Accident investigation and PPRuNe (Discussion)

[vunzke]

I was just wondering.....suddenly it went very quiet regarding the MD 83 accident. No more comments ...no results from any investigation... :bored:
Has the investigation already ended and have any results been published about this accident regarding cause etc?... or is there a reason for this information stop...:confused:

apart from that HAPPY NEWYEAR FOR EVERYONE and keep posting!

[PBL]

vunzke,

there is no activity because the available public data has been exhausted.

ICAO conventions require a preliminary report in 30 days and the final report whenever it is ready. This rarely takes less than a year and rarely more than six years.

PBL

[vunzke]

PBL,

Thanks for the info, its just that preliminaries either and was wondering what the status was... was just wondering since usual these threads dont suddenly go quiet... on the other side...better to post confirmed info than the (often) "amateur specialist" opinions :E

Happy new year again

[PBL]

vunkze,

actually, in contrast to many of my colleagues, many professional pilots and at least one moderator, I think that some "amateurs" did some pretty impressive work in this thread with this accident. Like trying to figure out where it was when no one else was saying. (People who poo-poo such things have likely not been involved in an investigation. There is often a helluva task getting even the most basic details straight.)

I also anticipate that what we have concluded so far on this thread will turn out to be the truth. Other opinions may differ.

PBL

[vunzke]

PBL,

although not really the subject of this thread... I do (partly) agree with you. "help" is always OK, i just beleive we should refrain := from drawing "conclusions" before the people who are trained and appointed to do so do. No problem with suggestions and opinions :D.

its a bit like in the cockpit.... I ALWAYS support passengers giving me input about observations from the cabin... however i hold it my prerogative (in the cockpit) to draw the "conclusions" as to what action to take.

having sais that... its a different discussion i guess....

with respect:ok:

Vunzke

[PBL]

i just beleive we should refrain from drawing "conclusions" before the people who are trained and appointed to do so do

No, friend. People "trained and appointed" have political constraints and opinions just like anyone else. Most of them do a first rate, sometimes outstanding, job *within those constraints*. But satisfying those constraints often distorts what is proposed in their published report.

Many of us feel that the best objective results are obtained by publishing the data as early as possible, letting everyone who so wants have a go at analysis, and critique of others, and then focusing on those explanations that prevail. It's not perfect, and it is not efficient, but then many of those people are likely working pro bono with a view to other ends (such as tenure, or future private contracts) so nominal efficiency doesn't matter.

This point of view, by the way, extends much further than accident reports, into the assessment of any safety-critical system, and is held by many senior safety-critical system specialists besides myself.

The reason we hold it is what we know of actual accident investigations, as well as what we know of safety cases and such. You may be surprised by the number of senior accident investigators at major agencies who would welcome it too.

PBL

[chuks]

Perhaps it's just that persecution complex kicking in, but why is it air crashes, incidents and non-events that attract the armchair experts?

You never see this amount of speculation about auto accidents, for instance, do you? Some bus crashes, taking 50 grannies to their screaming doom and no one seems to want to try and guess if the driver was reading "The Beano" at the wheel or was subtly incapacitated or whatever. But it really does seem that many of you are absolutely fascinated by playing "Guess the Cause" within hours of each crash report so that some of the wildest theories get floated.

And now you are claiming that is wished-for and productive. Well, I never.....

I am sorry, but I really do believe the reason that crummy little bag of peanuts is so fiendishly hard to open is to give the SLF something to occupy their minds, rather than looking out the window to try and guess the reason for this or that motion, real or apparent, of their aerial conveyance.

If it were so useful to invite amateur speculation about the cause and circumstance of an air accident, why is there not a mechanism for that? Perhaps someone should get in touch with ICAO and offer to set up a panel of amateur experts to help in this way. Do not forget to involve the psychics, who can help in the searches.

[PBL]

chuks,

the obvious answer to your question is that road crashes are usually easy to explain, and commercial aviation accidents very much harder.

And if you have something against people discussing them in public, I suggest you avoid the discussions and go do something you find more entertaining.

PBL

[Mad (Flt) Scientist]

Chuks

Study the composition of the NTSB - that is the BOARD MEMBERS - and you'll find that ultimately, although they rely on specialists to make the investigation, the actual board members who have the final say are, in fact, "amateurs" - and often bring an outside perspective to the final report.

edit: took some finding...
Current Members of the Board are:
* Mark V. Rosenker, Chairman
* Robert L. Sumwalt , Vice Chairman
* Deborah A. P. Hersman, Member
* Kathryn O'Leary Higgins, Member
* Steven R. Chealander, Member

Links to their bios are here (http://www.ntsb.gov/abt_ntsb/member.htm)
None are "trained accident investigators" by any stretch of the imagination (two were pilots, but that's not the same thing, obviously)

As to "why is aviation picked on" - it isn't. Ask any, say, nuclear industry employee if he thinks they are immune to "armchair experts". Or the military in general. Or the police forces. Or ....

[PBL]

M(F)S,

it looks like a good argument but I am not at all sure.

At most times in the past, some NTSB board members had accident investigation experience of some sort. The latest composition could well be a political anomaly. Indeed I know people who are very unhappy with the current board composition as well as with some previous compositions.

The U.S. nuclear industry has a history of intervention by very senior scientists, such as the Lewis Report, which is one of the fundamental documents of system safety, even thirty years later. Also NASA space, with the Challenger report including exemplary contributions by a certain R. Feynman, who I understand wrote a set of intro physics textbooks which people like :)

It turns out that Professor Lewis is also very interested in aviation. Given his hard-won achievements with the nuclear industry, I wonder why he was not invited to convene a committee for Lewis Report II on aviation safety?

One possible answer, and I should like to emphasise I am engaging in political speculation here: because major public pronoucements on aviation safety in the U.S. is traditionally the domain of amateurs? Discuss.

PBL

[vunzke]

I tried to hold my breath but damn...i cant resist to reply... risking contradicting my previous statement that this thread was not intended for "this" discussion....
Many of us feel that the best objective results are obtained by publishing the data as early as possible, letting everyone who so wants have a go at analysis
Yet "most" of us feel that it is just unnecessary delaying the outcome and (sorry but i disagree strongly with you here PBL) the "efficiency" IS important because the sooner we know the outcome the sooner we can learn from it.
People "trained and appointed" have political constraints and opinions just like anyone else. Most of them do a first rate, sometimes outstanding, job *within those constraints*. But satisfying those constraints often distorts what is proposed in their published report
This is very strange for a pilot... in the cockpit we work with constarints aswell.... SOP's, OM's and QRH's... we operate the aircraft within these "constraints" because it is proven to be the safest way. yes we do consult our fellow crewmember in case of an emergency but i defenately wont make a PA announcement asking for "idea's" from my passengers before following the MFDU procedure. i will take observations from passengers serious yes... but within the "constraints" of my SOP's and OM's and the funny thing is.... if we wouldnt...and something would go wrong.... oh my:ugh:.... "pilot error":=, "..didnt follow SOP's":=, ..... insurance company happy...newspaper extatic... NEWS NEWS!!... and if my procedures change for whatever reason I sure feel a lot better if the reason behind this amendment is made based on the knowledge and findings of "professionals" rather than the general public.

[PBL]

vunkze,

understand your reticence, but if you're asking for evidence to persuade you of what I said, then I can provide it. First step is probably to visit our WWW site and look at some of the WBA examples. Next step is probably to meet and discuss at some convenient moment. And if after all of that you are still not convinced, well, then that is your privilege.

PBL

[vunzke]

Always ready for a beer ... i mean discussion :ok:and certainly willing to visit your WWW (which one?) to see what you have to say Im in Riga at the moment.... your gladly invited...

Other than that... still curious about the MD outcome:O

BTW...do you ever sleep?... :-)

[PBL]

stop infesting this tread

Is that your polite way of saying you don't agree with what I said?

So, what points can you make against the published evidence?

PBL

[PJ2]

PBL;

with the Challenger report including exemplary contributions by a certain R. Feynman, who I understand wrote a set of intro physics textbooks which people like :)

His, "What Do You Care What Other People Think? (http://books.google.ca/books?id=79ILhJ2bi9gC&dq=%22what+do+you+care+what+other+people+think%22&ots=ACLlycsxIf&sig=Rm9FmT1ZqBESgKJArYTAigHxZac&hl=en&prev=http://www.google.ca/search?hl=en&q=%22what+do+you+care+what+other+people+think%3F%22&sa=X&oi=print&ct=title&cad=one-book-with-thumbnail&pgis=1)" is very readable as is his "The Character of Physical Law (http://books.google.ca/books?id=k6MQrphL-NIC&q=character+of+physical+law&dq=character+of+physical+law&as_brr=0&pgis=1)".

In support of the "interested amateur" and to elaborate on a point being made, let us unpack the notions of "amateur" and "professional", notions of the expertocracy, which, though not the spawning ground, the Internet has certainly fed and created new cults of "plastic language". Ivan Illich espoused the domain of the amateur and is worth reading.

Such terms are of recent origin and come from the preceding notion of guilds where the need for specialist knowledge gave rise to "specialist education" which gave rise to exclusionary groups which "had" the royal jelly, so to speak, the intention of which was to leave out others despite what increasingly came to be known as "amateur" contributions. The two notions have more to do with social control and power than they do with describing how various people who are so described may (or may not) contribute. Conferring the title of "professional" infers, but does not confer knowledge while the notion of "amateur" provides a way for professionals (those of the guild), to marginalize "untrained" commentary as intrusive or otherwise plain wrong and thus illegitimate.

Regarding the "trained specialists pronouncing" argument, there is of course merit to the point but it is not, as is assumed by so many here and elsewhere, not, by virtue of titles and letters-after-names, an exclusionary process from which one pronounces, it is partly from education and training but it is also from the ability to think and see critically and to be keenly aware of the reversal of that popular phrase, which goes, "I'll see it when I believe it".

After all, intelligent inquiry can do some very good work as has been observed on the Turkish MD82 accident thread, to which this entire contribution addresses itself albeit in a round-about way.

I am in full support of releasing as much information as possible and this is from a flight safety specialist's point of view. There is a natural winnowing process in such an open discussion which is, after all, seeking truth not blame. Such a view is idealistic because, as has been correctly stated, appointments to positions of authority do have political aspects to them.

Notwithstanding Feynman's example of "amateur sleuthing", the best example of a non-specialist doing superb investigative aviation work is the Moshansky Commission and it's Report in the accident at Dryden, the recommendations of which were largely though not wholly adopted by Transport Canada, (which was heavily criticized in the Report, and to which strong criticisms have since been directed regarding SMS (which I have called "the de-regulation of flight safety"), by the same man). Here was a man who knew nothing about aviation yet had tremendous access to wide-ranging information, all with good results.

I wouldn't begin to compare the work done on PPRuNe with the Moshansky Report of course because the means, the goals and discussion levels are vastly different as one expects on a public forum with contributors of varying backgrounds but informed speculation along with the ecology of ideas can bring about interesting and correct conclusions even though they may be "unofficial".

[alf5071h]

Re amateur and formal investigation; there is both opportunity and need for two forms (or levels) of ‘investigation’.
Formal investigations are often constrained by considerations beyond the ICAO guidelines e.g politics, practicality, experience. Many of these reports fail to explain why an accident occurred, or insufficiently to provide specific safety solutions. This might be due to the lack of data or inability to understand the human activity from the available recordings. Any resultant safety activity in the latter case would be speculative. I believe that these limitations also apply to why-because (W-B) analysis.

An alternative (amateur) analysis is valuable when conducted by operators and individuals who ask ‘could this happen to me’. The process of thinking about an accident has safety value; it can be equated to a safety audit on a specialist subject. This is also somewhat speculative, but can occur more quickly while the event is fresh in peoples minds (greater training effectiveness), and can be more proactive in looking ahead to avoid a similar accident, as opposed to a formal report of how to avoid the accident we have just had.
The value of the audit can be greater where specific details of the situation and activities leading to the accident are known, hence the need to publish ‘public’ data (not all data) quickly and without comment. This process can be aided with use of web forums and appropriate ‘eye-witness’ reporters; and even with some erroneous data the safety activity of thinking about the situation would not be significantly compromised.

The difference between the two; – a formal report has accountability to a higher authority (usually government).
A safety audit, thinking about safety has accountability, but this is within the operation or directly to the individual providing professional development; perhaps of far greater value than formal reports.

[RatherBeFlying]

News of an accident gets attention and our natural first reaction is to understand how it happened so that we can hopefully not step in the same trap, especially as there are a limited number of typical accident types.

The urge to developing an understanding of any particular accident fades with time. By the time the official report makes its way through the mill and gets released, the immediacy is no longer there. Typically the post report comment one sees in these forums is generally much less in quantity than in the weeks immediately after the accident which is another indication that interest has faded.

It is basic human nature to react more strongly to events in the last few weeks than a few years ago.

Preliminary data from accidents does help pilots reflect on what happened and what they need to keep in mind not to fall in the same trap. Much of that will reinforce lessons and SOPs already learned.

Eventually the conclusions and suggestions from the official reports are fed into the regulatory mill.

I have also had the misfortune to witness and attend an atypical fatal accident along with many other pilots at the same location. There was a lot of soul searching to gain some understanding of what went wrong and what we need to do to not have another one like it.

[chuks]

"find something more entertaining..." than speculation about the cause of air crashes. Well, yes! I don't find this sort of thing "entertaining" at all, one reason I am against it!

I find a lot of it ghoulish, in fact. It is exactly on the level of slowing down, way down, to gawk as you roll past the latest road accident. Back home you give it a few minutes of quiet speculation about what happened but that's all. Here, it gets quiet and it's "Hey! Where did everyone go?"

People on the NTSB are working with information provided by experts, not nudniks trying to guess if the pilot "hit an air pocket," say. When the deliberately low-toned report is published, guess who reads and, hopefully, uses it? "Experts," that's who. You can believe me when I tell you that I pay close attention to them.

[PK-KAR]

better to post confirmed info than the (often) "amateur specialist" opinions
Feel free to discriminate and filter as you wish. Safety investigators have at times looked into what has been said by "amateur specialists"... Sometimes they need to see what they've missed, what info has been leaked to them but not to the investigators etc.

However, investigators do not take them into account without investigating the alternatives either. COnclusions made here are not professional conclusion, but can be useful.
I agree with PBL on the following:
People "trained and appointed" have political constraints and opinions just like anyone else. Most of them do a first rate, sometimes outstanding, job *within those constraints*. But satisfying those constraints often distorts what is proposed in their published report.

I extend such agreement throughout that post #292.

But trying to force down people's throats that the conclusions of "amateur specialists" are the right ones is a different matter altogether... and I don't agree to such intentions.

This is very strange for a pilot... in the cockpit we work with constarints aswell.... SOP's, OM's and QRH's... we operate the aircraft within these "constraints" because it is proven to be the safest way.
Yes, but they do need to improve those manuals and procedures as time goes by. Any improvements that is undertaken in a systematic manner should be welcomed, whether it would be adopted is subject to professional analysis.

An alternative (amateur) analysis is valuable when conducted by operators and individuals who ask ‘could this happen to me’.
Bingo! Couldn't have said it better myself...

The common interest here is safety improvement, and not to find the black sheep... and it does provide a measure to incite public interest into understanding what aviation is all about.

Sure, amateur specialists can be very wrong, but they can also come up with the right facts very quickly and accurately. On the accident analysis, the same thing can and has happened. But as I said above, even if it's correct, the official version does not necessarily mean the same... The nudniks aren't always dumb nudniks... some go about it very logically and systematically.

There have been cases where accident investigators have admitted "we know that's what happened, but we can't publish is... <insert reason here>"

I'd love to have the data they have, but I don't envy the official responsibility and the political pressures.

PK-KAR

[chuks]

There are many cases when, for one reason or another, the truth is left undiscovered or even concealed. Even the very high-profile Concorde crash led to allegations that maintenance errors caused a critical mis-alignment in the landing gear that went ignored in the official report for some reason.

Many accidents in the Third World go essentially un-investigated and under-reported. And? Guess why aviation there can be so dangerous.

I, too, watched with interest as that physicist just cut through all the palaver to swish the bit of o-ring around in the icewater and show how inelastic it had become, in the case of the Challenger accident. But bear in mind that there you had a brilliant mind at work backed up by many hours of expert investigation.

I guess I just get a bit testy from my day job. That primarily has to do with safety, efficiency and, way down the list, keeping the SLF happy. It is often so that the safety-related stuff makes the SLF rather UN-happy, when, depending on their social status, wealth, etc., they may let me know about that! As in, "I have a meeting in Charlotte and I need to know when we are ready to go!!!!"

"What, you think I have a remote control in my pocket that will make the fog at our destination disappear, you moron?" In my dreams! No, what I say is just, "Sorry, sir, we are working on that. Would you like another cup of coffee, perhaps? Doris!" The guy figures I am not very bright, not being able to answer a simple question with a direct answer. But, hey, if I were really, really smart then I would be a powerful and successful businessman, not just a humble airplane driver. Such is life, eh?

The problem often is that people try to extrapolate from what they know, often quite a lot, yes, to guess what it is we have to work with. That is entertaining, I guess. On the other hand, when some widget factory goes bankrupt, is it entertaining to try and guess what mistakes the Chairman made to cause that to happen?

[bsieker]

Even the very high-profile Concorde crash led to allegations that maintenance errors caused a critical mis-alignment in the landing gear that went ignore

Have you read the report? It's still on the BEA website. It's rather long, though.

The incorrect re-assembley of the landing gear bogie is discussed in detail, examined as to its causes (not following maintenance procedures, incomplete work-shift handover, sloppy management and non-use of specialised tools, ...), recommendations are given about improving maintenance procedures, etc. But it was ultimately found not to have been a cause to the accident.

This is confirmed by my Why-Because-Analysis (after a lengthy discussion with a professional expert, correspondence in the appendix) which I performed for my Diploma thesis (to be found at http://www.rvs.uni-bielefeld.de -> Publications -> Theses -> "Visualisation Concepts and Improved Software Tools for Causal System Analysis", Part II. Direct Link to the PDF (http://www.rvs.uni-bielefeld.de/publications/Diplom/sieker.pdf).)

There are no indications in the flight data recorders that there was any undue influence to aircraft performance from the landing gear. There was no unusual sideways force, and acceleration was normal, until it hit the titanium strip.

[...] in the case of the Challenger accident. But bear in mind that there you had a brilliant mind at work [...]

I'm not saying there is "another Feynman" on this thread, but some of the people so indiscriminately labeled (or should I say "libeled"?) as "amateurs" may be brilliant minds, and perhaps also backed up by years of analysing aviation accidents and socio-technical avionics problems, having written peer-reviewed and -acclaimed papers about the matter.

[...] widget factory goes bankrupt, is it entertaining to try and guess what mistakes the Chairman made to cause that to happen?

I guess it might be, although perhaps "entertaining" is the wrong word. Interesting or enlightening might be more like it. But it it will be a lot harder, because people are so much less deterministic than technical systems. We have speculated about the idea of applying the Why-Because-Analysis concept to purely social/socio-psychological phenomena, but never pursued it wholeheartedly.


Bernd

[MrNosy2]

I see nothing wrong on suggesting possible scenarios about what might have happened based on known facts if the person doing it knows what they are talking about. An official report (if any) might not normally be released for, say, 18 months after the event so it is useful to discuss what is known about accidents in advance of the final report. Its not just this forum where this happens - reviews of recent accidents are carried out by a number of organisations, e.g UK Flight Safety and, especially IATA who host a meeting of about 15 to 20 airline safety managers every year at the start of January to review the accidents during the previous year and try to see what lessons might be learned.

The main problem with this accident is that, as far as I'm aware, the Turkish authorities have not issued any statement of facts (unless its tucked away in Turkish somewhere?). Compare this, for example, with the situation in the UK where the AAIB might well have been expected to have issued a Special Bulletin on such an accident if it happened in the UK by now containing the known facts.

[lomapaseo]

also give a thought that it is rare for a detailed discussion or analysis to be published where operational errors may have contributed to the accident chain.

After all the most important things to the rest of us are product updates , or manual updates. These are almost always put forth even without the benefit of a long drawn out report process. Things that are unique to an internal process (regulatory compliance, operator training sylabus, etc. etc.) rarely get published or at least take a much longer time to appear in the public domain.

From my view, most accident investigations are well served to get the right words out quickly to prevent future accidents if you read between the lines of the first months information following an accident.

Now if it's blame or finger ponting that you are looking for, don't hold your breath.

[Clarence Oveur]

Now if it's blame or finger pointing that you are looking for.....It seems to me, reading this and other well visited threads, that there have been a recent influx of people who see a purpose in just that. Included are, rather disappointingly, people who's credentials initially suggested otherwise.

[twistedenginestarter]

One of the most fascinating aspects pf PPRuNe is the flood of input and analysis after a major accident. Sometimes the likely causes are identified fairly quickly. In the case of the MD-83, it's not so obvious. However you always get people saying we are not allowed to speculate. As with this thread, often there's a theme that what you say is automatically worthless if you are not a certain type of professional. But that's not the real issue. These people have a sort of religious aversion. Nobody needs to read these threads. They know that there's going to be no official enquiry findings published 12 hours after a crash, so why are they browsing? Also the curious thing is these discussions are mainly credible. You can't expect 100% but most people are making rational contributions or asking pertinent questions. Of course there's a lot of missing facts especially in the first hours and days, so it is speculation, but what is wrong with that? We'd all be very dull if we ignored things we didn't know were 100% factual, and what exactly would be achieved?

[lomapaseo]

... You can't expect 100% but most people are making rational contributions or asking pertinent questions

subjectively from my view, way too many are more willing to expound than to ask questions that might provide a tad more credibility to their contributions.

Those that do offer contributions with pointers at appropriate followup questions for fact finding are the easiest to read and ponder as well as to evaluate as new facts are developed.

[DingerX]

I had a pompous, academic-sounding dull contribution, complete with references to the 1854 amateur investigation into the Soho cholera outbreak, but thought better of it.

90% of all contributions are questionable, and they don't discriminate by profession. Every job involving professionals has non-professionals who go about telling the pros how they should do their job. That Widget-factory owner has his fan club too -- just check the minutes of the annual meeting, or his stock forum. If you want to know how bad it can really get, listen to a Sports radio talk show.

Any intellectual endeavor that involves sifting through data should welcome additional (and non-standard) sources of data as well as interpretations, as long as it bears in mind that most data are ultimately meaningless, and most interpretations wrong. But even the act of refuting the most absurd WAG is useful: it forces a reconsideration of the basic situation. So you can change the composition of the debaters, but they'll still be spouting crap most of the time.

Pros do lots of things well, but they don't have all the resources amateurs have. While pros must work systematically through a field, the amateur only works on the stuff s/he finds stimulating. When that "stimulating stuff" is not equal to "Working systematically through the field", the results are necessarily skewed, and the amateurs may not have the "big picture". But that's not necessarily bad. Any archaeologist commencing survey of an area knows that, in addition to lining up everybody for a grid-by-grid study, it helps to ask the locals if there's anything around they should know about.

What doesn't help is when someone makes an appeal to their own authority where a) that authority does not give them competence to speak on the case at hand, or b) how that authority gives them competence to speak on the case is not clear or specified, or c) they don't have the authority they claim for themselves.
a) "I've flown Cessna 172s in MSFS. There is no way MD-83 landing gear will fail to come down"
b) "As a professional pilot, I can say unequivocally that no pilot would land in those conditions."
C) "I have flown the Concorde on transatlantic sectors, and once to the Antarctic Research Station and Alien Detention Facility in McMurdo Bay"

The Latin word for professional guild survives, although its scope has been reduced to only one institution: universitas

[hetfield]

What a great posting!

Congratulations.

hetfield
:D

[alf5071h]

I have previously argued in this forum about the advantages of informed speculation about incidents and accidents. Also there has been extensive debate on why and how to control the unwarranted contributions from the non-professionals. However, there still remains opportunity for well meaning contributors to reflect on the manner and content of their posts.

Speculation can provide both opportunities to learn new or refresh aspects of flight safety, but also practice individual thinking and analysis skills which are essential components of operating safely (via CRM), i.e. keep an open mind, see the other persons point of view, awareness of human error and limitations, etc.
Both learning and depth of knowledge thrive on experiencing situations first hand; incidents and accidents is one area that this should be avoided, thus we have to learn from others. ‘Day dreaming’ or visualisation is also a powerful learning tool associated with speculation, this enhances experience by adding patterns of thought and solutions for use in future unexpected situations by considering ‘what if’, but supported by sound knowledge.
‘What if’, is a powerful investigative tool for incidents and accidents, and also for examining our own thinking and behaviours.

Many posts engage in meaningless exchanges of ‘accuracy’ or ‘I know better’, whereas the effort might be better spent in expanding knowledge or researching issues particularly for posts which commence ‘I believe … ’.
In aviation, if you don’t know then your belief is very tenuous (often worthless), and thus it is essential to find out, gain greater understanding, double check, or compare data, before pronouncing. Similarly, Captains of the industry (crews and in forum threads) should lead through example by encouraging and educating with measured posts and responses – some of the other contributors might be crewing with you shortly.

Forum speculation offers opportunity to gain experience and practice skills of thought and communication. This opportunity should not be abused. All of the above requires self discipline, which is of course is the foundation of airmanship.

What Can You Learn from Accident Reports? (www.tc.gc.ca/civilaviation/publications/tp185/3-07/Pre-flight.htm )
A tool for Human Factors Accident Investigation, Classification and Risk Management. (cradpdf.drdc.gc.ca/PDFS/unc18/p519247.pdf)
Systems safety in the wake of the Cave Creek disaster. (/www.safetycouncil.org.nz/Editorial/CaveCreekPaper.pdf.)

[twistedenginestarter]

a) "I've flown Cessna 172s in MSFS. There is no way MD-83 landing gear will fail to come down"
b) "As a professional pilot, I can say unequivocally that no pilot would land in those conditions."
C) "I have flown the Concorde on transatlantic sectors, and once to the Antarctic Research Station and Alien Detention Facility in McMurdo Bay"
I don't recall anything like this being said and I didn't find anything via Search. Ironically you're criticising others yet justifying yourself with non-facts. If some such such non-sequitur appeared in one of these threads, you should quote that. This does two things - i) it potentially proves such a thing happened, whilst b) allows us to challenge your analogy.
Whilst it's true that professional airline pilots will know some things that armchair enthusiasts won't, the same is not true of logical analysis. I have two science degrees - Am I better than you at analysing theories? I don't know. You can't call it. However people like you want to. You want to say that only certain unspecified 'professionals' are allowed to theorize. It would be interesting to know what defines those professionals, incidentally. Being a pilot is not a qualification for analysing accidents although obviously it helps.
Try this analogy: pilots are like criminals, they have to use skill, experience and daring to do things in real time. Investigators are like policemen. They are slow and careful and have all the time in the World to think things through. Now tell me the only people who can be policemen are criminals or ex-criminals.

[DingerX]

Those are intentionally not statements actually made, but examples of fallacious appeals to authority, and we could dig up on these threads examples of all three forms quite easily.

My argument is quite the opposite of what you suppose: logical arguments are valid or not regardless of who makes them. That hasn't changed for a couple thousand years.

And sure, I agree that when it comes to "accident investigations", pilots are amateurs. They have (or should have) an interest in them, and they are extremely familiar with a segment of it. But I think you've got the temporality of cops and criminals mixed up. The analogy fails.

[Clarence Oveur]

At the risk of sounding all Rumsfeldian, there are those who do not know, how much they do not know. Consequently they believe themselves more knowledgeable than they actually are. Add to that a need, or desire, to be seen as an equal or accepted to a certain group, and you have the recipe for conflict.

The sound advice offer by alf5071h should be kept in mind by all.

[AirRabbit]

Study the composition of the NTSB - that is the BOARD MEMBERS - and you'll find that ultimately, although they rely on specialists to make the investigation, the actual board members who have the final say are, in fact, "amateurs" - and often bring an outside perspective to the final report.
edit: took some finding...
Current Members of the Board are:
* Mark V. Rosenker, Chairman
* Robert L. Sumwalt , Vice Chairman
* Deborah A. P. Hersman, Member
* Kathryn O'Leary Higgins, Member
* Steven R. Chealander, Member
Links to their bios are here
None are "trained accident investigators" by any stretch of the imagination (two were pilots, but that's not the same thing, obviously)
As to "why is aviation picked on" - it isn't. Ask any, say, nuclear industry employee if he thinks they are immune to "armchair experts". Or the military in general. Or the police forces. Or ....
In view of your statement “None are ‘trained accident investigators’ by any stretch of the imagination (two were pilots, but that’s not the same thing, obviously);" here is a quote from the “bio” of Robert Sumwalt.
A trained accident investigator, Mr. Sumwalt participated in several NTSB investigations including the crash of USAir flight 427 in 1994 near Aliquippa PA, and USAir flight 861 near Birmingham Alabama in 1998. He also participated in the Transportation Safety Board of Canada's investigation of the accident involving Swissair flight 111 off the coast of Nova Scotia in 1998.
From 1991 to 1999, Mr. Sumwalt conducted aviation safety research as a consultant to NASA's Aviation Safety Reporting System, studying various issues including flight crew performance and air carrier de-icing and anti-icing problems.
Mr. Sumwalt has co-authored a book on aircraft accidents and he has written extensively on aviation safety matters, having published over 85 articles and papers in aviation trade publications and he has broad experience in writing aircraft operations manuals and airline and corporate aviation policy and procedure guidelines. He has been a regular contributor to Professional Pilot magazine.
In 2003, Mr. Sumwalt joined the faculty of the University of Southern California's Aviation Safety and Security Program, where he was the primary human factors instructor.

[lomapaseo]

Lastly, we've never established any "qualification" for an "investigator": everyone shows up, with their own perspective and background. Often the paid "investigator" is the least qualified of the group (workers from the industry).

This is difficult to understand

Who is the "we" in the above:confused:

What's a "paid" investigator vs an "unpaid" investigator:confused:

If you refer to ICAO annex 13 for guidance than "expertise" is the only guidance that I can think of and even there it does not distinguish what kind of expertise. Mostly what is available are a collection of enough expertise to get the job done and in that the most critical expertise are those that know what they do know vs what they don't know.

Recognizing what you don't know and and then seeking help as needed is what gets the job done. If by industry folks you mean the manufacturers then they often serve as conduits via telephone to sources of specific expertise rather than as all around investigators themselves.

[Mad (Flt) Scientist]

My apologies to Mr Sumwalt; I admit I scanned the bios quite quickly.

My statement was based on knowing the background of some of the others on the board, having noted their various comments during the Pinnacle/Jefferson City board meeting ... the quality of which didn't seem particularly dependent upon their specific background.

In addition, I think it's quite important that the board be seen not to be a creature of the industry; it is, after all, one of the mechanisms by which the general public assures themselves of the safety of the transportation system, and if it were staffed entirely by industry insiders, there'd be even more people willing to cry "conspiracy" at every turn. It does, after all, fulfill a quasi-judicial/legal role, and we don't apply any expertise qualification to a jury on a capital trial....

[krujje]

It does, after all, fulfill a quasi-judicial/legal role, and we don't apply any expertise qualification to a jury on a capital trial....

MadFS, are you saying that the quality of NTSB board members is reflected by their inability to avoid doing that particular duty? :E

[krujje]

PJ2:

Notwithstanding Feynman's example of "amateur sleuthing", the best example of a non-specialist doing superb investigative aviation work is the Moshansky Commission and it's Report in the accident at Dryden, the recommendations of which were largely though not wholly adopted by Transport Canada, (which was heavily criticized in the Report, and to which strong criticisms have since been directed regarding SMS (which I have called "the de-regulation of flight safety"), by the same man). Here was a man who knew nothing about aviation yet had tremendous access to wide-ranging information, all with good results.

Moshansky was not a man who knew nothing about aviation... he was in fact a licensed pilot and aicraft owner. Furthermore, I would argue that this was in fact an example of an expert doing a superb investigation... maybe not an expert in aircraft accident investigation, but certainly an expert at reasoning and sifting through tremendous amounts of information to get to the truth, which is what was needed.

[AirRabbit]

My apologies to Mr Sumwalt; I admit I scanned the bios quite quickly.

In addition, I think it's quite important that the board be seen not to be a creature of the industry; it is, after all, one of the mechanisms by which the general public assures themselves of the safety of the transportation system, and if it were staffed entirely by industry insiders, there'd be even more people willing to cry "conspiracy" at every turn. It does, after all, fulfill a quasi-judicial/legal role, and we don't apply any expertise qualification to a jury on a capital trial....
First - sir, you are, indeed, a gentleman with character. Thanks.

Second - I think your statement about the NTSB is on target. The role they fill in accident investigation is not only valuable to the aviation industry, i.e., by pointing out the "probable cause" of accidents and incidents, but they also serve as a quasi-watch dog for the FAA. The Board isn't always right ... and they are often victims of political issues (as most persons are) ... but they are right a lot more than not and generally do a monumental service to the aviation idustry.

[ICT_SLB]

Probably should point out that the NTSB like CASB also deals with rail, maritime, road & pipeline accidents so Board members may have, & been appointed for, expertise unrelated to aviation. This is of course unlike BEA or the AAB.

[PJ2]

Reply to post #39;

krujje;

Thank you for the important correction.

to get to the truth, which is what was needed.

...and is still needed, apropos his comments early last-year regarding SMS and what I would term, "the de-regulation of safety oversight in Canada": Safety cuts risk air disaster: Judge - Toronto Star, March, 2007 (http://www.thestar.com/News/article/186973)

SMS in and of itself is a good safety system because, in part, it supports monitoring and change through the intense collection and use of data.

SMS however, does not provide a robust external audit process and instead puts airlines in charge of both the collection and use of safety data AND the audit of such safety processes to determine "effectiveness". The process can work successfully so long as data is first, taken seriously and second, acted upon. That is not always the case when short-term commercial goals are the usual priorities. Regulatory oversight is often required to counter such commercial pressures and it is unclear how SMS will address the issue.

[krujje]

...and is still needed, apropos his comments early last-year regarding SMS and the de-regulation of safety oversight in Canada: Safety cuts risk air disaster: Judge - Toronto Star, March, 2007 (http://www.thestar.com/News/article/186973)

I had a chance to hear Judge Moshansky speak in person last year. My understanding is that he is not against SMS itself, in fact he considers it a very good development (as I think the article says). SMS, when added to the existing safety infrastructure, has a lot of potential for decreasing the accident/incident rate.

However, it seems like Transport Canada is implementing SMS as a replacement for the existing system, outsourcing its safety responsibilities, as it were. Indeed, this was the message from Merlin Preuss at CASS 2006... from memory (so don't call this a quote or anything)... that fiscal constraint at the regulatory level and the expansion of the aviation industry have made SMS a necessity. Basically, TC doesn't have enough money to accomplish all of the regulatory activities they are charged with carrying out.

However, this was the principal thrust of Judge Moshansky's conclusions following the Dryden inquiry: that the downsizing of government in the 80's (at least in Canada), aka "fiscal restraint", and at the same time de-regulation of the industry leading to an explosion of growth in necessary certification activities (everybody and his brother was opening a new airline at the time), led to a situation which allowed the Dryden accident to occur. Reading the Moshansky report is a real eye-opener.

Right now, based on the Dryden experience, it looks like we may be seeing the foundations being laid for a future accident, which with hindsight (like with almost every accident) everyone will say was preventable if only sufficient funds had been invested, etc.

SMS is not a bad thing, but I think it's being implemented for the wrong reasons, or rather some people are using it to further goals which are not necessarily safety-related.

[PJ2]

Right now, based on the Dryden experience, it looks like we may be seeing the foundations being laid for a future accident, which with hindsight (like with almost every accident) everyone will say was preventable if only sufficient funds had been invested, etc.

I think so.

Placing a commercial enterprise motivated only by profit in charge of "expensive" safety processes will inevitably put such processes (and resources) at risk in terms of financial support and focus.

The operation becomes one of patch-work, ad-hoc crisis-management activities instead of one guided by a properly implemented, correctly resourced and fully utilized SMS program. In large airline operations the problems multiply because communications of "expensive" priorities tends to be pushed out by stronger commercial, (cost-control) messages. Short-term commercial goals do not support long-term planning of safety programs which tend to cost a great deal of money but produce "nothing" in return that can be shown on a balance sheet. If for example safety data is "inconvenient", (ie, will result in demonstrable commercial losses if acted upon), that data can tend to be "set aside" or quietly forgotten in the daily pagaent where "next!", is all-important. Resourcing safety programs faces such internal opposition as you may know and box-ticking becomes the solution.

Such traditional approaches only prevent the second accident, as you mention in the quote above.

[krujje]

Here's the irony. Corporations like to say that they are ultimately responsible to their shareholders, which is true to a certain degree (but that's a whole different discussion). Shareholders as individual people care about airline safety... nobody wants to die in an accident. But. Shareholders as investors start selling when profits go down. When enough people sell and not enough buy, the share price goes down (basic market forces). When share prices go down long enough, CEO's get the boot. Now it's true that CEO's don't ultimately decide everything that goes on in a corporation (the all-seeing, all-powerful CEO is mostly a myth), but they do set the tone. So when a CEO fears for his/her job, and decides that profits are more important, this sets the field for the rest of the organization; it filters and percolates down through the whole management structure, right down to the janitor. The corporation as a whole will therefore go to great lengths to keep share prices up, including trading safety for short-term commercial gain. Ultimately, it comes down to individual shareholders sending a mixed message: they say they want safe travel, but they aren't willing to pay for it, as shown by the action of selling when profits go down. What's a poor CEO to do?

[PJ2]

What's a poor CEO to do?

Indeed, poor CEO. :rolleyes:

What that CEO needs to do is to listen to hisher "canaries-in-the-mine" with an active, open ear.

S/he needs to know where the long-term risks to profit (and even the organization's mere existence) are, send out the message to employees first, that inappropriate risk will not be tolerated, enact a protective safety reporting policy that is responsive, accept that mistakes will be made but that they will be made on the side of caution not risk, educate the shareholders that while aviation is a business with risk associated with it that such risk is being robustly managed in a healthy, fully-supported manner (upon which s/he comprehends and can intelligently report) and finally invite the media in to show how well the organization is managing the business in all it's aspects and not just the eye-candy-for-shareholders-and-passengers side.

Truth plays well in today's corporate environment but few CEOs are willing to risk public displays of safety conciousness because of the perception of "protesting too much". In my view, honesty and dealing straight is a better strategy...up to a reasonable point. It's part of the business, but so is all the rest and rightly so.

Now....tall order I know, especially with the last point regarding the media. But in Canada, a newspaper series last year took the industry strongly to task for ignoring this aspect of the travel business. Airlines reaction was defensive, sometimes to the point of emotive rather than rational response and it made them look as though they were hiding things. The public is smart and deserve better.

So long as the message is, "cost is king and profit is first", employees and shareholders alike will assume that safety is being looked after under SMS and will prioritize accordingly until a very bad surprise awakens everyone to the truth. Unless awareness and then change in the form of balanced priorities occurs, that is the path we are on at present - it is only a matter of time.

[krujje]

I agree.

Research has shown (see for example a book called "The Addictive Organization", can't remember the authors sorry) that organizations work in both the top-down sense (CEO setting the tone) as well as the bottom-up sense. What this means is that organizations will tend to reflect the personalities and goals of the people who make them up. So in order to change the way the organization deals with safety, it's necessary to change the way each person in the organization deals with safety. Eventually, this kind of change works it's way into the decision-making process and the SOPs of the company. This is why one of the major points of SMS is that safety is everyone's priority. SMS is more than a system to be implemented, it has to be a cultural change. I like to think of it as the difference being going on a diet to lose weight, and actually changing your eating and exercise habits. The first works short-term, but you eventually put the weight back on and worse... the second is a lifestyle change and the effects are almost permanent.

I've actually gone through the exercise of pointing out minor safety issues which were completely outside my realm of responsibility, all in the name of "safety is everyone's priority" and was pleasantly surprised to find that I got a positive response and thank you from the people I addressed my concerns to. I found it a very encouraging sign.

[PJ2]

krujje;

Very glad to hear it. We've done the same and been completely ignored. Thus the "timbre" and "bias" of the post... :ugh:

[lomapaseo]

Just a couple of coments relative to the new twist in this thread.

Typically an oversight body audits the safety process from time to time. Under Continued Airworthiness Part 39 its the likes of the FAA, CAA, etc. etc. The process must be acceptable to them, else you could lose yout TC.

Of course its true about bean counters, counting beans, but the safety process should have been adequately funded and staffed in the first place to pass it's audit.

Then we have the top dog or CEO. This guy really worries about public perception and getting hammered in both the board rooms and cocktail parties and when things go wrong he's worse then a sea captain in holding underlings accountable for safety. If there's any negative pressure against safety it's more likely to come from middle management if you can define that level.

[PEI_3721]

Typically an oversight body audits the safety process from time to time. Typically, (in my experience) an oversight body only audits the documents which indicate that an operator has a safety process.

One of the major omissions in SMS is the process or at least the depth of process which investigates incidents and mishaps (thus lack of data or inaccurate data). These are the low level events which are often the precursors to more serious problems, but are rarely investigated in sufficient depth to identify the underlying contributor factors.
I cite the very good UK CAA (EASA) system of mandatory reporting (MOR). Again, my experience with several operators suggests that only a first level of investigation was used to close the report. This could be the reporters perception of the event (opportunity for flawed perception), that of the operator (opportunity for operational bias – keep the good name), or the safety/QA department – usually under time pressure or not equipped/experienced to undertake an in-depth analysis.
More surprising was the acceptance of this process by the CAA, where only rarely was there any follow up or questions to the manufacturer (aircraft or component) and apparently no independent investigation by the CAA; it was a data gathering system apparently without validation. Yet MORs were used as the basis for many safety initiatives; – flawed data?
There are similarities with ASRS, where the reward of immunity from punishment in the event of a transgression is often seen as immunity from investigation. Where there is some follow up, the process is also depends on the integrity/ability of reporter, who in keeping with human nature, may well provide reports/answers to match those expected by the question/industry e.g. altitude bust - ‘I was distracted’ – because that is an expected / acceptable answer without the difficulty of further explanation or deeper analysis.
Note the alleged erroneous safety assessment / report by NASA – they are involved with ASRS.

[PJ2]

lomapaseo;

The process must be acceptable to them, else you could lose yout TC.

Yes, but "acceptable" must be a sufficently high standard and that is both a political decision as well as an operational safety one. For example, it is my belief that if an airline passes the IOSA process the issues raised by PEI_3721 as well as other issues still obtain and in my view safety is not fully served as per our expectations of what SMS is and what is accomplishes.

While the actual IOSA process is comprehensive in its structure the answers to the questions are, again in my view, not always the whole picture and where a thorough audit process is intended, a less-than-thorough one can result, where shortcomings are "noted" and changes and/or improvements made after the passing of the audit.

In short, while the structure of oversight is essentially an audit of documents and processes, examining that what actually happens within the airline is in accordance with the documentation is not part of the IOSA or TC process or is at best a surface examination. The details are left "in-house", and that is where the risk in SMS arises.

Under SMS, "everyone" is responsible for safety, which is complete nonsense and entirely impractical not to say a conflict of priorities. A flight operations manager simply does not become a safety "expert" or specialist overnight and is far more likely to default to old habits and priorities which are entirely cost and schedule-driven. Take for example, the complexities of implementing an FDA Program. Are line managers going to take such a project on? Not at all. If "everyone" is responsible for safety, where does the leadership come from to implement such fundamental programs? Where do the justifications for resourcing such programs come from and how do they survive when such audits accept box-tick FDA programs?

Perhaps the notion will mature but, like the MCPL notion, I think the accident rate will have to rise before the realities of these cost-control initiatives settle in to the statistics.

[Tee Emm]

The process of thinking about an accident has safety value; it can be equated to a safety audit on a specialist subject. This is also somewhat speculative, but can occur more quickly while the event is fresh in peoples minds (greater training effectiveness), and can be more proactive in looking ahead to avoid a similar accident, as opposed to a formal report of how to avoid the accident we have just had

Agree. With the full accident report often taking many months to publish - and even then depending on the country of origin, it may not be in the Pprune readers own langauge, interest may have long since waned. Despite it's knockers Pprune has proved to be a most valuable flight safety "journal." The well written paragraphs in the preceding posts by some of the most knowledgeable contributors testify to this.

I am all for immediate opinions on the possible causes of an accident because some of these may prove spot on. As a former aircraft accident investigator in the military many years ago, I had precious little effective training. I recall with embarrassment being sent to the scene of an accident armed with an old Poleroid camera, a note-book and bugger-all knowledge - in fact it was training on the job with a vengeance.

If Pprune and the internet been available in those days, I for one would be quickly scanning contributors posts to pick on a facet of the accident which had previously escaped me. As it was, with no CVR or FDR available then most of the time we made an educated guess on why a crash occurred.

Of course you may have to wear occasional uneducated points of view on Pprune pages but it takes only a quick scan to sort the difference between well thought-out discussions and the bogan element. Naturally the final accident report may prove some of us wrong - but I am sure most will be mighty close to the truth.

[krujje]

PJ2:

Under SMS, "everyone" is responsible for safety, which is complete nonsense and entirely impractical not to say a conflict of priorities. A flight operations manager simply does not become a safety "expert" or specialist overnight and is far more likely to default to old habits and priorities which are entirely cost and schedule-driven. Take for example, the complexities of implementing an FDA Program. Are line managers going to take such a project on? Not at all. If "everyone" is responsible for safety, where does the leadership come from to implement such fundamental programs? Where do the justifications for resourcing such programs come from and how do they survive when such audits accept box-tick FDA programs?

I disagree in part with your statement here. I don't believe that the concept of everyone being responsible for safety is complete nonsense, nor do I see how it would necessarily be a conflict of priorities. While it's true that you can't expect anyone to become a safety expert overnight, why is it necessary to be an expert in order to make a legitimate contribution?

To make an analogy... I don't have to know the ins and outs of the city sanitation system to pick up a piece of stray trash and throw it in the trashcan. I could easily ignore the trash and let it accumulate, but if I've decided to make picking up the trash one of my priorities, no matter what I'm doing, then it can become second nature. On the other hand, relying solely on good samaritans to ensure a clean city is stupid.

I think what the concept of "safety culture" tries to avoid is the situation where people can tell themselves that it's okay to put aside the safety questions because there are "experts" in the system to take care of that.

[PJ2]

krujje:

I don't believe that the concept of everyone being responsible for safety is complete nonsense, nor do I see how it would necessarily be a conflict of priorities.

Sorry, not communicating very well - my fault. "Everyone responsible for safety" doesn't exclude specialists of course, the assumption being that within the culture where everyone contributes and has a responsibility to make sure oneself and others don't "run with knives". I know you're aware but for the sake of discussion, many, including "the top", assume that safety is not doing unsafe acts, period. If we just don't do things that are unsafe, we'll be okay. We know this is isn't what a safety culture is however, not, at least, a full and operating one.

None of us wish an accident ergo we will act safely; - it is upon that foundation that such 'first-level" thinking is based and so far as it goes, it works and "the streets will be clean", to extend your metaphor a bit.

However, again to extend the metaphor, the streets ought not to be trash-ridden in the first place because we all (should) have an ecological awareness which prevents us from trashing our nest.

In fact, carry it further, and there should be no "trash" to dispose of in the first place, (I really don't want to take this thread too far away - but ever taken all the packaging off the groceries you've just come home from and returned it all to the grocery store? Quite a reaction...).

Now we know that this is ideal and likely unachievable but we all agree it's a worthwhile goal.

Safety specialists and targeted safety programs such as ASRS, LOSA, FDA/FOQA, AQP and so on present an "ecology of mind" (a culture with an ethic, if you will) within the safety arena in much the same way that the extended metaphor would have non-polluted streets, (etc etc).

I realize this is simplistic and there are all manner of rabbit trails and yeah-but's that could be pursued, (some more worthwhile than others) but I would like to convey that I believe that while safety is "everyone's business", such is not exclusive of the need for specialists. The mistake in SMS design is, in my view, that it lets the regulator off the hook except for an audit/oversight role, (substantially less involvement, ostensibly due to the need to lower costs), an initially naive view of what safety is all about by operations managers who are not accustomed to stopping an operation in the same way that the guys in the cockpit might and are instead mission-oriented, and an airline where costs drive all decisions and then, where overt and imperative, safety considerations, if not too expensive, are taken into account.

The above is not intended to be a controversial statement to elicit response - this is a complex topic and not all can be said that needs saying in one sentence - I fully realize that such a black-and-white statement is not exactly how it works. Airlines have enormous interests in preventing an accident and by design, their daily operations reflect this deep concern in a thousand ways which are transparent to the user because they are "the culture". We are discussing safety within a period of metamorphosis - from traditional approaches like kicking tin, into "SMS-like" approaches which encourage the collection and examination of flight data and incident reports so that prevention, not investigation, becomes the goal.

What I meant by my foreshortened statement was, where safety is "everybody's business" and the airline assumes that such work as necessary to "make things safe" is being done, it becomes extremely difficult to implement complex and expensive safety programs because the justifications are, as is the case with safety, very difficult to specify in an economic model that requires specific definitions of the problem, targets, goals and a business case to defend the budget. "Everybody" can't just do that so it falls to a now-dwindling group of safety specialists to lobby for, create and implement programs like FDA. If management isn't onside and the CEO has no idea what "FDA" (or some other such pnemonic) means, then such programs are almost impossible to implement let alone actually use in daily operations.

I do not believe that SMS, as presently constituted and being enacted in Canada, will do this and instead will render the safety environment less, not more effective. Critical safety data such as DFDR and QAR (FDA) data is not protected in law in Canada (in the same way the CVR is) so while SMS requires the collection of information, it may, (not necessarily will) be "available" to the courts via the "public interest" route. That is not an SMS culture that adheres to "what" not "who" - we have already had a case where data has been used in a criminal case in Winnipeg. Also, the CVR of an accident aircraft was listened to by the families of victims. There are those who are today pursuing via the OSH process, flight data for their own narrow, industrial (not safety) purposes.

I hope I am wrong but it is far too early to tell.

[Mad (Flt) Scientist]

I am also uncomfortable with the "everyone is responsible" mantra. resposnsibility balances with authority; you can't be considered responsible for something which you have not the authority to address. Safety (at least in the short term) is expensive - though the comment "if you think safety is expensive, try having an accident" is very true. So the people "responsible" for safety must also have the authority to make the necessary allocation and diversion of resources.

Everyone can - and should - contribute to safety.

But responsibility lies at the top - and even if they delegate the conduct to middle managers and safety specialist, they are STILL, IMHO, "responsible".

My fear with the "everyone is responsible" idea is that it dilutes the real responsibility. By analogy, the Chief Constable is responsible for the conduct of his force; rolling out a "we are all responsible for keeping the streets safe" campaign dilutes his responsibility not one iota.

[john_tullamarine]

The thread has a few comments about moderation and site policy ..

It may be useful to revisit some aspects of forum ethos -

(a) PPRuNe is ours, collectively, to enjoy subject to the fact that others, elsewhere, own and accept risks associated with the operation of the site

(b) the folk at the top of the totem pole set the underlying tone but moderators are given a pretty long leash in how individual forums are administered

(c) in Tech Log, the basic idea is for minimal active moderation. This can only work if the contributing folk maintain a reasonably high standard of personal integrity and general behaviour .. as is the norm for the forum

(d) personal attacks will be subject to edit or deletion. Where individuals raise complaint (and we have folk varying from thick-skinned to very sensitive) there often is no simple solution

(e) if posts get too far toward the conspiracist swamps, probably we will pull on the reins a little .. there are other places where such discussions might be more appropriate

(f) the moderators are mindful that there can be a fine line between moderation and dictatorship

(g) hopefully we don't fall into the trap of excessively fancying the professional expert's over the knowledgeable and competent amateur's opinion .. as most experts will acknowledge, while the average expert has made far more mistakes than the average amateur ... he/she generally hasn't had time to have made all possible mistakes ...

(h) if a thread is not interesting, or gets too far into the silly side of things, generally it will die a quick, quiet death as it sinks into the oblivion of the archives ...

(i) an overarching concern is that of education and the need for subjects to be revisited to address the needs of the continual turnover in new chum PPRuNers ...

I guess what the above all means is that we are never going to get it "right" ... we will just try to keep it working away to the general benefit of the readership .....

[alf5071h]

MFS re “Responsibility” #54. Like many words used in aviation they have several meanings often dependent on the context of use or the user’s perspective.
The top down view which you present is one view, which IMHO is often associated with blame and often follows accident investigation.

An alternative view that I favour is to use the word ‘accountability’. This can be applied in a similar way as responsibility, but accountability looks more to the future, what can / should be done before an event and thus avoids aspects of blame.
Accountability might better fit the view that everyone is accountable for safety.

We are accountable to ourselves for our thoughts and behaviour, both of which have strong associations with safety; pilots are accountable for the safety of their crew and the passengers, and as such contribute to the safety of the operation. This line of thought continues upwards through management, regulation, and government; thus this is a bottom up approach to safety.
Accountability is another way of encouraging ‘grass roots’ involvement in safety – individuals are empowered to ‘own’ procedures, to report errors, be a catalyst for change. The bottom up flow of safety information is an opportunity to remind those who have the power to change procedures, funding, even influence cultures. Management can be reminded of their accountability – their “responsibility” downward to the grass roots.
Many of the better accident reports represent an upward view.

We cannot sit back and expect that management will make us safe (you were not saying that), but often this is a view held in industry and thus the grass roots do not engage with safety, they do not contribute. Apply this view to you police analogy; yes we can do something, perhaps not much, but we should at least engaged with the problem; if we don’t then the potential for complacency, indiscipline, and lowering standards in aviation could be mapped to an analogy of a changing UK society, PC, and failing law and order; and how is that accident going to be investigated.
Thus it is an appropriate reminder for everyone to remember that they are accountable for safety before the incident/accident.

[twistedenginestarter]

Airline flying is stunningly safe and despite the growing impact of third world operators and low cost airlines (and third world low cost operators) it seems to be getting even safer. Perhaps one reason is the fact that crash investigations are so public and that so many people take an interest in the details, amateurish or not .

[PBL]

Airline flying is stunningly safe and ...... it seems to be getting even safer. Perhaps one reason is the fact that crash investigations are so public and that so many people take an interest in the details, amateurish or not

Succinct, pertinent, incisive.

There is another factor. ICAO signatories are obliged to investigate (some) accidents and report on them according to a standard format. And most nations are ICAO signatories. I think minimal international standards play a role, even if they are minimal.

I took a couple weeks off to rethink my participation in PPRuNe, and was gratified to find this thread, which it seems I partially started. It also seems from moderator's comments as if the thread has been extensively pruned of immoderate comments. Let me say that there are professional safety people contributing to this thread and what is left after moderation represents a series of worthwhile comments.

Let me also state my interests. We (I and my coworkers) investigate inter alia aircraft accidents. Two of the recent accidents we have been asked to investigate have been of extensive interest to PPRuNers. The third one is a microlight aircraft accident. Interestingly enough, I believe the microlight accident contains the most significant lessons to be learnt about criminalisation of accidents. Those PPRuNers who are not aware of this trend are in my opinion well advised to inform themselves. I hope to be able to write about it, once official proceedings are concluded.

I welcome the interventions from PJ2 and alf5071h on "safety culture". I myself am not so particularly concerned with this aspect of safety, but I recognise its value, as do all safety professionals with whom I regularly correspond. In the microlight accident to which I referred, the lesson about developing a functioning safety culture is perhaps the most important lesson to be learnt. The big question is how to implement one.

And (of course) I would like to restate my original point that attempts from creative people to answer questions are helpful, no matter what the background of those creative people. Much of the Turkish MD-83 thread centered on where the impact point actually was. I suspect that those who found this discussion pointless (including, it seems, some moderators) have never been involved in the investigation of an actual accident. Stuff that should be banal is sometimes unusually hard to figure out. That is the way of the world.I suspect it will remain so.

PBL

[krujje]

PBL:

I believe I've read some of your work, and found it quite insightful. I personally believe that the process of investigation is made more meaningful by varied, conflicting and sometimes combative discussion. Any contribution which is based on provable fact and logic should be admissible, regardless of the source.

Much of the Turkish MD-83 thread centered on where the impact point actually was. I suspect that those who found this discussion pointless (including, it seems, some moderators) have never been involved in the investigation of an actual accident. Stuff that should be banal is sometimes unusually hard to figure out. That is the way of the world.I suspect it will remain so.

This is a good point which should be remembered. The answers are not always so easy as reading out the data from an FDR and shouting "Aha!". I have been through an experience where the various parties involved could not even agree on what happened, much less why, and as far as I know still haven't. It was quite frustrating, needless to say.:ugh:

[lomapaseo]

I personally believe that the process of investigation is made more meaningful by varied, conflicting and sometimes combative discussion

and I might add typically free of insults unlike those on a message board where one can hide behind a user name and no worries about losing some teeth in a bash :)

[john_tullamarine]

... but we manage to keep some of the more outlandish folk in line .. at least some of the time ..... fortunately Tech Log discussions generally tend to be goal oriented most of the time ...

[PBL]

I have been through an experience where the various parties involved could not even agree on what happened, much less why, and as far as I know still haven't

That is the case in the microlight accident we are working. There was a specific structural failure, and there was a loss of control and tumble. The question is which came first. Prosecution, following accident investigation authority, says failure caused tumble. We say equally (or more) likely that tumble caused failure. I was lucky to come across, and recommend the engagement of, a forensic structural engineer who has all but proved it by looking much more closely than others at some critical parts as well as at the design and certification basis of the aircraft.

PBL

[krujje]

pbl:

That is the case in the microlight accident we are working. There was a specific structural failure, and there was a loss of control and tumble. The question is which came first. Prosecution, following accident investigation authority, says failure caused tumble. We say equally (or more) likely that tumble caused failure. I was lucky to come across, and recommend the engagement of, a forensic structural engineer who has all but proved it by looking much more closely than others at some critical parts as well as at the design and certification basis of the aircraft.

Sounds like an interesting case. If you rule out fatigue failure based on metallurgical examination and can categorically say that no foreign objects were involved, then you're left with either under-designed structure (or structure which was not built to the design specs) or some event, such as a gust, which overloaded a correctly designed structure. This would be the case for failure causing tumble. But then, as you say, you could also argue tumble causing failure. Then I guess you have to look for the reason for the tumble. I look forward to reading about it when you publish. Did you work with BFU at all on this?

[krujje]

lomapaseo:

and I might add typically free of insults unlike those on a message board where one can hide behind a user name and no worries about losing some teeth in a bash :)

Although sometimes... even in a face to face, especially with certain personality types, you can't stop the discussion from degenerating... some people inspire confidence, some people inspire violence. :)

[PBL]

Did you work with BFU at all on this?

No. It's an English case.

PBL

[Zorst]

In which order does Occam's Razor say the events occurred?

What was the cause of the tumble, if not structural failure?

What good is 'all but proved'? 'All but proved' means 'has not proved'.

[PBL]

What was the cause of the tumble, if not structural failure?

Sorry, discussion must wait until judicial proceedings are over.


What good is 'all but proved'? 'All but proved' means 'has not proved'.

The prosecution in a criminal case in England must show that what they say happened happened beyond reasonable doubt. The prosecution must prove; the defence must show only plausibility of an alternative. So "all but proved" is very helpful to a defence.

PBL

[Zorst]

Yes, but the alternative you have offered is not plausible without a cause for the tumble.

Do you have an answer for Occam's Razor?

[lomapaseo]

John Tullamarine

... but we manage to keep some of the more outlandish folk in line .. at least some of the time ..... fortunately Tech Log discussions generally tend to be goal oriented most of the time ...

agree good job:ok:

Unfortunately the idea of a Thread in the News&Rumors section with a title intended to embarass and bring into ridicule well intentioned supporters of this board will have a very negative effect in the long run.

I couldn't help but notice that the same old garbage still exits in the active professional sounding B777 accident thread while some true gems of knowledge by some expert posters (not speculation) are relegated to the so called garbage thread.

I had always found it more infomative to open ideas for the discussion and examination on this message board prior to talking to the press, having experienced some of my posts being relegated by the moderators to the garbage thread I may have to rethink the usefulness of PPrune as a sounding board prior to launching into the thought pieces in the public domain.

[Nardi Riviera]

I couldn't help but notice that the same old garbage still exits in the active professional sounding B777 accident thread while some true gems of knowledge by some expert posters (not speculation) are relegated to the so called garbage thread.

Have you considered that moderators cannot be online 24/7? So that they may only have managed to merge threads and start a new one in order to keep a minimum of "control" during the most active period?

I have read all posts, and agree that about 10% is worthwhile. Sure takes some patience to sift through the chaff to find the few grains of wheat...

Finding this one was like entering an oasis. ;)

[krujje]

I have read all posts, and agree that about 10% is worthwhile. Sure takes some patience to sift through the chaff to find the few grains of wheat...

I took a look at the number of posts in the 777 thread and decided to wait for the official report... :)

[Mad (Flt) Scientist]

This perhaps does not perhaps belong right here, but there has been much breast-beating of late about how terrible journos are and how "picked on" the poor airline industry is, especially in the context of accidents.

Some of you may have seen a supposed photo of a "creature" on Mars that has been doing the rounds recently. Chris Lintott of the BBC's Sky at Night program has posted a commentary (http://chrislintott.net/2008/01/23/i-give-up/) on the less than stringent BBC article (http://news.bbc.co.uk/2/hi/science/nature/7205004.stm) on this photograph. It should be noted that this is actually a four year old story as the photograph comes from the first pictures Spirit took from the landing site.

Any frustration anyone here feels at media simplification and plain nonsense is easily equalled by his clear dismay. Here's the start of his commentary; follow the link for the rest...

BBC : Mystery image of ‘life on Mars’

Chris : There is no mystery. It’s a rock.

BBC : An image of a mysterious shape on the surface of Mars, taken by Nasa spacecraft Spirit, has reignited the debate about life on the Red Planet. A magnified version of the picture, posted on the internet, appears to some to show what resembles a human form among a crop of rocks.

Chris : There is no mystery. It’s a rock. By ‘reignited the debate’ they mean ’some people on the internet get easily overexcited’.

BBC :While some bloggers have dismissed the image as a trick of light, others say it is evidence of an alien presence.

Chris : Is this supposed to be balanced reporting? It’s a rock.

and so on...

(Mods, if you decide to move this please tell me where you put it; I plan on referring people to it when they next complain about the Daily Mail etc...)

[twistedenginestarter]

This whole BA038 thing has been a real PPRuNe rollercoaster. It's been amazing how much World attention it has garnered. However I have to confess, sadly very little useful information has come out. This is really odd because you couldn't have a better crash - everyone walks away and its right under the noses of tons of professionals in one of the most intensively monitored pieces of aeronautical real estate. And you couldn't have a better group of people than PPRuNers. It's beginning to look like a subtle problem so it almost justifies all the wait-and-see brigade remarks, although don't let them hear I just said that.

[john_tullamarine]

Sure takes some patience to sift through the chaff to find the few grains of wheat...

..that's much of the problem for mods .. PPRuNe is a diversion from the ups and downs of whatever day job we have ... and there is only so much time which can be spent scanning the posts .. when an event of exciting proportions comes along the uninformed component of threads takes a skyward leap and it becomes very difficult to keep things on something approaching an even keel ..

Hopefully we are stemming the tide of excessively overt enthusiasm in Tech Log on this one .. albeit that we are having to run hard to even look like keeping up with it ...

[Flash2001]

Just as an example of the utility of the informed amateur: The Campbell family investigation which forced the NTSB to change its conclusions as to the cause of the United 747 cargo door loss that cost 9 lives over the Pacific Ocean.

Note that the Campbells receive no credit in the amended report.

After an excellent landing you can use the airplane again!

[krujje]

Also look at Gordon Vette with the DC-10 crash on Mt. Erebus. He did quite a lot of research into the psychological and physiological aspects of human perception in order to show that it was quite possible for a pilot to fly straight into a mountain in VMC. He wrote a book called "Impact Erebus" which is quite an interesting read. He was a professional pilot, so in that sense not an amateur, but he was an amateur when it came to human psychology and perception. His arguments had no effect on the official investigation report, but they did have a large influence on the inquiry.

In the end, what distinguishes a professional from an amateur is that professionals are paid for their work and amateurs are not. Anybody who takes the time to learn about a topic and ask the right questions can in time form valid opinions on that topic. If that were not true, then there would be no professionals.