Pilots Palermo ATR Crash received 10-year sentences [Archive]

Magplug

23rd Mar 2009, 20:30

I executed a Go-Around at a major Italian airport a couple of years ago because despite being cleared to land the guy in front had yet to clear the runway, and in my judgement had no prospect of doing so. Now I am as happy as the next guy to land with one clearing but this was just not even close to do-able. So we went round and informed ATC as to why.

By the time we landed from the second approach the local CAA deputation were ready to meet us for a complete ramp check and lots of questions as to why we had done what we had done. The aircraft was attended by an inordinate number of 'officials', we counted 16 various flavours of police officers at one stage.

I never got to the bottom of the story as we left 2.5 hours later having satisfied the local authorities by filing an ASR by fax to the company in UK with full details, (company requirement anyway :confused: ). We thought at the time that ATC might have wished to shift the blame for a lack of separation on finals onto us so preemptively called out the local authorities to investigate. Attack is the best form of defence after all! I even invited the officials to download the FDR data to prove we were flying iaw ATC instructions, but they declined. I have no doubt from my experiences that should there have been ANY suggestion of malpractice or contravention on our part we would have been detained in Italy.

You only have to look around the way they operate to see how backward the place is. This BS procedure with CCTV cameras to check you are ready w/tug before you get your ATC clearance. The apparent turf war that seems to be in progress between ENAC and airport authorities about who controls which bit of the concrete...... A conflict that results in no communication between the two and in no way enhances flight safety. The whole place seems to be a job-creation scheme with each and every official exercising his jealously guarded authority to the max. In the event of any accident or incident in Italy their first reaction is to throw everyone in jail and then start asking questions later. When that enquiry finally happens the emphasis is firmly upon 'who can we hang' rather than what can be learnt.

If you need to divert with a problem, I would strongly recommend one of the more enlightened European nations... unless you want to be thrown in jail.

Mind you, a few thousand Euros in an official back-pocket seems to solve virtually all problems :rolleyes:

Permafrost_ATPL

23rd Mar 2009, 20:45

Regardless of the fairness/unfairness of the judiciary in Italy, what did the accident report say about the cross-checking of the fuel uplift vs fuel gauges? I assume there was a discrepancy?

Not trying to be the devil's advocate here, just not familiar with the details of the accident.

P

deltayankee

23rd Mar 2009, 20:52

Considering the aircraft ditched due to a fuel gauging problem following installation of an incorrect part number, it seems bizarre that the flight crew bore the brunt of the punishment.

Discuss.

I checked the coverage in Italian media. Apparently the position of the court is that it is not the fault of the F/C if the fuel gauge was incorrectly installed but they could have handled the resulting ditching better, saving some lives. The arguments are that they did not warn the pax to prepare for ditching, that they landed with a tailwind across the swells, that the ROD was too high. In addition it was later determined that they could have reached Punta Raisa airport from where they were.

To the public these perhaps sound reasonable arguments, but there is clearly plenty of room for appeal -- especially the flawed logic about what might have been done. A better lawyer might have helped.

For Italian speakers, there is a detailed summary of this in "ATR, Le Cause della Tragedia" from La Repubblica at Atr72, le cause della tragedia | Palermo la Repubblica.it (http://palermo.repubblica.it/dettaglio/atr72-le-cause-della-tragedia/1608169)

saucy jack

23rd Mar 2009, 22:02

Permafrost, if I recall correctly from coverage at the time, it was reported that the crew signed off a fuel uplift of something like just 90 litres for their return trip from Italy to Djerba. So yes......this suggests a discrepancy which could/should have been picked up on before the flight.

deltayankee

23rd Mar 2009, 22:13

the crew signed off a fuel uplift of something like just 90 litres

According to today's summary of the case in La Repubblica the actual figure was 250kg.

JanetFlight

24th Mar 2009, 03:02

I didnt know that the crew survived..:rolleyes:

vonbag

24th Mar 2009, 06:13

Good day to all,

Here is the final report of ANSV (Italian Aviation Safety Board)
"Accident involved aircraft ATR 72, registration marks TS-LBB
Ditching off the coast of Capo Gallo (Palermo – Sicily), August 6th 2005":

http://www.ansv.it/cgi-bin/eng/FINAL%20REPORT%20ATR%2072.pdf

Good continuation,
Paolo

Baron737

24th Mar 2009, 08:42

If you need to divert with a problem, I would strongly recommend one of the more enlightened European nations... unless you want to be thrown in jail.Good idea. One of our CPT´s is not able to fly to Italy, as he would go to jail because
of some security bullsh... some years ago.

ProM

24th Mar 2009, 09:08

Well I've just read the conclusions of the report linked to Vonbag and its difficult to justify 10 years from that.

yes the crew did not follow correct procedures (and in particular feathering which would have reduced the rate of drop). But the report admits that although the aircraft theoretically could have made palermo, with only standby instruments and whilst trying to re-start etc it would have been very difficult to do so in practice. The report also concludes that is not clear which direction the plane landed with respect to swell and that the pilot could not determine swell direction and changed course towards some boats to aid rescue efforts (which seems sensible).

Good luck to any appeals

lamer

24th Mar 2009, 09:09

so you're telling us that your "airline" has convicted criminals masquerading as captains actually flying passengers around? :ooh:

who do you work for again?

;)

Bus429

24th Mar 2009, 09:31

I checked the coverage in Italian media. Apparently the position of the court is that it is not the fault of the F/C if the fuel gauge was incorrectly installed but they could have handled the resulting ditching better, saving some lives. The arguments are that they did not warn the pax to prepare for ditching, that they landed with a tailwind across the swells, that the ROD was too high. In addition it was later determined that they could have reached Punta Raisa airport from where they were.

The old hindsight bias or what? Lot easier after the fact.

deltayankee

24th Mar 2009, 10:20

The old hindsight bias or what? Lot easier after the fact

Yup. I am not surprised that the prosecution tried this but I am amazed they made it stick. This kind of sim session only makes sense to learn lessons for the future.

bluepilot

24th Mar 2009, 10:43

this accident is to be broadcast on national geographics "air accident investigations" next monday. It will be interesting to see how the flight crew are portrayed in the film.

I hope the italian authorities see sense on this one, but I doubt it :* :ugh:

John_Mc

24th Mar 2009, 11:26

Judging by the comments on this thread already, I doubt the news article I'm pasting below is accurate. Where did they get that the pilot was praying from??

Italy convicts crash pilot who paused to pray - The Irish Times - Tue, Mar 24, 2009 (http://www.irishtimes.com/newspaper/breaking/2009/0324/breaking25.htm)

Italy convicts crash pilot who paused to pray

A Tunisian pilot who paused to pray instead of taking emergency measures before crash-landing his plane, killing 16 people, has been sentenced to 10 years in jail by an Italian court along with his co-pilot.
The 2005 crash at sea off Sicily left survivors swimming for their lives, some clinging to a piece of the fuselage that remained floating after the ATR turbo-prop aircraft splintered upon impact.
A fuel-gauge malfunction was partly to blame but prosecutors also said the pilot succumbed to panic, praying out loud instead of following emergency procedures and then opting to crash-land the plane instead trying to reach a nearby airport.
Another five employees of Tuninter, a subsidiary of Tunisair, were sentenced to between eight and nine years in jail by the court, in a verdict handed down yesterday.
The seven accused, who were not in court, will not spend time in jail until the appeals process has been exhausted.
Reuters

John_Mc

24th Mar 2009, 17:40

Possibly, but what he was praying for is irrelevant. A professional pilot trained to deal with emergency situations starts praying at a time when he is needed most.

I'm amazed there hasn't been more discussion about this on here:eek:

planeenglish

24th Mar 2009, 17:54

Deltayankee wrote: The arguments are that they did not warn the pax to prepare for ditching

After this accident it became law in Italy that cabin crews have members who speak Italian. It seems that the passengers weren't able to understand the commands from the flight attendants before impact and after. I don't know if they were speaking English to them or not but for ENAC it doesn't matter. Italian speaking crew members are required for flights inbound or outbound in Italy.

PE

FrequentSLF

24th Mar 2009, 18:00

After this accident it became law in Italy that cabin crews have members that speak Italian. It seems that the passengers weren't able to understand the commands from the flight attendants before impact and after. I don't know if they were speaking English to them or not but for ENAC it doesn't matter. Italian speaking crew members are required for flights inbound or outbound in Italy.

Do you think that the SLF in Italy shall pass a ICAO level 4 proficiency test before boarding the plane?

ElNino

24th Mar 2009, 18:28

Italian speaking crew members are required for flights inbound or outbound in Italy.

I have not heard this rule before. Has anyone documentary evidence as to its veracity?

bjornhall

24th Mar 2009, 18:42

That Reuters article is appaling, and I'm sad to see the BBC has picked up the same nonsense.

prosecutors also said the pilot succumbed to panic, praying out loud instead of following emergency procedures and then opting to crash-land the plane instead trying to reach a nearby airport.

The problem with that statement is that there are a great many of us who know, for a fact, that if Reuters' version of the prosecutor's claim is true (important caveat!), then the prosecutors are lying. The last five minutes of CVR recording (the actual recording, not the transcript) was leaked and was available on the web for a brief while. Lots of people had time to listen to it. As unacceptable as that is, at least it allows us to see right through the prosecution's "case".

From listening to the recording, you can tell a great many things, for instance:

- There was no "praying out loud". That is a downright lie. There are some low whispers, the last few seconds before the ditching, that might be prayers (I don't speak Arabic so I can't tell). But the crew was still flying at the time.

- There is absolutely nothing on the CVR that even with the most absurd degree of imagination could be indicative of "panic".

- The flight crew warned the cabin three times in the last few minutes before the crash, in French and in English ("brace for impact"). The cabin crew, and at least some of the passengers, would have understood the calls.

- The crew worked together very efficiently throughout the event. The captain handled flying and communication, the first officer handled checklists. In particular, it was a pleasant change to actually hear a ditching or forced landing checklist being actioned. That is quite rare; crews faced with an off-airport landing usually get stuck in the first emergency checklist they action, and never progress to the relevant forced landing checklist. This first officer started actioning the ditching checklist on his own initiative as soon as the captain informed ATC they would be ditching. That included taking the relevant actions, and reading out loud the advice on attitude etc from the checklist to the captain.

This conviction is an absolute disgrace. :*

FrequentSLF

24th Mar 2009, 18:49

This conviction is an absolute disgrace.

Yes I do agree. A couple of points
1) Why the warning was not made also in Italian? At least from the FA?
2) Instead of blaming the judiciary system, why do not blame the defense lawyer, which was not able to provide the proper evidence to prove the innocence? Is part of a judiciary system to accuse someone and to prove or not such accusations, IMHO the blame shall go to the defense lawyer.

deltayankee

24th Mar 2009, 19:36

Why the warning was not made also in Italian? At least from the FA?

Perhaps neither of the two spoke enough Italian.

Instead of blaming the judiciary system, why not blame the defense lawyer?

I also agree that the defense lawyer did a very poor job but Italian legal practice has some oddities. One is that it seems in many cases that the first sentence -- called "not definitive" -- is extremely harsh but after the appeals they hand down a definitive sentence that is quite often the exact opposite. Maybe the lawyer is waiting for the next phase before making a serious effort.

I also agree that the Reuter's piece was outrageous. There is enough serious news in this story to fill a whole paper and they focus on one racist insinuation. Perhaps the "praying" they describe was nothing more than the "Jesus wept" you might hear in any flight deck when things go pear shaped.

One other thing that struck me about this case is that they seem to assign the blame 50/50 to the captain and F/O. Is this correct, and if it is does this mean that they do not recognize the responsability of the captain in making the decisions?

Enrik767

24th Mar 2009, 19:36

here you can listen to the last 5 minutes of the CVR :

YouTube - They were doing their job as professionals till the end (http://www.youtube.com/watch?v=7ZSGw51ZkmA)

im really angry with Reuters article and the italian court :*:*:*

Latearrival

24th Mar 2009, 21:32

Just listened to the CVR. The "news" stories are total crap. I can't comment on what the pilots coulda and shoulda done to achieve a better outcome but the Captain and FO appear to have been trying to do their jobs given the extreme circumstances. Isn't the airline to blame for not rostering crews that can communicate effectively with pax? The sentence seems unduly harsh!

This is probably a dumb question....but is there a pilots' association that ever gets involved in trying to bring public attention to something that seems to be an obvious injustice?

manrow

24th Mar 2009, 21:39

Latearrival, the answer is No.

Zuco103

24th Mar 2009, 23:00

Pilot who paused to pray in crash-landing sentenced to 10 years in jail

A Tunisian pilot who paused to pray instead of taking emergency measures before crash-landing his plane, killing 16 people, has been sentenced to 10 years in jail by an Italian court along with his co-pilot.

Pilot who paused to pray in crash-landing sentenced to 10 years in jail - Telegraph (http://www.telegraph.co.uk/news/worldnews/europe/italy/5043287/Pilot-who-paused-to-pray-in-crash-landing-sentenced-to-10-years-in-jail.html)

Is that a good enought reason for you??

Zuco103

24th Mar 2009, 23:12

...A fuel-gauge malfunction was partly to blame but prosecutors said the pilot had succumbed to panic, praying out loud instead of following emergency procedures and then opting to crash-land the plane instead trying to reach a nearby airport...

Ex Cargo Clown

24th Mar 2009, 23:19

Italian speaking crew members are required for flights inbound or outbound in Italy.

I've never heard of that rule, but if it is true then it is up there with the most stupid rules I have ever heard of in my entire life.

triton140

24th Mar 2009, 23:39

Having read the report, I think Rome and Palermo ATC have a lot to answer for - seemingly badly handled from their side, but nary an adverse comment ......

Ex Cargo Clown

25th Mar 2009, 01:25

Simple answer to this, anyone flying to, from, or overflying Italy, pull your CBs for CVR and FDR.

It's absolutely outrageous this nonsense from quite possibly the most corrupt and awful country in the EU (if not the World).

FrequentSLF

25th Mar 2009, 01:33

I've never heard of that rule, but if it is true then it is up there with the most stupid rules I have ever heard of in my entire life.

What is the main reason for having FA? Safety.
If they cannot communicate in an emergency with the SLF safety is compromised.
Otherwise I am the most stupid SLF on earth.

20driver

25th Mar 2009, 01:38

Listening to the CVR I really found the ATC to be obtuse to put it mildly. They were told we are going in, get help moving and they keep coming back with useless babble.
To be fair you have two groups communicating in a second language so this is difficult but I would gives the flight crew much higher marks than ATC.
All things considered I do think the crew did a good job with the emergency
(They are getting one hell of a pass on the fuel uplift - shades of the Gimil glider)

20driver

Interesting side note. This site is always saying the pilots are being shafted with the release of CVR. Anyone one see a bit of hypocrisy in that? Would everyone be happier with an "official" summary of the transcript in this event.

Ex Cargo Clown

25th Mar 2009, 02:00

What is the main reason for having FA? Safety.
If they cannot communicate in an emergency with the SLF safety is compromised.
Otherwise I am the most stupid SLF on earth.

You'll find that all emergency instructions on board are illustrated.

If the PAX are too thick to understand that, then that is their problem. Do you expect two FAs to speak every language on the planet ??

Think about the logical conclusion to this argument. BA flight LHR-PEK, the rostered FA who speaks Chinese goes sick at the last minute. What do you do, delay the flight as it has 50/50 English/Chinese speakers as PAX ????

Cash Machine

25th Mar 2009, 04:30

http://news.bbc.co.uk/2/hi/europe/7962082.stm:confused::confused::confused::confused:

FrequentSLF

25th Mar 2009, 05:36

Think about the logical conclusion to this argument. BA flight LHR-PEK, the rostered FA who speaks Chinese goes sick at the last minute. What do you do, delay the flight as it has 50/50 English/Chinese speakers as PAX ????

No the flight shall not be delayed, just roster another Chinese speaking in stand-by.

You'll find that all emergency instructions on board are illustrated.

If so, what is the need to have FA on board?
IMHO it makes a lot of sense to have at least one FA speaking the language of departure and arrival airports

bjornhall

25th Mar 2009, 06:37

IMHO it makes a lot of sense to have at least one FA speaking the language of departure and arrival airports

You are aware that there was an Italian speaking flight attendant on the flight, right?

Daniel_11000

25th Mar 2009, 07:02

At least one Italian-speaking flight attendant is required for wet-leased-in aircraft, not for scheduled flights from other Countries. In other words, if an Italian airline flies its scheduled flights under its code, with a Foreign aircraft (operated and under control of a Foreign airline), then on board that Foreign airline at least one FA need to be Italian speaking. The solution is frequently found in having on-board a FA of the Italian airline momentarily seconded to the foreigh airline.
D

Bobbsy

25th Mar 2009, 07:40

A usually-just-lurking SLF here.

Thank you to Enrik767 for the Youtube link. I would not normally agree with CVR recordings being leaked like this but I had been sucked into believing the Reuters/BBC version about an unprofessional "praying" crew. Hearing it for myself, nothing could be farther from the truth.

It's pretty clear that this crew is being royally shafted by whoever released the "praying instead of flying" version of the story...likely the Italian authorities.

Bob

His dudeness

25th Mar 2009, 09:09

The italians love to strike for the smallest things. Why on earth is the pilot association of Italy not acting? This ruling will set an example. And it is ridiculous.

bullet190

25th Mar 2009, 09:52

One thing that would've pissed me off something rotten whilst is such a stressful situation was the ATC asking several times whether they were going to make the field and just not adding anything beneficial during the whole 5 mins. I've no knowledge of the ATR but a 20nm glide from 4000ft seems rather hopeful. Not much he could've done about the a/c but stop repeating the same question and maybe show some initiative and tell the pilots that he was sorting out some out of rescue and leave them to concentrate on landing the a/c.

If it was a 20nm glide that was needed (I don't know that exact figure) then there's no way they would have been able to do that from 4000'. Even an up to date jet would struggle to get 10nm from 4000' and an ATR would be less than that.

Having now listened to the CVR the point concerning ATC is something that also crossed my mind. Although I can totally understand their willingness to help sometimes you have to know when to keep quite and let the crew do there job. :=

Ber Nooly

25th Mar 2009, 13:14

Did anything happen to the maintenance crew who were the reason for the crash in the first place by putting an 42 gauge in a 72??!!

Ber Nooly

25th Mar 2009, 13:30

Here's the Accident Investigation Final Report...

http://www.ansv.it/cgi-bin/eng/FINAL%20REPORT%20ATR%2072.pdf

Note the cause listed on pages 198 is the maintenance f*ck up. It cites nine contributing factors, 8 of which were totally non-flightcrew related!

islandjumper

25th Mar 2009, 14:02

^BC-EU--Italy-Pilots Sentenced,0357<
^Pilots' group blasts Italy over air crash trial<
¶ BRUSSELS (AP) _ The international pilots' association on Wednesday denounced the long prison sentences given to the pilot and co-pilot of a charter flight that crashed off Sicily in 2005 killing 16 people.
¶ "Once again the compulsion to apportion blame has outweighed the greater need to improve the safety of air transport," said a statement released by the London-based International Federation of Airline Pilots' Associations.
¶ The federation said that a court in Palermo, Italy, on Monday convicted the two pilots of manslaughter and sentenced them to 10 years each. It also sentenced five other people, including executives of the Tunisian charter operator, to lesser prison terms.
¶ Italian aviation authorities say the ATR-72 went down Aug. 6, 2005, after running out of fuel, because the fuel gauge on the plane was the wrong model and did not show that the fuel tanks were nearly empty.
¶ The judges determined that the captain lost control of the situation. According to the plane's cockpit voice recorder, he ceded command of the plane to his co-pilot and began praying, Italian media reported.
¶ But the federation said the flight crew reacted to the loss of power in a textbook fashion and completed a successful ditching at sea. Under international accident investigation rules such circumstances would not be grounds for a criminal prosecution.
¶ Italy has been criticized in the past for its stance on accident related prosecutions and "this case provides another example of this policy," said Gideon Ewers, the group's spokesman.
¶ The pilots' federation "calls on the Italian Government to act now to amend the laws which continue to have a detrimental effect on air safety, and in doing so improve the safety of the traveling public," he said.
¶

bsieker

25th Mar 2009, 14:27

The official report mentions an enclosed CD-ROM with ...
Animated reconstruction of Flight TUI 1153:
take-off from Bari and final phase of the flight

Has anyone seen that? I cannot find it on the popular internet video services.

(I don't think it will give any new insights, just curious in this case.)

And I also hope that higher court instances will see wisdom and overturn the sentences. This would be ridiculous if it weren't so sad.

Bernd

Ber Nooly

25th Mar 2009, 16:12

¶ The judges determined that the captain lost control of the situation. According to the plane's cockpit voice recorder, he ceded command of the plane to his co-pilot and began praying, Italian media reported.

So, if Italian media say it then it must be true? I have a lot of dealings with Italians and I have noticed there is a natural tendency against all things muslim. The tone of the above implication that the captain said "here, you fly the thing, I'm going off to pray" is nothing short of criminal in itself.

planeenglish

25th Mar 2009, 17:39

Here is the mandate in Italian. (http://www.enac-italia.it/repository/contentmanagement/node/n756372012/reg-lingua_italiana.pdf) Mandate in English. (http://www.enac-italia.it/repository/contentmanagement/information/n1820253298/translation_regitallangonboard.pdf)
Best,
PE

Magplug

25th Mar 2009, 19:19

My observations:

The proceedings started off with a rather shameful turf war typical of the Italians. The ditching position (according to my plot) lies 3nm into International Waters so the responsibility for investigation lies with the state of registration. Clearly not content with this situation the Italians muscled in in search of the guilty.

The French BEA, representing the state of manufacture, made several complaints that their participation was impeded by the Italian judiciary. See the letter at the end of the report.

On departure from Tunis the Captain should have verified any fuel uplift discrepancy using a calculation based on the fuel delivery note. For some reason this note was not available and he elected to depart without verification of any uplift discrepancy. Most companies require a manual drip-stick check in these circumstances to manually verify the fuel on board. The FO was not involved in this decision.

There appears to have been no rationalisation of 'Arrival Fuel' against 'Fuel used' on arrival in Bari. Following refuelling another refuel discrepancy occurred that was not explained by any prevailing circumstances. Again, a manual fuel check should have been performed with the participation of the FO in the decision process. The Captain elected to depart without.

I have listened to the CVR recording (shamefully released by the Italians to the media), and I conclude they spent an understandable amount of time attempting to relight an engine before completing the ditching checklist. The No1 CCM spoke Italian and evidently all passengers were wearing life jackets when they hit the water - They were not unprepared for ditching as reported.

The Italians seem to have gone to inordinate lengths in subsequent simulator trials to prove that the crew could have glided to Palermo.... How does this contribute to the investigation and future safety ? In the two trials quoted a pair of very experienced training Captains made it.......just. The second, a regular line crew did not. You might ask yourself if a controlled ditching right next to a likely rescue vessel is preferable to a crash landing as you cross the coast..... you will always have an Italian Judge to tell you that you made the wrong choice.

I don't think I have ever seen a report so bureaucratically verbose that seems intent on showing the world how clever they are. It is clear from the beginning that despite the ICAO preamble of 'not apportioning blame', that is precisely what they have achieved.

The pilots were guilty of not carrying out standard 'fuel-uplift' and 'fuel-used' checks that would have revealed the core problem. The fact that the FO was not involved in either of the fuel discrepancy decision processes might be very telling from a CRM and cultural perspective.

Like many incidents, after the initial cock-ups I believe the subsequent handling and preparation for ditching was handled as well as any line crew might be expected to do.

Negligence.... Yes..... worthy of 10 years in jail...... I don't think so. If you think sitting in the RHS carries little or no responsibility then think again.... Kegworth proved that a long time ago.

Remember, when in Italy..... It's a third world country just waiting to throw you in jail. Make sure your operation is whiter than white, and make sure you are both involved in ALL safety critical decisions.

SPA83

25th Mar 2009, 21:41

ANSV

2.13.2 Accident origin and analysis.

The accident originated from the incorrect replacement of the fuel quantity indicator (FQI) performed the day before. However, this should not be considered the main cause.

The event has been analysed not only as a human error performed
· by mechanics/technicians who replaced the FQI not searching for the correct item
· by the aircraft’s crew who, although they had the possibility of notice the incorrect replacement, did not perform any corrective action
but also as a series of organizational errors.

All people involved in the event did not received sufficient aid from the system in which they were operating to avoid the so-called fatal error.

The error that caused the accident has been determined by errors carried out by so-called “front-line” operators, but such errors occurred in a critical operational situation which, if it has not been so, maybe would have prevented the accident itself.

The aetiology of the event shows in fact the presence of multiple factors:
· errors committed by ground mechanics when searching for and correctly identifying the fuel indicator
· errors committed by the flight crew
· non respect of various operational procedures
· lack of adequate control by responsible persons of various sectors of the operator’s organization
· lack of an adequate quality control system
· lack of accuracy of data entered in the spares management system database
· mechanics not adequately trained on use and procedures for spares search with the spares management system
· deficiencies in maintenance and configuration control for the fleet’s aircraft
· procedural deficiencies in technical management and maintenance of the aircraft
· low qualitative standard for maintenance operations
· inadequate surveillance of the operator by the competent Tunisian authority
· lack of Flight Data Monitoring system
· lack of adequate Safety Management System

From the above mentioned considerations, it is possible to affirm that in the event two types of errors (failures) occurred: active and latent failures.

justanotherflyer

25th Mar 2009, 23:31

which in any case is minimal, is perfectly understandable in the cultural context of the pilots' origins, as natural to them as a westerner imprecating his own secular or other divinities with swear words, pleas or curses.

Psychologically it is just as likely to be helpful as it is to be hurtful to the pilots' efforts, allowing an excess of tension and anxiety to be expended as they focus their efforts on the relight attempt and the ditching procedures, while all the time the useless ATC voice booms distractingly in the background.

For Reuters to make a 'story' out of this element is totally shameful. But 'technical problems contribute to crash' is so less attractive a headline to the entertainers (sorry, I mean editors) of that once-upon-a-time renowned news organisation.

Airflight69

26th Mar 2009, 00:28

Really poor performance by ATC. I can also see the mistakes on pilots part and praying is not it. Manually checking the fuel should be mandatory. Ground mechanics are, without a doubt, the ones to be blamed here. The pilots, in this case, deserve no more than a wrist slap and a ban from commercial aviation.
But on the other hand, to contradict myself, the PIC must carry out all the relevant checks prior to departure and should be held responsible in failure to do so.

OFF TOPIC.
(note to self) so that`s what level 4 English sounds like. Phew, that`s a stone off my chest.

Artisan

26th Mar 2009, 00:56

The delegates to the 64th Conference of the International Federation of Air Line Pilots’ Associations (IFALPA) unanimously voiced their dismay yesterday when informed that once again the compulsion to apportion blame has outweighed the greater need to improve the safety of air transport. In Palermo yesterday sentences, totaling 62 years, were handed down against the flight crew and management of Tuninter in connection with the August 2005 ditching of an ATR72 off the coast of Sicily.

The technical investigation into the circumstances leading to the crash revealed that it happened because an incorrect fuel gauge sensor was fitted to the aircraft which, in turn, lead to a double engine failure due to fuel exhaustion. The flight crew reacted to the loss of power in a textbook fashion and completed a successful ditching at sea. Under the internationally accepted approach to accident investigation such circumstances would not be grounds for a criminal prosecution.

IFALPA strongly believes that this prosecution was totally unwarranted given the facts of the accident and furthermore once again calls into question its commitment to the improvement of air safety. Italy has been criticized in the past for its stance on accident related prosecutions and this case provides another example of this policy.

IFALPA calls on the Italian Government to act now to amend the laws which continue to have a detrimental effect on air safety and in doing so improve the safety of the travelling public.

Piltdown Man

26th Mar 2009, 01:03

If this crew are guilty then so are two other parties. The goons from the "Hang 'em high" squad from the Italian justice department (Justice? My RRrr's) and the plonkers from the ANSV. The report will be used by other investigators, but only as an example of how not to write one. The Italians should be ashamed of themselves. Little will be learnt from this debacle other than to install paper shredders and disk erasers on all aircraft that fly near Italian airspace.

We deserve more from the Italians than this.

PM

Luap

26th Mar 2009, 02:23

....................
Prosecutors say that after both the plane's engines cut out, the pilot succumbed to panic, praying out loud instead of following emergency procedures and then opting to crash-land in the Mediterranean instead of trying to reach the nearest airport.
............................
quote from: http://news.bbc.co.uk/2/hi/europe/7962082.stm

http://www.youtube.com/watch?v=7ZSGw51ZkmA
On this cvr recording, no panic or long prayers are heard. Could it be possible that this cvr recording isn't complete, or where long prayers removed by editing the sound?

Or are the prosecutors lying?

Bobbsy

26th Mar 2009, 04:00

SLF here again.

I've had a skim through the ANSV report and notice that it gets pretty political at times, with complaints (probably justified) about the police hanging onto the CVR and FDR for a couple of weeks before letting the proper crash investigators get access. The report is actually used at one point to call for changes in legislation to remove police and judicial powers during the investigation.

Knowing a bit about the Italian system, my fear is that politicising a report like this "got up the noses" of the police and prosecutor's office and they decided they needed a show trial to prove that ANSV is "soft on the industry". The "praying not flying" allegations, as far as I can see, come from the prosecutor whose job it is to paint the accused as badly as possible.

So, if I'm right, the poor crew got caught in the middle of an Italian political power struggle.

Bob

Dan Winterland

26th Mar 2009, 04:55

In 1968, a Civil Air Transport (CAT) 727 crashed on approach to Taipei. The crew were following the ILS indications and flew into the ground. The ILS had previosly been reported as being unreliable but was still being used. Many on board were killed, but the flight deck crew survived. The crew were charged with manslaughter, the first time ever in aviation history that pilots had been charged with such a crime after an accident. In the meantime, the Taiwan authorites checked the ILS and decalred it safe, only letting the NTSB inspect the facility after 'routine maintenace"had been carried out.

CAT were an American airline which were based in Taiwan having moved there after the fall of China to the Communists, and were involved in many disagreements with the Taiwan authorities. It appears the charges were politically motivated. Many pilots were prepared to attest the ILS was malfuntioning , but were not called to give evidence during the court case. It was looking bad for the accused until the chariman of IFALPA went to Taipei and pointed out that IFALPA members were prepared to boycott Taiwan entirely.

The crew were aquitted when the Taiwanese realised IFALPA had the power to isolate their country.

Ernest Gann wrote a novel based on the incident called 'Band of Brothers'.

Southernboy

26th Mar 2009, 08:55

Politics has no place in safety critical industries or in accident investigations. Regulators & politicians are the ones who need to get a grip of this sort of thing.

The You Tube recording was of a crew finding themselves in a very tight spot indeed & attempting to stay calm & deal with it professionally. Maybe it wasn't perfect but few of us are.

If the pilots are guilty enough to be jailed, how about the regulators who are criticised in the report, the company management & specifically the person in charge of engineering shop procedures?

Of course there is the fuel number mis match but I don't find the report that clear on that issue.

deltayankee

26th Mar 2009, 09:24

it happened because an incorrect fuel gauge sensor was fitted to the aircraft

Surely then the manufacturer is also partly to blame. If there are two apparently identical but incompatible gauges it should not be possible to exchange them. This could be done with a simple mechanical modification like a pin that sticks out on one side for a 42 and the other side for a 72 and modify the panel accordingly so you can only install the right one.

gianmarko

26th Mar 2009, 09:50

Study finds criminal prosecution following accidents damages flight safety (http://www.flightglobal.com/articles/2009/03/19/324018/study-finds-criminal-prosecution-following-accidents-damages-flight.html)

unfortunately that is how things in italy are done. whenever something happens, justice system takes over, seize everything, throw everybody in jail then in the best case forget about it, or after years of court auditions distributes heavy sentences. there is indeed a battle between ANSV, aeronautical authorities and justice system because investigation are delayed or totally impeded by the justice system intrusions. last year a microlight was invoklved in a fatal accident, local authorities seized the wreckage then forgot about it. i think it is still unavailable for any investigation.

if italian ATC is as bad as it is, is also because they constantly operate in CYA mode, expecially after OE-FAN

gianmarko

26th Mar 2009, 09:54

"On this cvr recording, no panic or long prayers are heard. Could it be possible that this cvr recording isn't complete, or where long prayers removed by editing the sound?

Or are the prosecutors lying?"

italian media is 50% BS, 25% fabrication, 25% distortion

not that other mainstreammedia is much better, they all take the garbage from newsagencies

Michael Birbeck

26th Mar 2009, 10:50

Sadly, Italy, a great place in many ways, has a political and justice system, that is akin to the worst Banana Republics. Corruption is rife, adherence to the rule of law and the spirit of justice tenuous. Internicine fueding between agencies widespread. In some areas, organised crime actually runs the show. What has happened to these pilots is a travesty of justice and surely airline pilots worldwide should make it clear to the Italians that this is not on. This sentence should not be allowed to stand. Underlying this may also be a subtle form of religious discrimination or racism. An appeal to the European Court of Human Rights might actually wake the Italians up. A 3rd world state on a 1st world continent. :(

stickyb

26th Mar 2009, 11:41

I found it interesting to read the ICAO report on Italy AuditReports1-CSA (http://www.icao.int/fsix/auditRep1_csa.cfm)

They scored on or above average on all sections.

However, the section about legislation contains the following gem.
In practice, the ANSV and its investigators have full control over all elements of the investigation when the judicial authorities do not undertake any investigation. In the other case, subject to the decisions of the judicial authorities, access by the ANSV investigators to the elements of the investigation as well as the examination of aircraft parts and components may be significantly delayed or even prevented.

The Italians included a section on actions with a date of December 2006 to fix that issue..............

Daniel_11000

26th Mar 2009, 11:57

"..Underlying this may also be a subtle form of religious discrimination or racism. An appeal to the European Court of Human Rights might actually wake the Italians up. A 3rd world state on a 1st world continent"

Yes, I expected all of the above. As soon as somebody points out a real – or perceived – problem in Itlay, Ppruners all around the world start to judge our political/social/judiciary system, which is something I really appreciate when and if this becomes a constructive (compared to distructive) critique.
Accusing our system to be ‘racist’ and then classifying Italy as a ‘3rd world state in a 1st world continent’ says it all about the moral honesty (and subtle racism, this time for true) of the person who is happily dividing the world in three classes…

Michael Birbeck

26th Mar 2009, 12:44

Daniel 11000

There is nothing "racist" about defining a country in terms of 1st, 2nd or 3rd world status. It simply a review of key indicators across a list of internationally recognised metrics of the development of a country (of which the justice system is one element). To be fair Italy (a country I like) ticks many of the 1st world boxes. Sadly the Italian justice system is a scandal. Whatever happened to the precepts of Roman Law that underpin the justice system core to many systems here in Europe? And yes, I did study Roman Law and , yes, I did study in a 3rd world country. South Africa to be exact. Make of that what you will!:ok:

Daniel_11000

26th Mar 2009, 13:24

So now it seems to me that we disagree only on the fact that some Countries can/cannot be classified as ' 3rd world'... (or 1st, or 2nd..)
Daniel

airship

26th Mar 2009, 13:36

Never lose sight of the fact that we're discussing an Italian court's decision. An ostensibly 1st world country and EU member. But whose law-making processes and/or judiciary have often caused the Economist newspaper to express grave concerns over the past decade or so. Especially all those laws and/or amendments which almost 'miraculously' save/d Silvio Berlusconi from prosecution over various alleged offences...

So far as I'm aware, the ATR airplane in question is a product of a consortium, that is to say, a joint-venture between EADS and (you guessed right) Italy's FINMECCANICA / Alenia Aeronautica. The court basically found that all of the blame rests on shoulders well down-stream of the manufacturer/s, oh well...

It's a sobering thought (or should be) that in today's EU, a decision by any one of the EU member states' courts against any individual, regardless of where they are currently in the EU, is expected to be acted upon without any further due process etc. So that if an Italian kangarou court decides you're due 10 years' nick, and you're found in UK, the UK are obliged to send you over to Italy without any extradition process or whatever required beforehand (have I got that right?).

Like some others here, I'm extremely disappointed by all the media reports about the prayers (which the CVR doesn't support). As always, it would be useful to know just how much of their income such media depend on from the commercial enterprises involved. Or how many BNP supporters buy their newspapers...

Had this particular ATR airplane been flying nearby the Hudson, instead of in Italian airspace with poorly English-speaking ATC controllers, the outcome might have been quite different (even with the same casualties), with all the media acclaiming the pilots' efforts...?! :rolleyes:

NotPilotAtALL

27th Mar 2009, 04:28

Hello,

It's a sobering thought (or should be) that in today's EU, a decision by any one of the EU member states' courts against any individual, regardless of where they are currently in the EU, is expected to be acted upon without any further due process etc. So that if an Italian kangarou court decides you're due 10 years' nick, and you're found in UK, the UK are obliged to send you over to Italy without any extradition process or whatever required beforehand (have I got that right?).

Yes you got it right .. :ok:
That's the EAW (European Arrest Warrant)
SCADPlus: European arrest warrant (http://europa.eu/scadplus/leg/en/lvb/l33167.htm)

Regards. http://smilies.sofrayt.com/%5E/a/bye.gif

BuzzLightyears

27th Mar 2009, 08:11

Ridiculous, simply OUTRAGEOUS

... and by the way everybody knows that exept for a couple of exemption the Italian Magistrates do not have a very good reputation :mad:

diddy1234

27th Mar 2009, 09:53

Instead of following check lists after a fuel problem, this pilot decided to pray.

Crash pilot who paused to pray is convicted | U.S. | Reuters (http://www.reuters.com/article/newsOne/idUSTRE52N63B20090325)

I am sure others will, but I won't comment on this.....

HEATHROW DIRECTOR

27th Mar 2009, 09:56

Well, the Archbishop of Canterbury said God isn't going to help us. Maybe that pilot hadn't been told!

Love_joy

27th Mar 2009, 09:58

Had just been reading this in the Irish Press.... crazy.

Also a link here: Pilot who paused to pray in crash-landing sentenced to 10 years in jail - Telegraph (http://www.telegraph.co.uk/news/worldnews/europe/italy/5043287/Pilot-who-paused-to-pray-in-crash-landing-sentenced-to-10-years-in-jail.html)

SweetChariotXV

27th Mar 2009, 10:06

YouTube - Tuninter Ditching Black Box (http://www.youtube.com/watch?v=rVPv_mrU95w)

not sure they deserved 10 years for this... it wasn't as if they were praying completely the last few minutes prior to impact. The inevitable was about to happen, in the last few seconds he / they prayed.

Long D

27th Mar 2009, 10:11

They read the checklist, you people like to fun of anything, so what if they prayed. What is wrong with prayer. I hope you won't be put in any situation as this, then we know whom will you be calling upon. If you are sure then there will be no screams on the tape.

dontdoit

27th Mar 2009, 10:12

IFALPA...hello, hello, anyone home? Come out of your useless talking shop and show us what you're made of ! There but for the grace of God & the grace of Swiss Cheese go all of us who operate into, out of, or through Italian airspace. I thought we had seen the end of this sort of nonsense with the Swissair guys who had the misfortune to end up in jail after going off the end at the old Athens airport, but obviously not. Disgraceful.

Michael Birbeck

27th Mar 2009, 10:17

Don't believe everything you read in the press. Also try and note what other threads are covering the same topic. :ugh:

The (disgracefully) leaked CVR shows a professional crew (pretty much unaided by woeful Italian ATC) making a decent fist of ditching the aircraft. A couple of murmured prayers prior to touch down are hardly the basis for a case against these men even though I for one would be swearing, not praying.

Airflight69

27th Mar 2009, 10:34

Well it seams their prayers have been answered, they survived the crash. On a more serious note there is no difference between saying "god help us" or "holly sh*t". They still carried out the relevant check list before impact.
Are you people trying to say that more lives would have been saved if the pilots were not religious and had not prayed?

JammedStab

27th Mar 2009, 11:43

Is there a transcript of the CVR written down?

Lurking123

27th Mar 2009, 11:48

Having read the very comprehensive accident report, it seems to me that the Swiss cheese was running in overdrive but there were also a number of culpable errors (fuel mis-management) by ground ops personnel and aircrew. The 'praying' bit is merely a headline grabbing element.

Ber Nooly

27th Mar 2009, 12:00

Michael, maybe it's actually a good thing that the CVR was leaked. :ok: Imagine if it wasn't and all we had to go on were the media reports....what hope would the crew have of support from you pro pilots in their appeal? Very slim at best. At least now you've all heard the real story and can put your weight behind it to turn around this disgraceful decision. :D

bullet190

27th Mar 2009, 14:28

True, but if the CVR were not available it would not have been used in the case against them - it's a double edge sword.

It's an argument for not having FDR's and CVR's - which is not a good thing in itself, at least not when anywhere near Italian airspace anyway. :yuk:

funfly

27th Mar 2009, 14:53

Listening to the last few minutes of cockpit conversation there is obviously a lot of professional work being carried out. But do we know who was talking and have we any indication that the captain was involved in this or was he the person mumbling "Oh God" in the background? - in which case he had lost authority.
Surely the main failure was the lack of fuel checks prior to departure. Calculate flight time plus additional times, check fuel uplifted, stick your nose (or something) in the fuel tank. I would hope that this procedure is mandatory before each flight.
Fuel is one of the few things that can cause an aircraft to stop in the air under normal circumstances, to not have enough at any time is unforgivable.

Clandestino

27th Mar 2009, 15:33

The official report does not support the thesis that
the main failure was the lack of fuel checks prior to departure. It was contributory factor, but main factor was installing the improper FQI. Also being former ATR driver, acquainted with the peculiarities of ATRs electric system, I strongly believe that captain was flying the aeroplane and F/O was reading the checklist after the engines quit. Sticking maintenance noses up the fuel tanks caries a delay penalty and it's done only if the crew suspects something is wrong with fuel gauges. Not making fuel checks on the leg to Bari or checking the uplift against the FQI were mistakes that turned to be lethal but they were mistakes, not something you'd get convicted for in civilized country as mens rea was definitively absent.

EDIT: Rephrased for clarification.

Teddy Robinson

27th Mar 2009, 16:27

A gross error check would have stopped the problem on the ground.

The vile 'tabloid' headlines are a disgrace and shows the weakness of syndicated news.
If one paper reports it, the others report the reports, it must therefore be true :yuk:

Bladecrack

6th Apr 2009, 23:06

this accident is to be broadcast on national geographics "air accident investigations" next monday. It will be interesting to see how the flight crew are portrayed in the film.

I watched the programme mentioned above, and I thought it was very good. Yes, the Captain did make a couple of mistakes, (not confirming fuel uplift prior to departure, and not feathering props and reducing airspeed after 2nd engine failure, however they didn't realise at the time that they had run out of fuel) but the primary cause of the accident has to be the installation of the wrong FQI. I think the crew tried their best with the information they had under the circumstances. It was a shameful decision to prosecute them and hang them out to dry... As for the media trash about pausing to pray :yuk:

Can someone familiar with the ATR 72 tell me why they did not get a low fuel warning? Surely there should be a low fuel indication directly activated by low fuel level and separate from the FQI?

Flightmech

7th Apr 2009, 00:21

Based on the National Geographic programme information, it appears the low fuel warning was not applicable. If the low warning is taken from the FQI, then because the wrong FQI was installed it still read 1800Kg with the tanks dry! Maybe an ATR tech can confirm if its taken from the FQI or a tank unit.

GXER

7th Apr 2009, 12:50

I have read the investigation report (not in depth, it's a bit too turgid).

From the facts in the report, my view is that the captain was seriously negligent, although a 10 year jail sentence appears extreme. I don't have the competence to comment upon the flying ability displayed but the serious fault that, imo, amounted to gross negligence was the fact that he noted the anomaly in the fuel upload record but dismally failed to follow through.

Having identified the anomaly, the captain had several choices - he could have delayed departure until the 'missing' (in fact, non-existent) docket was found. Or he could have performed a 'drip-stick' measurement. If he had done either of these, the 'fuel remaining' misreading and incorrect FQI would have been identified. He also had a second (or third) opportunity to trap the original error (incorrect FQI) by performing the fuel used reconciliation at the intermediate stop (I'm not sure whether this is mandated or simply recommended/advised).

If I understand correctly, the reconciliation of previous fuel reading + fuel upload (as per the upload docket(s)) to current fuel reading is the first and last line of defence against an erroneous FQI indication. The entire purpose of that cross-check must be to trap errors and/or faults. As someone posted above, insufficient fuel is one of the few things that is will certainly result in an otherwise serviceable a/c making an early landing. In this case, the failure to apply unexceptional due diligence, on a matter that required no knowledge or training other than the ability to perform simple arithmetic, set at naught the inherently sound purpose and outcome of the cross-check procedure.

The captain's failure in this case is more serious and inexplicable because this was the first flight of the a/c after the FQI had been replaced; a fact that (I suppose) was noted in the technical log which the captain had (or should have) examined.

The other (to my mind) very serious fault that is mentioned but not given sufficiant prominence in the report is the absence in the procedure for replacing the FQI of a simple check to validate that the unit is functioning correctly. All that the manufacturer's procedure guide requres, it seems, is a visual confirmation that the LEDs on the unit illuminate. Well - that's no more than confirmation it has a power supply and is completely inadequate for validating its performance. How the hell is it possible for that procedure to be carried out without (at least) some 'sanity test' type of check that it is giving a more or less correct indication?

However, serious as that fault is, my view is that the captain's was more serious because his check was the last (and only) line of defence against a faulty FQI. Even the right FQI (new or not) could have been giving an erroneous reading.

In my job, I deal with financial calculations. I NEVER assume any calculation I perform is correct until I've done it at least twice and got the same answer each time. If I make a mistake, my employer may lose money (and so, as a result, may I), but nobody dies.

His dudeness

7th Apr 2009, 15:08

However, serious as that fault is, my view is that the captain's was more serious because his check was the last (and only) line of defence against a faulty FQI. Even the right FQI (new or not) could have been giving an erroneous reading.

Well, if the airplane was released to service, why should the captain NOT believe the gauges, as everyone does until they are written up for rectification?

Superpilot

7th Apr 2009, 16:01

Well, if the airplane was released to service, why should the captain NOT believe the gauges, as everyone does until they are written up for rectification?

Ditto.

Why not?

GXER

7th Apr 2009, 16:52

Well, if the airplane was released to service, why should the captain NOT believe the gauges, as everyone does until they are written up for rectification?
Because the cross-check was telling him (quite literally) "something doesn't add up". That's why it exists.

MarcoAER

7th Apr 2009, 18:33

Dear Crossfitter,

Could you please tell us what is your flight experience? Where do you get conclusion?

[..]...dealing with a primitive form of life on earth.

Did you ever study history?

As somebody already said, we had the Senate and the Coliseum. We invented military tactics that are still used nowdays.....while you were dancing around fires.

And probably planes wouldn't fly without technologies invented by italians. eg. battery - Volta, radio - Marconi.

Signed: An Italian Flight Instructor.

Bladecrack

7th Apr 2009, 19:15

Gents,

Can we leave the standard pprune petty arguments about which country in Europe is best and get back to the topic in hand? :ugh:

Ultimately, I think the flight crew have been very harshly treated by the Italian authorities. Which one of you is completely immune to making any sort of human error? The point is, that when they ended up flying a glider, they did their best under the circumstances, with the information they had.

I think the sentence they received could influence a flight crew's decision making in similar situations in the future, in that part of the world. Would you be motivated to try your utmost in a similar scenario, knowing that if you do survive you can expect a long prison sentence if any blame can be attributed to you or your colleagues?

captplaystation

7th Apr 2009, 20:39

Shades of Monty Python Life of Brian if I'm not mistaken " so then , tell me, what did the Romans do for us then "?
Don't think the list included ATC, or fair and uncorrupted / politically interfered with accident investigation however.

punkalouver

8th Apr 2009, 11:48

Does anybody have a link to the CVR transcript?

Thanks

biscuit74

9th Apr 2009, 18:42

YouTube - They were doing their job as professionals till the end (http://www.youtube.com/watch?v=7ZSGw51ZkmA)

GXER

12th Apr 2009, 08:39

I have just watched the National Geographic programme about this accident. It gives a fair (if incomplete) summary of the events and the investigation, and correctly (in my view) credits the crew for their judgement in handling the ditching.

Reflecting on my recollection of the investigation report, about which I posted earlier (http://www.pprune.org/4844895-post94.html) in this thread, I have realised there is a spectacular fallacy in one of the key recommendations - namely that the FQIs for the ATR42 and ATR72 types should be redesigned with different connectors, so they cannot be mistakenly interchanged. The entire premise of the recommendation is that different connectors would ensure that the error of installing the 'wrong' FQI cannot be repeated. That is false. The FQIs rely on internal logic to provided a fuel quantity indication that is based on data provided by a number of sensors in the tanks. To prove this is false, simply ask this question - suppose that type 42 and type 72 FQIs did have different connectors but that a 'type 72' FQI had been mistakenly programmed at manufacture with 'type 42' logic and this was fitted to the accident flight. All of the subsequent errors and the resulting accident would have occurred in exactly the same way!

A post-installation cross-check (e.g. drip-stick measurement) to validate the accuracy of the new FQI WOULD have trapped such an error (and makes the argument for different connectors redundant).

Such a fault would also have been trapped by the diligent application of the simple cross-check against refuelling records. This procedure is based on the simple equation:

Reading 1 + fuel loaded - fuel used = reading 2.

Fuel used is measured independently of fuel reading and this procedure, if applied, is virtually infallible. For it to fail in a way that allows a fuel quantity indication to be materially erroneous (and go un-noticed) requires that two independent fuel measuring systems fail not only simultaneouly but in a way that gives equal and opposite measures of error. The maths for calculating the probability of that happening are beyond me, but I would imagine it would meet the 10^-9 test.

A better recommendation would have been to emphasise the critical importance of the cross-check prcedure in assuring sufficient fuel quantity for any planned flight.

glad rag

12th Apr 2009, 10:31

So the FQI was replaced by a variant from another mark of aircraft, and was not calibrated/functionally tested/fuel zeroed.

I have to say that on reading the report the error is not as simplistic as first thought.

If the misinformation was still available for the inquiry team then it points to the supplier of that information.

However there is still the issue of responsibility for fitting the "wrong" item unquestioningly.

The pilots screwed up OK, but the majority of the error was not theirs.

RBpilot

15th Apr 2009, 02:27

"Did you ever study history?

As somebody already said, we had the Senate and the Coliseum. We invented military tactics that are still used nowdays.....while you were dancing around fires."

this guy made such a stupid and racist comment, i don't even want to talk about it.
I'm italian and i'm proud to be, but i really can't stand this stupid comments...

"Dear Crossfitter,
Could you please tell us what is your flight experience?"

Dude you are probably a brand new 22 years old CFI with 800 hrs on cessna's on your back, i guess that makes you an authority in aviation :ugh:. When you'll be a real pilot and you'll get to fly real airplanes then you would be able to ask (with that cocky tone) about somebody else flight experience but now you should have a look at your flight experience first.

"sciolist"... Noun, archaic. "a person who pretends to be knowledgeable and well informed".

MarcoAER

15th Apr 2009, 03:43

for RBPilot: last time I checked my logbook showed 4 digits. I've been instructing for the past 4 years. Over 2000 hrs to be exact.

You don't have to be a CFI to ask about some other people experience, especially with such stupid comments.
Sometimes I am wondering if some people are just hiding behind a computer. They comment without having even been close to a flight deck.

What's your "REAL" experience, buddy?

My comment wasn't racist. It was a FACT. This forum is made of PROFESSIONALS.
PROFESSIONALS want FACTS.
It seems like all I can see are OLD JOKES and SAYINGS about Italians that don't depict the reality.

We have many problems in Italy. We also have many good things. Like all other countries.

In today's technology. Most of the accidents happen because of BASIC HUMAN mistakes. STUFF that I teach everyday: aka (FUEL DISCREPANCY = USE THE DRIPSTICK).

You don't need 5 type ratings to understand that. The Aircraft can bite for the most simple reasons.

RBpilot

15th Apr 2009, 20:06

"My comment wasn't racist. It was a FACT. This forum is made of PROFESSIONALS.
PROFESSIONALS want FACTS."

This one was his comment:

"Did you ever study history?

As somebody already said, we had the Senate and the Coliseum. We invented military tactics that are still used nowdays.....while you were dancing around fires."

all the ppruners are willing and anxious to know that the italians invented military tactics and built the coliseum while others where dancing around fires (hey guys this is because professionals want FACTS!!! and it's not a racist comment!!!)

"for RBPilot: last time I checked my logbook showed 4 digits. I've been instructing for the past 4 years. Over 2000 hrs to be exact."

Still, with that background you are a newborn in aviation. Expecially if those 2000 hrs are cessna's hrs.

"You don't have to be a CFI to ask about some other people experience, especially with such stupid comments.
Sometimes I am wondering if some people are just hiding behind a computer. They comment without having even been close to a flight deck."

Who's hiding behind a computer?
What about you? have you ever been close to a flight deck?

"What's your "REAL" experience, buddy?"

At this point i guessed you haven't learned the lesson at all Captain, that's the problem with some wannabes like you, they think they got it all.

MarcoAER

16th Apr 2009, 03:15

"What's your "REAL" experience, buddy?"

You still haven't answered MY question, Skipper. :rolleyes:

captplaystation

16th Apr 2009, 10:43

You don't have to even have a pilot's licence to know where this went wrong, a kid with a calculator could work it out.

Intended departure fuel minus arrival fuel, convert to litres, that is the expected uplift. If the actual uplift is much different to that, start asking questions.
The duff fuel readings merely served to hide what an enquiring mind (or at least the application of sensible cross-checks as a minimum ) should have noticed.
After the flameout, we have what sounds like exemplary behaviour by the crew, not in any way helped by crap ATC. Don't see there is much more to say.

cavok_italy

17th Apr 2009, 11:42

And instead od crying to the injustice, check news before commenting.

Those pilots have been prosecuted (and they haven't been phisically in jail) because they advise the cabin crewat the last moment of the ditching, not on the prescribed times. And they could also do a better job. There have been a trial for that.
One more thing: what do you think if you fill your car with 10 liters of fuel, for going 1500 kms? That a miracle has gone and you can leave trusting they will last?

Italy is the country of burocracy, I agree. But not of the injustice, at least not more than any other country.

There are people who can't go back into the USA just because they didn't pay a parking spot fine....

So, be smarter with your comments...

virginblue

26th Apr 2009, 17:49

bjornhall

27th Apr 2009, 18:19

So it might be time to get off the high horse until you have gotten some insight into Italian criminal law and its application by the courts - rather than jumping to conclusions by reading what papers write.

The sentence is wrong, whether it is in line with Italian law or not. That they were even put on trial is wrong. If it is actually correct according to current Italian criminal law, then that is a fault with the law.

The criticism that many of us voice in this thread is directed against the Italian legal system; both the laws themselves and how the laws are applied. The simple fact that the crew was put on trial and convicted is sufficient knowledge of the Italian judical system to make that assessment. Calling Italy a third world country in that respect might be a bit unfair to third world countries; many of them actually follow Annex 13.

That Italian law is in violation of Annex 13 is an opinion shared by, among many others, both the Italian, the French and the Tunisian accident investigation boards. They would know, wouldn't they?

Finally, you might wish to recall that the thread started as an outcry against what the papers wrote. Rather, it is those who insist the accident was a result of the crews' failures who parrot the newspapers.

tarjet fixated

27th Apr 2009, 18:55

bjornhall,

how not to quote you 100% ?!?!?
As an italian I think I can happily state that we are talking about a 3rd world country in many ways, and our judicial system is one of them for sure (3 very questionable aviation related sentences in the past few years from the LIN accident to the CAG conviction of 2 ATCO to this one we are talking about and I'm not mentioning the ongoing pathetic investigation about the Cessna crash out of CIA).

The FSF has filed an official complaint this issue and I'm afraid change can only come from outside the country.

Riu

27th Apr 2009, 22:35

TAKEOFF TUBE - Voice recorder Tunisair ditching (http://www.takeofftube.com/view/1385/voice-recorder-tunisair-ditching-/)

it is written tuniser but it is actually tuninter.. to you the commets.

vonbag

28th Apr 2009, 07:43

Cavok_Italy -
[...]
...they advise the cabin crewat the last moment of the ditching, not on the prescribed times.
[...]
In the Final Report, at page 162 and under point 2.4 (pg. 169-170) "Operations in Passenger Cabin", it is written that, descending through 12.000 feet, the captain ordered the senior flight attendant to prepare for ditching...
In the partial CVR audio -- that lasts only about ( < ) 5 minutes (when impact sound is heard) -- we all could hear,
as the captain says (again) back to the Cabin about 2 minutes before ditching:
" Preparé pour emergency, ditching... "
he appears to be interrupted by the ATC transmission.
I have been listening to this partial recording many times. It only spreads over 5 minutes and I could not interpret (I could make up only a few words , apart from what is already written in the Final Report) what was said by ATC.

It would be very interesting to have the complete CVR transcript, like already asked by others.
Do you know if this is available?
Thank you in advance.

Capvermell

7th Feb 2010, 11:29

I find it unhelpful that you guys get carried away by the "10 year" aspect of the sentence. Unless you are learned Italian legal scholars, you are most likely not in a position to comment whether the sentence is out of line with Italian sentencing standards. That someone would get a one-year suspended jail sentence in your country for a certain crime does not necessarily mean that it must be the same anywhere else. I would see your point if a 16 times manslaughter "usually" results in a much more lenient sentence in Italy, but nobody has made this point so far (and probably lacks the knowledge to do so). Also nobody knows how sentencing works in cases of multiple convictions.A ten year sentence (especially if it means actually getting out of jail after say five years) would be perfectly reasonable for a genuine act of manslaughter that had killed 16 people. The problem though is that any failings committed by the pilot and co-pilot here in no way constitute manslaughter (also how the hell did the co-pilot get the same sentence and not only half the sentence applied to the captain who clearly carries the final can for any acts of negligence that did occur). The only suitable charge here in respect of any of the parties involved is one of negligence, since whilst the end consequence of the chain of events was a crash and many deaths there was no reasonable possibility of any of the parties involved being able to see in advance that the death of others was a possible end consequence of any failings committed on their part. Neither pilot acted anywhere nearly culpably enough to be charged with anything criminal and certainly nothing more than negligence.

Numerous other pilots must have left an airport without managing to find a missing fuel docket and then not used the tanks dipstick and not had this happen to them (because in their case an inaccurate fuel guage was not also part of the picture) and the Gimli Glider and Air Transat guys were ultimately considered heroes, even though there was some initial attempt to discipline them in both cases for failing to follow procedure. The difference between any errors committed by these pilots or those in the Gimli Glider or Air Transat cases are pretty indistinguishable and it is only the difference in the outcome (i.e. nobody killed in those cases) that is the main difference in the sanctions applied. Also the manner of the final ditching (near perfectly executed despite the break up of the plane) actually saved some lives. If these guys had screwed that part up they would have been beyond any punishment by the courts.

I do hope this will get appealed to the European Court of Human Rights and gets overturned and that these guys are soon freed from jail and at most banned from flying for three years or something. Since although they made a mistake I'm perfectly sure they would actually be some of the safest pilots in Tunisia around if they ever given their licences back. I do agree that the actions here seem thoroughly racist and that I highly doubt that if Alitalia had been involved that any of the people considered responsible would have received more then suspended sentences.

I also wonder how many of the judges responsible for this sentence had still nonetheless managed to run out fuel in their own cars. There are not many of us who have driven for 30 years who have not run out of fuel, which says to me that this kind of human error is really not that difficult to make.

EDIT:- Reading more it would seem the pilot and co-pilot and the officials of the airline are not actually in jail and Tunisia will not extradite them. So can we presume that to some extent all the sentences here are a token political gesture for the Italian media by the judiciary to be seen to be doing about the deaths of Italian citizens on an African airline but were imposed safe in the knowledge that none of the individuals sentenced would actually serve any time in jail. Of course that doesn't make the verdicts right or acceptable though.

What has happened to the pilot and co-pilot now? Are they even fit to fly again yet and did the Tunisian government rescind their pilot licences either temporarily or permanently?

Teddy Robinson

7th Feb 2010, 17:21

:D very well put

Capvermell

7th Feb 2010, 17:35

Does anyone know if any of the Italian passengers on the plane were relatives of and/or were in some other way connected with any senior politicians or members of the judiciary in Italy?

The Alaska Airlines failed jackscrew caused crash strikes me as an event where the actions of certain maintenance employees were much closer to being deserving a charge of manslaughter but where no such charges were ever brought.

captplaystation

7th Feb 2010, 19:45

Seems to me the blame , if any exists, needs to be put on the "REGULATORY AUTHORITIES " Ha Ha! ! " in this case Tunisia, for allowing this airline to operate with a tech-log & procedures that did not call for a simple cross-check /reconciliation of the fuel uplifted vs what you expected to uplift.
It isn't complicated, every reputable company I flew for had it, and the ones who didn't ? well, you just answered your own question.

Anyhow, glasshouses/stones and all that.
Ask the dolts in ENAC (Yes ITALY! ! ) how they allowed Capt's in Blue Banana to fly MXP/Tel Aviv with an unusable centre tank on a B734 without tech stopping, and indeed to enter in the tech-log gems like . . . Fuel on departure 9200kg/ fuel burned 13000kg ! ? :rolleyes: only 10 yrs ago, do you think anything changed :hmm: Never could find the air-to-air fuelling probe on the external check :rolleyes:
Not to even mention the cock-up with SAS in MXP, I don't think they should really shout too loudly about air safety, as they did after Flash Airlines, holier than thou indeed, thought ENAC was in Roma last time I visited, not Vatican City. . . .wanna discuss the Alpi Eagles "twin " tech-logs etc etc ? ? No, better not, and all the scum involved in all this, are still DOV's or still active in the administration, who said Mafioso ?

Capvermell

7th Feb 2010, 20:09

and all the scum involved in all this, are still DOV's or still active in the administration, who said Mafioso?

Believing that somebody must be made the public fall guy so as to protect the backs of others who are more powerful and better connected also strikes me as a distinctly Italian solution.

Of course the French BEA are no better in respect of the Concorde crash where the most blatantly guilty parties are not prosecuted because they are French whereas any foreigner involved in any kind of peripheral way can be hauled to court for the most trivial level of indirect involvement,:\

Perhaps the time has come for an EU wide aviation safety body to rival the NTSB.

quickturnaround

8th Feb 2010, 06:44

Dear Collegues,

I am very curious to hear/read the motivation of the judge in this rather harsh verdict, is it available on any webside?

Thanks, QTA

ATC Watcher

8th Feb 2010, 19:08

What has happened to the pilot and co-pilot now? Are they even fit to fly again yet and did the Tunisian government rescind their pilot licences either temporarily or permanently?

Capt Gharbi was seriously injured by the crash and remained medically unfit for 2 years after it. . He is now a sim instructor and is fighting to get back his licence , IFALPA has lauched a campain trying to help him get back his flight privileges.
F/O Kebaier has been re-employed by Sevenair ( the follower of Tunitair) since 2007 and is still F/O with them ( or was the last time I saw him in Spring last year ) .

stphen

12th Feb 2010, 08:58

its really intolerable listening to these type of incidents. its amazing that what consideration they are giving to their pilots training.

captplaystation

12th Feb 2010, 09:25

Could we have that again in Level 4 (or above) English please.

stepwilk

13th Feb 2010, 01:22

He's American (as am I). "Level 4" is in a parking garage.

dulcym

13th Feb 2010, 02:01

I think that 10 years jail is harsh. I believe that alot of what has been reported in the press e.g. praying etc. is baloney, but that doesn't take away from the fact that innocent people were killed.

If a civilian can be convicted of vehicle manslaughter for incompetent driving, why not a pilot for a similar offence?

A. Le Rhone

13th Feb 2010, 09:33

Why? Because almost any fool can drive a car and easily judge what is and is not incompetent driving.

Very few people can fly aircraft, let alone airliners, yet they deem themselves capable of judging "competence". Farcical.

So the salaries for professional aircrew are plummeting, the T&C falling and very few people are choosing to pursue aviation as a career.

Add to this the potential for professional crews to be judged by clueless laymen as incompetent and you have the makings of the whole industry grinding to a halt for lack of anybody willing to subject themselves to such stupidity. Lets just add some money-grubbing lawyers into the equation to really accelerate this stupidity eh!:ugh:

dulcym

13th Feb 2010, 12:02

Why? Because almost any fool can drive a car and easily judge what is and is not incompetent driving. Very few people can fly aircraft, let alone airliners, yet they deem themselves capable of judging "competence". Farcical.
That's an amazing level of arrogance you display there. I doubt it would have any real value in a court of law. Similar attitude that doctors used to have - you can't sue me! I'm a doctor! I'm above the law!

So the salaries for professional aircrew are plummeting, the T&C falling and very few people are choosing to pursue aviation as a career.
Any profession goes through ups and downs, it's called supply and demand! Right now the industry is in a rut but it won't always be like that. Hardly an argument though that justifies incompetence.

Add to this the potential for professional crews to be judged by clueless laymen as incompetent and you have the makings of the whole industry grinding to a halt for lack of anybody willing to subject themselves to such stupidity. Lets just add some money-grubbing lawyers into the equation to really accelerate this stupidity eh!The whole industry grinds to a halt? Sounds like an emotionally exaggerated outburst to me that I can hardly take serious.

punkalouver

4th Jul 2010, 23:46

I just finished reading the report. I thought that it was quite well done. Wish the ANSV would put out more english reports. Near the very end, however, is one of the most bizarre things I have ever seen in the many accident reports I have read over the years.

It is not unusual fpr comments to be made at the end of a report such as this by representatives from another country. In this case, the Tunisian DGCA claims that the accident did not happen in Italian waters(denied by the Italians) and therefore the Tunisians should have been the lead investigators. They say that the Italians were claiming that the "Tunisian authority was shackling the investigation process and Italian authority have banned Tuninter further to first ANSV findings and recommendations."

At the end the Tunisians say "ANSV is not competent to conduct this investigation" and "Above mentioned report is null and void".

While there have not been many crashes in Tunisia, the was an Egyptair 737 a few years back. No report has ever been seen by me. I wonder if they wanted this one to disappear as well. Just like so many other accident investigations in Africa.

no-hoper

9th Jul 2010, 19:17

Nothing about Italy and justice from my side.Only some words about ATR ,maintenance and the crew.

There was no reason to replace the indicator asap.The report is showing there are only 4 digits u/s-this means it was an ongoing problem because digits are failing one after the other over a long period.The calculation of the amount of fuel is not affected and a second indication (repeater) is available as well.
So a MEL release for at least 3 days is no problem.(may be it is a 10 days
item)
Sufficient time to order a correct part number.
Now we have the engineer with the wrong part ordered by another engineer.Bad situation-no doubt.
First thing at my type course regarding chapter 28 was:be carefull,there are indicators showing/calculating with LBS or KG and 42 or 72 options as well.All engineers i know are aware of this problem.
At each replacement of this indicator you have to compare the old and the new amount of fuel.Due to a lot problems with fuel indication on older ATR (the crashed one had more than 30.000 cycles) fuel indicator replacement is very often a part of t/s to eliminate the origin of the problem.I'm sure the guy did not changed this part for the first time,
but he learned nothing...
And the crew:i never met a crew accepting an aircraft with a split more than 100 kg during refueling !this crew received the aircraft with nearly to
tons more indicated than reported in the log.And they refueled it twice with a split of nearly 50%.Unbelievable !
It is a 10 minuit job to confirm the correct aount of fuel with the sticks !
So for me a combination of very very poor maintenance and a crew who had the wrong job.