SIA Engineering Co., which handles its parent airline's
maintenance. The shutdowns won't affect the long-range certification for
the aircraft, he said.

Backup Airports

The 777 aircraft are now allowed to fly no further than 120 minutes
single-engine flight time from backup airports, while Singapore Airlines is
pushing to increase this to 180 minutes, said the aviation regulator's
Tjoeng. That would allow the jets to be used on certain transpacific
routes, now operated with four- engine A340s and Boeing 747s.

In 1999, Singapore Airlines agreed that it would sell its entire fleet of
A340s to Boeing, and ordered 777-200s to replace them. The carrier's
remaining A340s are to be phased out of the fleet over the next three
years, as new 777s arrive, and are being marketed to potential buyers by
Boeing.


[This message has been edited by 7times7 (edited 23 May 2001).]

[mk1eyeball]

B777 18o mins to nearest alternate,
mid pacific turn back to japan, stronger jetstream than forecast/experienced outbound,
shotdown history of Trent.....gulp....rather you than me!!!!!