Voyager Plummets (Merged)
Well, if it is effectively all over:
I do wonder about that too even though I hope it is not true. But yes, aspects of this investigation do alarm me and seem to fall short of a just and fair process.
During MilAAIB training the legal aspects and police primacy, if or when there is any possibility of criminal conduct, is beaten into you and the SI members have access to legal advice at all times. This has caused much angst in the past when police efforts have effectively undermined a timely accident investigation but the framework exists to protect all so that justice and fairness prevails. Irrespective of the verdict of this case I am very uncomfortable as to how this investigation was carried out.
I find the evidence and opinion contained within the SI report deeply troubling with more than a hint of reinforcement bias. The use of a simulator and a 'camera similar in size' just does not make a compelling case when the SI opines that the camera could not work free by itself.
The physical evidence faithfully recorded in the SI shows that the camera and stick changed shape and had physical damage, so the forces and interactions were dynamic. At or around the time the camera came free the aircraft was transitioning from negative G to positive, the aircraft was over-speeding and crew & equipment were crashing around all over the flight deck. The copilot faithfully recounts the state of chaos and the amount of stuff thrashing around the flight deck, yet the SI fails to even consider or even mention how this could have changed the situation with respect to the restriction.
The SI went on to opine that the captain's 'ok, ok, ok' mutterings were linked to him consciously removing the restriction. The human factors evidence included in the SI suggested that the pilot was completely channelised at this point, hence the repeated and non-standard behaviours. The SI has not offered how, at such a pinnacle of stress, did the captain recognise the hazard. Worryingly the SI displays more than a little bias and economy of truth when they state in their report that:
Even if we set aside the bias shown in the editing of the evidence above the final sentence is an absolute howler. The rather less edited / padded DFDR data recorded earlier in the report shows that the Captain's 'ok, ok, ok' quote (using the time stamp) came at the point where the aircraft was transitioning from going ever-downwards to recovering to more normal flight. This recovery was not initiated by either pilot but by the aircraft protection systems. Given the acknowledged stress / panic during the dive the aircraft recovering would have come as some relief to both pilots. The pilots may have even believed that it was their efforts that had initialised the recovery rather than the aircraft. As such, muttering 'ok, ok, ok' at this point looks natural and not incriminating.
My final point is the legal aspects and the conduct of the SI at the point where they considered potential criminal aspects. At that stage the primacy moves to the police so that evidence can be secured and statements can be made under PACE with appropriate access to legal representation. What we have learned is that at least one SI member carried on with interviews. Not only that he apparently told at least one witness (the co-pilot) of their potentially criminal findings and (allegedly) compounding this breach of a criminal investigation by turning-off the tape machine and threatening violence.
I have no knowledge of this case outside of the public domain info and I don't know either of the pilots. I have no idea if the captain is guilty or not, but I have grave misgivings about the motives, bias and apparent misconduct by one or more members of the SI. Indeed, I can only conclude that the SPA had to think long and hard about proceeding to court once it became clear that the testimony of at least one key witness (the co-pilot) had been tainted by the SI.
Whatever the verdict I do not think the SI & MilAAIB process is operating in a fair and just manner. The Service has long maintained that witnesses giving evidence to an SI do not need legal representation, even though service personnel can be compelled or ordered to attend. Sadly, I think that position is completely untenable.
During MilAAIB training the legal aspects and police primacy, if or when there is any possibility of criminal conduct, is beaten into you and the SI members have access to legal advice at all times. This has caused much angst in the past when police efforts have effectively undermined a timely accident investigation but the framework exists to protect all so that justice and fairness prevails. Irrespective of the verdict of this case I am very uncomfortable as to how this investigation was carried out.
I find the evidence and opinion contained within the SI report deeply troubling with more than a hint of reinforcement bias. The use of a simulator and a 'camera similar in size' just does not make a compelling case when the SI opines that the camera could not work free by itself.
The physical evidence faithfully recorded in the SI shows that the camera and stick changed shape and had physical damage, so the forces and interactions were dynamic. At or around the time the camera came free the aircraft was transitioning from negative G to positive, the aircraft was over-speeding and crew & equipment were crashing around all over the flight deck. The copilot faithfully recounts the state of chaos and the amount of stuff thrashing around the flight deck, yet the SI fails to even consider or even mention how this could have changed the situation with respect to the restriction.
The SI went on to opine that the captain's 'ok, ok, ok' mutterings were linked to him consciously removing the restriction. The human factors evidence included in the SI suggested that the pilot was completely channelised at this point, hence the repeated and non-standard behaviours. The SI has not offered how, at such a pinnacle of stress, did the captain recognise the hazard. Worryingly the SI displays more than a little bias and economy of truth when they state in their report that:
"...immediately prior to the camera becoming free, the Captain said, "ok..... ok, ok, ok," [superimposing it on the DFDR trace and adding a text caption where the camera came free to link it all together for the reader]. It was not possible to confirm what this referred to. The Panel noted that there were no obvious changes in either the flight deck indications or the aircraft attitude at this point."
My final point is the legal aspects and the conduct of the SI at the point where they considered potential criminal aspects. At that stage the primacy moves to the police so that evidence can be secured and statements can be made under PACE with appropriate access to legal representation. What we have learned is that at least one SI member carried on with interviews. Not only that he apparently told at least one witness (the co-pilot) of their potentially criminal findings and (allegedly) compounding this breach of a criminal investigation by turning-off the tape machine and threatening violence.
I have no knowledge of this case outside of the public domain info and I don't know either of the pilots. I have no idea if the captain is guilty or not, but I have grave misgivings about the motives, bias and apparent misconduct by one or more members of the SI. Indeed, I can only conclude that the SPA had to think long and hard about proceeding to court once it became clear that the testimony of at least one key witness (the co-pilot) had been tainted by the SI.
Whatever the verdict I do not think the SI & MilAAIB process is operating in a fair and just manner. The Service has long maintained that witnesses giving evidence to an SI do not need legal representation, even though service personnel can be compelled or ordered to attend. Sadly, I think that position is completely untenable.
Just This Once
Excellent post. If anything, you've been too kind to BoIs/SIs. Pprune is full of examples of incompetence and maladministration in the conduct of inquiries. One of the worst was failing to even comment on there being no safety case for the Hawk seat; and by definition the aircraft case being contaminated. On Sea King ASaC (2003), an investigation was halted altogether when the truth emerged; MoD now deny it even took place. Going back further, the truth behind Chinook ZA721 30 years ago only emerged last year; a completely different version to the official report, giving weight to the evidence, given under oath, of the BoI being directed. Frankly, I'd take any SI report with a huge pinch of salt.
It will be interesting to see how MoD deals with the (alleged) offences by the Voyager SI member.
Excellent post. If anything, you've been too kind to BoIs/SIs. Pprune is full of examples of incompetence and maladministration in the conduct of inquiries. One of the worst was failing to even comment on there being no safety case for the Hawk seat; and by definition the aircraft case being contaminated. On Sea King ASaC (2003), an investigation was halted altogether when the truth emerged; MoD now deny it even took place. Going back further, the truth behind Chinook ZA721 30 years ago only emerged last year; a completely different version to the official report, giving weight to the evidence, given under oath, of the BoI being directed. Frankly, I'd take any SI report with a huge pinch of salt.
It will be interesting to see how MoD deals with the (alleged) offences by the Voyager SI member.
Join Date: Sep 2014
Location: Erewhon
Posts: 474
Likes: 0
Received 0 Likes
on
0 Posts
Well frankly it's become a bloody circus and certainly doesn't show the RAF, its institutions, or indeed its members in a good light.
The sooner it's over and the dust settles, the better - for good or ill.
The sooner it's over and the dust settles, the better - for good or ill.
I don't own this space under my name. I should have leased it while I still could
BWM, actually that is also previous as there has been little in the national media since the start. Only here have I seen anything of note. To the man in the street I suspect it is entirely invisible.
Join Date: Sep 2014
Location: Erewhon
Posts: 474
Likes: 0
Received 0 Likes
on
0 Posts
PN . . . are you SURE we've not been married 
(I reckon we must know each other . . . )
Seriously though, most of my friends are ex-aviators and we are all well aware of this incident.
Take your point but how many visits have been made to this thread by journos who love nothing more than to be negative (don't think they've needed much help with this one).
What a dog's breakfast.
(I reckon we must know each other . . . )Seriously though, most of my friends are ex-aviators and we are all well aware of this incident.
Take your point but how many visits have been made to this thread by journos who love nothing more than to be negative (don't think they've needed much help with this one).
What a dog's breakfast.
I don't own this space under my name. I should have leased it while I still could
Brian, agree aviators and ex are well aware and that journos love to rake, but the aviation community is tiny and as far as I know nothing has happened to disturb the national media.
There will a short shut storm with the verdict and then J Public will forget about it. Now if this incident had affected an A330 then I think the media and public would be more aware. I acknowledge it was covered in detail at the time.
There will a short shut storm with the verdict and then J Public will forget about it. Now if this incident had affected an A330 then I think the media and public would be more aware. I acknowledge it was covered in detail at the time.
JTO, can I too add my thanks for your post? This is a site for Professional Aviators (both Air and Ground). This forum is for Professional Military Aviators, who should be greatly concerned about your post. It's all very well being concerned about the RAF's dirty washing being shown in public, perhaps it would be more appropriate to be concerned about the dirty washing itself. As tuc points out this is yet another example of a dysfunctional SI to add to all the others that have been more about cover up than about the avoidance of accident repetition.
Whatever the fate of this Voyager captain, the fate of the RAF seems to be that if and when it receives its 100th birthday telegram it will be as any other centenarian, able only to shuffle around devoid of its former fitness, for airworthiness will be but a distant memory.
Professionals who care for the Royal Air Force must demand that the cover ups end, and that Air Regulation and Accident Investigation be wrested from the MOD, and then be made independent of each other. Only then can the return to fitness begin.
Whatever the fate of this Voyager captain, the fate of the RAF seems to be that if and when it receives its 100th birthday telegram it will be as any other centenarian, able only to shuffle around devoid of its former fitness, for airworthiness will be but a distant memory.
Professionals who care for the Royal Air Force must demand that the cover ups end, and that Air Regulation and Accident Investigation be wrested from the MOD, and then be made independent of each other. Only then can the return to fitness begin.
JTO
You raise some interesting points.
In the interest of Flight Safety we now all realise the dangers in having loose articles in the cockpit and what happens when they interfere with the controls. Flt Lt Townsend has acknowledged his part in the event, he has pleaded guilty to " negligently performing a duty by allowing his camera to become wedged behind the stick."
The more problematic is the subsequent reporting of the event, which is pertinent to the Just Culture (which is often misunderstood to be no-blame.) If, as you conjecture, the principle evidence to support the charges of perjury was incorrectly gathered and presented then it ought not to be considered. I am not confident that this was presented at the court martial. If your opinions are valid, then in the interests of justice and a just culture the court martial verdict, whatever it is, should be invalid and this may be shown in an appeal (is there such a thing in a CM and is it available to both sides?)
Of course the verdicts have validity in law, but that is not always coincident with justice.
You raise some interesting points.
In the interest of Flight Safety we now all realise the dangers in having loose articles in the cockpit and what happens when they interfere with the controls. Flt Lt Townsend has acknowledged his part in the event, he has pleaded guilty to " negligently performing a duty by allowing his camera to become wedged behind the stick."
The more problematic is the subsequent reporting of the event, which is pertinent to the Just Culture (which is often misunderstood to be no-blame.) If, as you conjecture, the principle evidence to support the charges of perjury was incorrectly gathered and presented then it ought not to be considered. I am not confident that this was presented at the court martial. If your opinions are valid, then in the interests of justice and a just culture the court martial verdict, whatever it is, should be invalid and this may be shown in an appeal (is there such a thing in a CM and is it available to both sides?)
Of course the verdicts have validity in law, but that is not always coincident with justice.
I've no idea what has been presented at court and no idea as to the verdict the CM is likely to reach. Personally I have quite a bit of faith in the SPA and CM process and the access to the appeals court.
I've limited my comments to the SI report and the comments released by the press regarding the SI panel member. I'm an air safety guy with T&E experience and approaching 30 years of military aviation. I don't have access to all the data that the SI could draw upon so perhaps they have a bigger picture. But I do not think the data and opinion published in the SI supports the conclusion they reached. Just comparing the time stamps on the DFDR snapshots undermines their narrative. The failure to consider the dynamic interactions, at a time when the flight deck resembled a shaken snow globe, sets off professional alarm bells.
I fear that the SI came to a conclusion (which may or may not be correct) and used the SI report to sell it to the command chain who, in turn, sold it to the police and SPA. The SI should have provided equal weighting to all possible options, highlighting where the evidence supported or detracted from them.
A just culture is not free of blame, but to get to the blame bit the process has to be just.
I've limited my comments to the SI report and the comments released by the press regarding the SI panel member. I'm an air safety guy with T&E experience and approaching 30 years of military aviation. I don't have access to all the data that the SI could draw upon so perhaps they have a bigger picture. But I do not think the data and opinion published in the SI supports the conclusion they reached. Just comparing the time stamps on the DFDR snapshots undermines their narrative. The failure to consider the dynamic interactions, at a time when the flight deck resembled a shaken snow globe, sets off professional alarm bells.
I fear that the SI came to a conclusion (which may or may not be correct) and used the SI report to sell it to the command chain who, in turn, sold it to the police and SPA. The SI should have provided equal weighting to all possible options, highlighting where the evidence supported or detracted from them.
A just culture is not free of blame, but to get to the blame bit the process has to be just.
Join Date: Apr 2009
Location: Hotel Gypsy
Posts: 2,821
Likes: 0
Received 0 Likes
on
0 Posts
In the interest of Flight Safety we now all realise the dangers in having loose articles in the cockpit and what happens when they interfere with the controls.
(For the youngsters - OHP was something used before Powerpoint
)
Not sure about equal weighting to all possible options. Equal consideration, yes, along with, as you say a consideration of the evidence, which in turn would lead to recommendations to improve safety. In this case the principle cause was evident and subsequently admitted to. In the interest of a just culture the reason why there was no initial true statement of events should be discovered.
I am ex military (20+years) with a background of flight safety. I have flown the A330 and am aware of the topography of the control column and sidestick area and the forces involved.
There are some here on this forum who have blindly defended the pilot, others who you say want to lynch him. I would like justice to be done.
I am ex military (20+years) with a background of flight safety. I have flown the A330 and am aware of the topography of the control column and sidestick area and the forces involved.
There are some here on this forum who have blindly defended the pilot, others who you say want to lynch him. I would like justice to be done.
Quote:
In the interest of Flight Safety we now all realise the dangers in having loose articles in the cockpit and what happens when they interfere with the controls.
Well, that lesson was being taught in the 80s when a spotty young CGB went through FTS and I'm pretty sure it wasn't a new OHP slide back then.
(For the youngsters - OHP was something used before Powerpoint )
In the interest of Flight Safety we now all realise the dangers in having loose articles in the cockpit and what happens when they interfere with the controls.
Well, that lesson was being taught in the 80s when a spotty young CGB went through FTS and I'm pretty sure it wasn't a new OHP slide back then.
(For the youngsters - OHP was something used before Powerpoint )
It is very logical to think that, as this subject has been covered in minute detail on various Powerpoints, OHPs, scrolls and stone tablets throughout the years of (military) training that went into producing today's airmen, they will all be fully aware of this issue at all points during their daily life. But in real life you can only say something so many times before people start shutting their eyes to it and dismissing it as 'yes, yes, we've heard all that'. It takes that crowbar, and the subsequent moment in the laundry room where you decide that the underpants in question are not fit for purpose anymore, to really drive the message home and never, ever forget it again. Before instructors start chucking loose items of hardware in the cockpits of their students as they send them off on their first solo, I am not advocating that we all go through this precise scenario but I would like to say that I think that we may rely a bit too much on the 'training covers everything' mantra.
There are two types of pilots out there. Those who have encountered that crowbar in mid roll (substitute pen, coffee mug, camera, notepad, kneeboard, spanner, phone or any other item of choice for crowbar if you want) and those who have not. I would venture a guess that the first group is a bit more enthusiastic in their teaching on this subject than the second group. Nothing wrong with being in either group but we need to accept that the relevant message is ingrained in each student with various degrees of effectiveness.
Going back to the Voyager incident. I for one think that this is the mother of all Swiss Cheese examples (even though I am not a huge fan of that particular model). In no particular order we have:
- Window of circadian low
- Low workload
- A distraction
- A very specific setting of the armrest
- An object that is exactly the right shape to fit against the sidestick base
- A not-fully-familiar cockpit (let's face it, how long has the Voyager been in operation)
- A flight control system without feedback to the controls
- An unfamiliar autopilot with various options to consider when faced with an anomaly
I'm sure that this list can go on. My main point here is that this particular combination of circumstances was on one hand so unlikely that I doubt if it would have taken more than five minutes during a type rating course, if at all, but on the other hand it is a great lesson for all of us in the non-crowbar group to take with us and, hopefully, help us to stay away from that group for a little while longer.
There are two types of pilots out there. Those who have encountered that crowbar in mid roll (substitute pen, coffee mug, camera, notepad, kneeboard, spanner, phone or any other item of choice for crowbar if you want) and those who have not. I would venture a guess that the first group is a bit more enthusiastic in their teaching on this subject than the second group. Nothing wrong with being in either group but we need to accept that the relevant message is ingrained in each student with various degrees of effectiveness.
Going back to the Voyager incident. I for one think that this is the mother of all Swiss Cheese examples (even though I am not a huge fan of that particular model). In no particular order we have:
- Window of circadian low
- Low workload
- A distraction
- A very specific setting of the armrest
- An object that is exactly the right shape to fit against the sidestick base
- A not-fully-familiar cockpit (let's face it, how long has the Voyager been in operation)
- A flight control system without feedback to the controls
- An unfamiliar autopilot with various options to consider when faced with an anomaly
I'm sure that this list can go on. My main point here is that this particular combination of circumstances was on one hand so unlikely that I doubt if it would have taken more than five minutes during a type rating course, if at all, but on the other hand it is a great lesson for all of us in the non-crowbar group to take with us and, hopefully, help us to stay away from that group for a little while longer.
Join Date: Feb 2017
Location: Planet Zorb
Posts: 16
Likes: 0
Received 0 Likes
on
0 Posts
At the risk of repeating previous posts. This is not an inquiry about the cause of the incident it is a Courts Martial for perjury (x2) and falsifying reports. The whole episode has not reflected well on the service, thanks to one officer. It has also not reflected well on a Squadron with an exemplary history and reputation. i served on 10 Sqn for 9 years, latterly as an executive officer. I await the outcome with great interest .
Airsound, we are looking to you, your reputation and your contacts for a rapid report.
Airsound, we are looking to you, your reputation and your contacts for a rapid report.
Last edited by Kitty Hawk 1; 28th Feb 2017 at 13:47.
He was also charged with and has admitted negligently performing a duty.
The preceding inquiry seems to form the basis of the prosecution evidence. If the inquiry is flawed the evidence may also be flawed and if so justice may not be served.
The preceding inquiry seems to form the basis of the prosecution evidence. If the inquiry is flawed the evidence may also be flawed and if so justice may not be served.
Join Date: Feb 2017
Location: Lyneham
Posts: 12
Likes: 0
Received 0 Likes
on
0 Posts
At the end of the day it was an accident. Yes it was serious and he's admitted that he was to blame but he clearly didn't do it on purpose.
There's a culture of taking electronic items on the flightdeck and it could have happened to anyone. It would be interesting to see if 10 and 101 have learned from this however from my last trip as a passenger tells me they have not...
None of us have been privy to the entire un redacted SI or all of the evidence that has been presented to the court martial so none of us are in a postion to make claims against the pilot in question.
I wonder if anyone on here as actually spoke to the pilot in question since the incident and heard his story from him. Probably not.
There's a culture of taking electronic items on the flightdeck and it could have happened to anyone. It would be interesting to see if 10 and 101 have learned from this however from my last trip as a passenger tells me they have not...
None of us have been privy to the entire un redacted SI or all of the evidence that has been presented to the court martial so none of us are in a postion to make claims against the pilot in question.
I wonder if anyone on here as actually spoke to the pilot in question since the incident and heard his story from him. Probably not.