Air Safety Implications?
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Air Safety Implications?
Aviation safety suffers further setback after Helios conviction - {Travel Daily News}
I wonder what the MAA will make of this and if it will have any implications on our 'Just Culture'?
Not good.
I wonder what the MAA will make of this and if it will have any implications on our 'Just Culture'?
Not good.
Unbelievable, if the article is correct.
You'd like to think EASA (which Greece are a member of) should say something about this - many basic things wrong here. I could think of several ways they could apply pressure, if the will was there.
You'd like to think EASA (which Greece are a member of) should say something about this - many basic things wrong here. I could think of several ways they could apply pressure, if the will was there.
The waters were muddied long ago in MoD when Director Helicopter Support, Director Helicopter Projects, Director General Air Systems 2 and the Chief of Defence Procurement all ruled that engineering and safety decisions made by engineers, within their delegated authority (and agreed to by Boscombe Down and the Aircraft Design Authority), could be overruled by non-engineers; but if anything went wrong the engineer should be blamed.
This precise scenario occurred before and after a fatal crash in 2003, and to this day the MoD maintains the engineer is to blame, despite the records showing he issued a directive to make the aircraft safe, only to be overruled.
The MAA are so busy faffing around reinventing wheels they haven’t got round to addressing this problem yet. Perhaps this Greek tragedy will give them a push.
This precise scenario occurred before and after a fatal crash in 2003, and to this day the MoD maintains the engineer is to blame, despite the records showing he issued a directive to make the aircraft safe, only to be overruled.
The MAA are so busy faffing around reinventing wheels they haven’t got round to addressing this problem yet. Perhaps this Greek tragedy will give them a push.
With all rights recognised to the author but some DII users cannot link to the article:
A Licensed Aircraft Maintenance Engineer has received a 10 year prison sentence by an Athens court for allegedly not resetting a cockpit switch following maintenance on the Helios Airways Boeing 737-300 which crashed into a mountain near Athens in 2005 after its oxygen supply failed and the pilots and most of the passengers fell unconscious.
It is difficult to grasp how aviation safety can be improved if the legal process surrounding an aircraft accident allows an engineer to be condemned to a prison sentence based on an "assumption" that a cockpit Switch (critical to flight safety) was set in the incorrect position. There was absolutely no evidence presented during the trial that the Engineers actions caused or even contributed to the accident. On the contrary, the conviction is based purely on the unproven supposition that the switch was left in the incorrect position although it was demonstrated by experts that that was unlikely. In fact some accident investigators maintain that the switch was still in AUTO (correct position) at impact. The factual evidence in the Helios case paints a rather different picture of the engineer than that suggested by this decision. The facts suggest an extremely conscientious and professional engineer performing the job at hand in an extremely professional manner.
Perhaps most importantly, the decision makes the ground engineer criminally responsible for the configuration of the controls of the aircraft, prior to the flight crew joining and carrying out their pre-flight and post take off checks. Such a proposition runs completely counter to the core proposition of division of responsibilities that every engineer and every pilot will recognise but which sadly various engineers and pilots called as witnesses on behalf of the prosecution felt able to deny.
Once again we are witnessing a judicial process that offered an opportunity to improve aviation safety failing to meet that challenge preferring instead to allocate blame on an uninformed and irrational basis and with a mindset that someone must pay because an accident sadly causing deaths has occurred and society demands a scapegoat. The current trend of criminalising aircraft accidents serves no other purpose other than to undermine safety and will ultimately lead to more accidents. Despite all the rhetoric about aviation safety being paramount, the introduction of safety and quality management systems, the simple fact remains that due to a failure on the part of Europe to create a centre of investigatory excellence for the industry and to eliminate the inappropriate use of accident reports for criminal purposes; instead pandering to the blame culture, safety systems will fail to deliver what air travellers want - Safety in the skies.
It is difficult to grasp how aviation safety can be improved if the legal process surrounding an aircraft accident allows an engineer to be condemned to a prison sentence based on an "assumption" that a cockpit Switch (critical to flight safety) was set in the incorrect position. There was absolutely no evidence presented during the trial that the Engineers actions caused or even contributed to the accident. On the contrary, the conviction is based purely on the unproven supposition that the switch was left in the incorrect position although it was demonstrated by experts that that was unlikely. In fact some accident investigators maintain that the switch was still in AUTO (correct position) at impact. The factual evidence in the Helios case paints a rather different picture of the engineer than that suggested by this decision. The facts suggest an extremely conscientious and professional engineer performing the job at hand in an extremely professional manner.
Perhaps most importantly, the decision makes the ground engineer criminally responsible for the configuration of the controls of the aircraft, prior to the flight crew joining and carrying out their pre-flight and post take off checks. Such a proposition runs completely counter to the core proposition of division of responsibilities that every engineer and every pilot will recognise but which sadly various engineers and pilots called as witnesses on behalf of the prosecution felt able to deny.
Once again we are witnessing a judicial process that offered an opportunity to improve aviation safety failing to meet that challenge preferring instead to allocate blame on an uninformed and irrational basis and with a mindset that someone must pay because an accident sadly causing deaths has occurred and society demands a scapegoat. The current trend of criminalising aircraft accidents serves no other purpose other than to undermine safety and will ultimately lead to more accidents. Despite all the rhetoric about aviation safety being paramount, the introduction of safety and quality management systems, the simple fact remains that due to a failure on the part of Europe to create a centre of investigatory excellence for the industry and to eliminate the inappropriate use of accident reports for criminal purposes; instead pandering to the blame culture, safety systems will fail to deliver what air travellers want - Safety in the skies.
Indeed, c-s, tuc rightly connects this Greek kangaroo court fiasco with the MOD one that has presided over the demise of UK Military Airworthiness for some 25 years. When the professionals are pushed aside, or merely choose to step aside, this is what happens. Worse still people die because the true causes of fatal air accidents are covered up by incompetence or malevolence and scapegoats blamed instead. All that will go on happening in UK Military Aviation unless and until Airworthiness Provision and Air Accident Investigation is wrested from the MOD and placed into the hands of an MAA and MAAIB, independent of the MOD and of each other. That has yet to happen.
Self Regulation Never Works and in Aviation it Kills!
Self Regulation Never Works and in Aviation it Kills!
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I don't know quite where military flights fit in but if the legal bods believe there is a criminal/negligence case to answer, then it could get messy. (Ie Catterick)
In a purely civil world, it is not plain sailing either - in the UK, US, Can Oz etc, they employ a very British 'adversarial' legal system - ie defence v prosecution and a Judge/Jury to decide the outcome. The accident investigators are left to get on with their job and become expert witnesses for either (or both) sides.
However, in many EU states (France, Italy, Spain etc), they have the Napoleonic legal system where the investigating judge/prosecutor call the shots and can override the safety investigation. So much so, that CVRs and ADRs get taken away from accident investigators. Furthermore, the systems appear prone to a 'default' setting of prosecuting the perpetrator of the final act in the sequence - ie crews, ATC and engineers. Organisational accidents seem to be alien to them - hence the poor engineer in this Helios case.
WRT to Brit Mil, I agree with Tuc that, should an accident like the MoK or Nimrod happen tomorrow, one has to ask how good would the MAAIB and MAA perform. Would they discover and highlight the contributions made by decades of neglect of the military airworthiness system (of which H-C only scratched the surface)? If one believes they would not - perhaps because of the extant undue political and hierarchical pressures - then maybe the MAA needs to review how it does business?
What could be done to prevent the focus being solely on the final link in the chain but also, on the organisational influences (should there be any). Could the MAA be removed from the tentacles of 'undue presure'? Dunno but it should.
Because and until the contibution of systemic MoD neglect since the 1980s is finally erradicated (along with the sinister ethos of that brigade of fools of air-rank) then we run the risk of more systemic accidents but where crews, controllers and engineers risk being scapegoated like the Helios engineer.
Re Helios fall-out, one sincerely hopes that the civil unions are on the case here. But to change the very fabric of a nation's legal system? That's a big ask.
In the meantime, if you are going to crash - try not to do it in France, Italy, Spain or Greece etc!!!
In a purely civil world, it is not plain sailing either - in the UK, US, Can Oz etc, they employ a very British 'adversarial' legal system - ie defence v prosecution and a Judge/Jury to decide the outcome. The accident investigators are left to get on with their job and become expert witnesses for either (or both) sides.
However, in many EU states (France, Italy, Spain etc), they have the Napoleonic legal system where the investigating judge/prosecutor call the shots and can override the safety investigation. So much so, that CVRs and ADRs get taken away from accident investigators. Furthermore, the systems appear prone to a 'default' setting of prosecuting the perpetrator of the final act in the sequence - ie crews, ATC and engineers. Organisational accidents seem to be alien to them - hence the poor engineer in this Helios case.
WRT to Brit Mil, I agree with Tuc that, should an accident like the MoK or Nimrod happen tomorrow, one has to ask how good would the MAAIB and MAA perform. Would they discover and highlight the contributions made by decades of neglect of the military airworthiness system (of which H-C only scratched the surface)? If one believes they would not - perhaps because of the extant undue political and hierarchical pressures - then maybe the MAA needs to review how it does business?
What could be done to prevent the focus being solely on the final link in the chain but also, on the organisational influences (should there be any). Could the MAA be removed from the tentacles of 'undue presure'? Dunno but it should.
Because and until the contibution of systemic MoD neglect since the 1980s is finally erradicated (along with the sinister ethos of that brigade of fools of air-rank) then we run the risk of more systemic accidents but where crews, controllers and engineers risk being scapegoated like the Helios engineer.
Re Helios fall-out, one sincerely hopes that the civil unions are on the case here. But to change the very fabric of a nation's legal system? That's a big ask.
In the meantime, if you are going to crash - try not to do it in France, Italy, Spain or Greece etc!!!
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You will find over the last few years there has been a swing to push more and more on the Licenced Engineer, mainly because the likes of the CAA are petrified of being sued..
I just love it that wokkamate thinks MOD has a just culture!
Actually, and despite the spin to promote a better appearance, MOD as a whole is just leaving an embrionic safety culture, which is before a learning culture, which is before a reporting culture, which is before a just culture, which is before a proactive culture.
There are very few areas civil or military that have made it to the end - in fact, I can't think of one! Shell Management, eat your heart out!
I know of one civil company that had a good reporting culture - but that was more to do with the fact that you couldn't sack the locals easily! If you know your EU employment laws you might know which country that was in?
On the bright side, some areas of MOD have made it to a reporting culture - just.
Actually, and despite the spin to promote a better appearance, MOD as a whole is just leaving an embrionic safety culture, which is before a learning culture, which is before a reporting culture, which is before a just culture, which is before a proactive culture.
There are very few areas civil or military that have made it to the end - in fact, I can't think of one! Shell Management, eat your heart out!
I know of one civil company that had a good reporting culture - but that was more to do with the fact that you couldn't sack the locals easily! If you know your EU employment laws you might know which country that was in?
On the bright side, some areas of MOD have made it to a reporting culture - just.
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When I was serving the FAA certainly had a very strong just culture and was pretty close to a proactive culture.....largely ruined by the top of the RAF shop insistence on the MAA which took us back towards the unjust culture of the RAF.
ps MAA would have happened whether H-C existed or not as the RAF saw it as the route to control all things air. Oops, there I go again!
ps MAA would have happened whether H-C existed or not as the RAF saw it as the route to control all things air. Oops, there I go again!
Pheasant
For a number of reasons I believe this is true.
But if Haddon-Cave had published the truth, presented to him in the form of numerous reports detailing the adverse effect of the RAF Chief Engineers’ actions (or failure to act) throughout the 90s, then I’m sure the MAA wouldn’t be the offshoot of the RAF we see today. Instead he bottled it, and praised the CE, which misled and misdirected everyone who has subsequently had to deal with the fallout.
There is at least one pprune poster here who suggested such a restructuring in about 2000. He, and the rest of us, were on a hiding to nothing because this was the same period in which senior staffs had relentlessly ruled that MoD(PE) / DPA could deliver functionally unsafe aircraft; and indeed should do so if it meant saving time or money.
Looking at it from a different perspective, on a number of occasions before and after this date I was asked to chair a committee to update the only Def Stan which laid down the procedures for managing airworthiness, in particular the delivery and maintenance of Safety Cases (the main subject of Haddon-Cave’s report). The very fact I was asked demonstrates people higher up in MoD knew of the systemic failings imposed by the Chief Engineer’s regime, especially under Alcock. In 1993 the instruction had been given not to implement the mandated procedures in this Def Stan, and funding was largely withdrawn. (They remained mandated under Controller Aircraft in MoD(PE), but as funding had been transferred to AMSO, CA’s staff had no means of meeting this legal obligation. This is the crucial evidence underpinning, for example, the fact the Chinook was unairworthy in 1994).
The update never happened because my superiors refused to release me for the requisite 2/3 days a month and, 3 years ago, the Def Stan was cancelled without replacement. But in anticipation of being allowed to do the work (the request would never have been turned down pre-1993) I produced the 1st draft, and still have it. In fact, unknown to MoD (and to prove a point
) in 2001 I used this draft as the basis of a Business Case and specification for a Cat A project (over £400M at the time), which was approved by the very people who said we shouldn’t be using it. Which simply demonstrated they knew cock all about practical implementation. A bit like MAA.
The resulting flagship contract remains current, which makes me wonder if they realise it calls up an obsolete Standard; and how do the auditors validate and verify the contract documentation, or the MoD demonstrate they are current and maintained? They (MAA) clearly don't realise this contract exists, or else they'd have used it as a template for the work they've employed scores of consultants to do for the last 2 years.
ps MAA would have happened whether H-C existed or not as the RAF saw it as the route to control all things air.
But if Haddon-Cave had published the truth, presented to him in the form of numerous reports detailing the adverse effect of the RAF Chief Engineers’ actions (or failure to act) throughout the 90s, then I’m sure the MAA wouldn’t be the offshoot of the RAF we see today. Instead he bottled it, and praised the CE, which misled and misdirected everyone who has subsequently had to deal with the fallout.
There is at least one pprune poster here who suggested such a restructuring in about 2000. He, and the rest of us, were on a hiding to nothing because this was the same period in which senior staffs had relentlessly ruled that MoD(PE) / DPA could deliver functionally unsafe aircraft; and indeed should do so if it meant saving time or money.
Looking at it from a different perspective, on a number of occasions before and after this date I was asked to chair a committee to update the only Def Stan which laid down the procedures for managing airworthiness, in particular the delivery and maintenance of Safety Cases (the main subject of Haddon-Cave’s report). The very fact I was asked demonstrates people higher up in MoD knew of the systemic failings imposed by the Chief Engineer’s regime, especially under Alcock. In 1993 the instruction had been given not to implement the mandated procedures in this Def Stan, and funding was largely withdrawn. (They remained mandated under Controller Aircraft in MoD(PE), but as funding had been transferred to AMSO, CA’s staff had no means of meeting this legal obligation. This is the crucial evidence underpinning, for example, the fact the Chinook was unairworthy in 1994).
The update never happened because my superiors refused to release me for the requisite 2/3 days a month and, 3 years ago, the Def Stan was cancelled without replacement. But in anticipation of being allowed to do the work (the request would never have been turned down pre-1993) I produced the 1st draft, and still have it. In fact, unknown to MoD (and to prove a point
) in 2001 I used this draft as the basis of a Business Case and specification for a Cat A project (over £400M at the time), which was approved by the very people who said we shouldn’t be using it. Which simply demonstrated they knew cock all about practical implementation. A bit like MAA. The resulting flagship contract remains current, which makes me wonder if they realise it calls up an obsolete Standard; and how do the auditors validate and verify the contract documentation, or the MoD demonstrate they are current and maintained? They (MAA) clearly don't realise this contract exists, or else they'd have used it as a template for the work they've employed scores of consultants to do for the last 2 years.
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Tuc,
An absolutely outstanding post. BZ.
This thread has highlighted a few important areas. First, just culture.
The FAA had (and still does have) a very solid Flight Safety culture and organisation, at the heart of which is a 'no blame' ethos. This was originally modelled on the USN's organisation in the 1950s, which goes to show that good ideas don't have to be new ones. I had close contact with the RAF's flight safety system after formation of JFH, and it was a real shock to be jumped back 20 years or so to a culture of blame, concealment and reaction. Honestly, it was that bad. As ever, i'd point out that most of the people involved were honest, conscientious and professional. But the system that they had developed was basically flawed.
Second, ownership of the accident investigators. I've been told that we now have an absolutely unique system in that our Air Accident Investigators are 'owned' by an Airworthiness Authority. In my mind, this is a hopelessly flawed arrangement. Their activities and reports can now be controlled by the very people who are accountable for the regulation and delivery of airworthy aircraft. Conflict of interest, anyone?
Finally, practical airworthiness. Tuc has hit the nail clean on the head here. Doing airworthiness properly is not 'easy', but neither is it impossible. It can be organised and delivered to support front line operations in a safe and flexible way, giving the operators what they need (Note - not always what they want) and what is acceptable safe. Some bits of it are harder to understand than others, but given halfway decent training and a bit of experience, plus adequate regulation and guidance, it's perfectly 'doable'. In my own experience, the MAA is not yet helping people get there.
Best Regards
Engines
An absolutely outstanding post. BZ.
This thread has highlighted a few important areas. First, just culture.
The FAA had (and still does have) a very solid Flight Safety culture and organisation, at the heart of which is a 'no blame' ethos. This was originally modelled on the USN's organisation in the 1950s, which goes to show that good ideas don't have to be new ones. I had close contact with the RAF's flight safety system after formation of JFH, and it was a real shock to be jumped back 20 years or so to a culture of blame, concealment and reaction. Honestly, it was that bad. As ever, i'd point out that most of the people involved were honest, conscientious and professional. But the system that they had developed was basically flawed.
Second, ownership of the accident investigators. I've been told that we now have an absolutely unique system in that our Air Accident Investigators are 'owned' by an Airworthiness Authority. In my mind, this is a hopelessly flawed arrangement. Their activities and reports can now be controlled by the very people who are accountable for the regulation and delivery of airworthy aircraft. Conflict of interest, anyone?
Finally, practical airworthiness. Tuc has hit the nail clean on the head here. Doing airworthiness properly is not 'easy', but neither is it impossible. It can be organised and delivered to support front line operations in a safe and flexible way, giving the operators what they need (Note - not always what they want) and what is acceptable safe. Some bits of it are harder to understand than others, but given halfway decent training and a bit of experience, plus adequate regulation and guidance, it's perfectly 'doable'. In my own experience, the MAA is not yet helping people get there.
Best Regards
Engines
Good post Engines. Strange, isn't it, that an arbitrary and seemingly unjust decision in a Greek court triggers a recognition here of the arbitrary and unjust system that is UK Military Airworthiness Provision and Air Accident Investigation? Our situation is far more serious though, for not only have juniors been made scapegoats (even posthumously) but people have died. 62 of them in Airworthiness Related Fatal Air Accidents featured in this forum alone. That is the real scandal, that professionals are aware of the dysfunctional system that purports to be UK Military Flight Safety, they have reported it to Coroners, Fatal Accident Inquiries, Houses of Commons and Lords Committees, the Media, the RAF Provost Marshal, MPs and Ministers, and yet it remains compromised. Air Safety is not a plaything of politicians and Air Marshals to toy with but a highly technical system requiring continuous updating and evolution. 1987 was the date that an asteroid hit that system and was as devastating in its effect as any that affected life on earth in pre history. We are still reeling from it a quarter of a century later. No amount of sticking plasters, changing signs on doors or names of organisations will put it right. There has to be open recognition of the corruption and negligence that has brought us to this pass, and the necessity to remove Regulatory Enforcement and Accident Investigation from the operator, AKA the MOD. Haddon-Cave recognised the need for an MAA and MAAIB but failed to ensure their independence, the most vital thing of all. Until that happens avoidable UK military fatal air accidents will go on killing and wasting needlessly.
Chug
Coincidentally, I was asked to give some thought to a prime example of this the other day (in the context of MoD’s behaviour over aircraft crashes). Quite the worst and most blatant example I could think of occurred in the Mull of Kintyre case. One has to remember that the aircraft had no operational clearance whatsoever for ANY Nav or Comms. Unknown to them, because the information had been withheld, the pilots were not permitted to rely on these systems in any way whatsoever. This was confirmed by Lord Philip, who referred to these as ”mandated restrictions” (para 2.2.8). (He omitted the fine detail, so one has to read the Release to Service separately to find out precisely what was “mandated”. MoD denied it's very existence, until Lord Philip put this in his report!).
On 28th January 1997, upon broadcast of a Channel 4 TV programme, the retired and highly distinguished Marshal of the Royal Air Force Sir John Grandy wrote to the current Chief of the Air Staff, ACM Sir Michael Graydon seeking views.
In his reply dated 4th February 1997, Graydon offered a few gems;
1. The President of the Board of Inquiry “carried out a barely adequate job” because he avoided “attribution of negligence to the pilots”. Nothing illustrates better the fact the case was prejudged in the minds of senior officers.
2. That the analysis of the “Farnborough scientists” (i.e. the AAIB) showed aircrew error “must have been the primary factor”. This is a gross misrepresentation of the AAIB’s position and wholly refuted by their lead investigator, Mr Cable.
However, by far the worst was this;
3. He states the aircraft “was off course by some MILES” when it hit the ground. He confirms that he and Wratten briefed Sir Malcolm Rifkind, Secretary of State for Defence, of the above.
Never can a single statement have better illustrated the systemic corruption and concerted efforts to brief against the pilots.
One wonders what the original letter from Sir John said, but the intent of Graydon’s is perfectly clear. It served to foster an image of grossly negligent, and even incompetent, pilots being “miles” off course in such a short time, and clearly designed to rebut any notion they were not negligent. One assumes it would have been highly inconvenient had the distinguished Sir John Grandy written to the press questioning the verdict. Worse, Rifkind would have considered such a "fact" pretty damning and he has since confirmed he'd have taken a different view had he known the truth.
This evidence was presented by the Mull Group who, perhaps due to legal advice, opined CAS had been misinformed or misunderstood. That is too polite – I think it was an outright lie which served to suborn the entire process, and entirely typical of MoD’s behaviour at the time and since.
Corruption? Yes. These actions were a gross perversion of the integrity required of any officer, but set the tone for entire generations. You only have to consider how long the MoD maintained these lies, despite knowing the truth. People have lost knighthoods for less. And anyone involved is tainted and has no place in the current regulatory system.
There has to be open recognition of the corruption and negligence that has brought us to this pass,
On 28th January 1997, upon broadcast of a Channel 4 TV programme, the retired and highly distinguished Marshal of the Royal Air Force Sir John Grandy wrote to the current Chief of the Air Staff, ACM Sir Michael Graydon seeking views.
In his reply dated 4th February 1997, Graydon offered a few gems;
1. The President of the Board of Inquiry “carried out a barely adequate job” because he avoided “attribution of negligence to the pilots”. Nothing illustrates better the fact the case was prejudged in the minds of senior officers.
2. That the analysis of the “Farnborough scientists” (i.e. the AAIB) showed aircrew error “must have been the primary factor”. This is a gross misrepresentation of the AAIB’s position and wholly refuted by their lead investigator, Mr Cable.
However, by far the worst was this;
3. He states the aircraft “was off course by some MILES” when it hit the ground. He confirms that he and Wratten briefed Sir Malcolm Rifkind, Secretary of State for Defence, of the above.
Never can a single statement have better illustrated the systemic corruption and concerted efforts to brief against the pilots.
One wonders what the original letter from Sir John said, but the intent of Graydon’s is perfectly clear. It served to foster an image of grossly negligent, and even incompetent, pilots being “miles” off course in such a short time, and clearly designed to rebut any notion they were not negligent. One assumes it would have been highly inconvenient had the distinguished Sir John Grandy written to the press questioning the verdict. Worse, Rifkind would have considered such a "fact" pretty damning and he has since confirmed he'd have taken a different view had he known the truth.
This evidence was presented by the Mull Group who, perhaps due to legal advice, opined CAS had been misinformed or misunderstood. That is too polite – I think it was an outright lie which served to suborn the entire process, and entirely typical of MoD’s behaviour at the time and since.
Corruption? Yes. These actions were a gross perversion of the integrity required of any officer, but set the tone for entire generations. You only have to consider how long the MoD maintained these lies, despite knowing the truth. People have lost knighthoods for less. And anyone involved is tainted and has no place in the current regulatory system.
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Scapegoat Indeed
well said Tuc, rarely do i find myself disagreeing with your view(s).
Having just spent a great deal of my time reading safety guidance/policy I am at a loss how the simple error of not resetting a switch can result in an isolated prosecution. Taking the article with a pinch of salt (as it provides insufficient detail) I am at a loss as to how the manufacturer is not to be held at all culpable for designing a system which effectively has a single point of failure and no adequate redundancy or additional safety checks. I am not questioning the reasonableness of the prosecution, more the choice of defendants in this particular argument.
IMO there are underlying similarities with Nimrod in this instance as it is questionable whether a sufficient FMECA and hazard identification has been carried out on the system and it has been operated with apparent scant regard for such a failure mechanism.
Let's hope the legal decision is not followed elsewhere in Europe.
H
Having just spent a great deal of my time reading safety guidance/policy I am at a loss how the simple error of not resetting a switch can result in an isolated prosecution. Taking the article with a pinch of salt (as it provides insufficient detail) I am at a loss as to how the manufacturer is not to be held at all culpable for designing a system which effectively has a single point of failure and no adequate redundancy or additional safety checks. I am not questioning the reasonableness of the prosecution, more the choice of defendants in this particular argument.
IMO there are underlying similarities with Nimrod in this instance as it is questionable whether a sufficient FMECA and hazard identification has been carried out on the system and it has been operated with apparent scant regard for such a failure mechanism.
Let's hope the legal decision is not followed elsewhere in Europe.
H
Obviously I'm not familiar with the 737 checklists, but I have to wonder why the pilots don't have some responsibility for getting airborne with a cockpit switch in the wrong position - a claim that is clearly in some doubt anyway.
If that was cause (and not the suspicion that there was a leaking door seal - the reason for the pressurization check being carried out) then the crew should have had at least two opportunities to set the pressurization switch to the correct position before take-off.
Even missing that, they would surely have had a cabin altitude warning as they were climbing to altitude. Would lack of pressurization not have caused equipment cooling issues too? I would think that would also trigger cockpit warnings.
So, my question is, what the hell were the crew doing? To me this is like a pilot running out fuel and then blaming the groundcrew for not putting more AVTUR in the jet.
My thoughts here in no way detract from the utter pig's ear the judiciary have made of this. I just think the blame is directed in completely the wrong direction.
If that was cause (and not the suspicion that there was a leaking door seal - the reason for the pressurization check being carried out) then the crew should have had at least two opportunities to set the pressurization switch to the correct position before take-off.
Even missing that, they would surely have had a cabin altitude warning as they were climbing to altitude. Would lack of pressurization not have caused equipment cooling issues too? I would think that would also trigger cockpit warnings.
So, my question is, what the hell were the crew doing? To me this is like a pilot running out fuel and then blaming the groundcrew for not putting more AVTUR in the jet.
My thoughts here in no way detract from the utter pig's ear the judiciary have made of this. I just think the blame is directed in completely the wrong direction.
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There's an interesting point here and I'd be grateful for any comment from more experienced safety practitioners.
The sort of incident being discussed here is one where a switch was not correctly selected, or left incorrectly set. The point is - how does one assess the probability of someone making an error like that? You can mitigate the effects by system indications and attention getters, but at some stage you get to the stage where if a pilot pulls a lever or makes a switch when it's not safe to do so, you probably have an incipient accident under way.
Even if you could mitigate it, you'd need to state a probability of error at the start of any fault tree analysis.
So, does anyone know of any approved criteria for assessing probability of operator error?
Best Regards as ever,
Engines
The sort of incident being discussed here is one where a switch was not correctly selected, or left incorrectly set. The point is - how does one assess the probability of someone making an error like that? You can mitigate the effects by system indications and attention getters, but at some stage you get to the stage where if a pilot pulls a lever or makes a switch when it's not safe to do so, you probably have an incipient accident under way.
Even if you could mitigate it, you'd need to state a probability of error at the start of any fault tree analysis.
So, does anyone know of any approved criteria for assessing probability of operator error?
Best Regards as ever,
Engines
Courtney, I doubt anyone who has posted here, including the OP, would disagree with you one iota. But it would be more appropriate if such analysis took place on another forum. This is a military forum and it is the military connections, and in particular UK ones, that are under discussion. I suggest that was clearly the purpose of the OP, and of everyone else who has posted. You suggest that the engineer is a scapegoat, for the pilots, the airline, the airworthiness authority, or whoever. You are almost certainly correct.
So what about the allegations made here about juniors, be they pilots or SOs being made the scapegoats of senior Air Rank officers? What about the allegations of outright lies told by senior Air Officers? What about allegations of corruption and gross negligence by senior Air Officers? What of allegations that the UK Military Airworthiness Regulations were wilfully suborned by, and on the direct orders of, senior Air Officers. These are the points that require urgent analysis by anyone who cares not only professionally but emotionally about the honour and integrity of the Military High Command. In particular it should be the concern of anyone, serving or retired, that the UK military airfleets be restored to airworthiness and be subject to professional air accident investigation. Are we as one about all these issues?
So what about the allegations made here about juniors, be they pilots or SOs being made the scapegoats of senior Air Rank officers? What about the allegations of outright lies told by senior Air Officers? What about allegations of corruption and gross negligence by senior Air Officers? What of allegations that the UK Military Airworthiness Regulations were wilfully suborned by, and on the direct orders of, senior Air Officers. These are the points that require urgent analysis by anyone who cares not only professionally but emotionally about the honour and integrity of the Military High Command. In particular it should be the concern of anyone, serving or retired, that the UK military airfleets be restored to airworthiness and be subject to professional air accident investigation. Are we as one about all these issues?