Voyager Plummets (Merged)
Many posts have fallen foul of hindsight bias.
The safety risk for an occurrence is a projection, a judgment of likely-hood and severity of outcome.
The risk in an event should not be judged after the fact, based on the outcome, on the findings of investigation, or on what could have happened. Nor should 'after-cast' risk / activity be based on the number of people who were subject to the risk during the event; a fatal accident is just as fatal for one person as for many.
Risk considers the potential for harm or fatality in a future event.
As a derivative of a civil aircraft with a 'novel' control system, then the risk of a jammed control would have had an extensive assessment. The certification would have considered system limiting and airframe integrity, and mitigating intervention by the second pilot; but other than for takeoff or landing this may not have considered the absence of that pilot; perhaps concluding that the risk was acceptable as defined by a previously agreed standard.
Arguably the risk of a similar event would be less because of publicity, but would that involve all similar aircraft, all operators irrespective of publicity, or at some future date when we forget lessons learnt.
Would the after-cast risk be judged differently if the second pilot was able to intervene earlier, or the pilot flying seen and removed the obstruction with minimum flight path deviation.
Judgement after the event might be appropriate where 'negligence' is defined as failure to exercise the skill, care, and learning expected of a reasonably prudent person; however the more serious category of 'recklessness' (appreciating that these definitions may not match those in a CM) - a conscious disregard of a visible, significant risk implies some predetermination and knowledge of the specific risk - the probability and outcome.
Negligence involves a failure in recognition - at the time; recklessness, a conscious disregard - intent, before the event.
Hindsight is a cruel weapon, but one which often backfires on those who judge.
"The hindsight bias is not about history and not a bias. Rather it is about controlling the future. Or, more specifically, about giving oneself the perception of being able to control the future." S Dekker
The safety risk for an occurrence is a projection, a judgment of likely-hood and severity of outcome.
The risk in an event should not be judged after the fact, based on the outcome, on the findings of investigation, or on what could have happened. Nor should 'after-cast' risk / activity be based on the number of people who were subject to the risk during the event; a fatal accident is just as fatal for one person as for many.
Risk considers the potential for harm or fatality in a future event.
As a derivative of a civil aircraft with a 'novel' control system, then the risk of a jammed control would have had an extensive assessment. The certification would have considered system limiting and airframe integrity, and mitigating intervention by the second pilot; but other than for takeoff or landing this may not have considered the absence of that pilot; perhaps concluding that the risk was acceptable as defined by a previously agreed standard.
Arguably the risk of a similar event would be less because of publicity, but would that involve all similar aircraft, all operators irrespective of publicity, or at some future date when we forget lessons learnt.
Would the after-cast risk be judged differently if the second pilot was able to intervene earlier, or the pilot flying seen and removed the obstruction with minimum flight path deviation.
Judgement after the event might be appropriate where 'negligence' is defined as failure to exercise the skill, care, and learning expected of a reasonably prudent person; however the more serious category of 'recklessness' (appreciating that these definitions may not match those in a CM) - a conscious disregard of a visible, significant risk implies some predetermination and knowledge of the specific risk - the probability and outcome.
Negligence involves a failure in recognition - at the time; recklessness, a conscious disregard - intent, before the event.
Hindsight is a cruel weapon, but one which often backfires on those who judge.
"The hindsight bias is not about history and not a bias. Rather it is about controlling the future. Or, more specifically, about giving oneself the perception of being able to control the future." S Dekker
Having just spoken to our Flight, they think the Just Culture has been upheld. In knowingly taken an article not on the RTS into the cockpit, making it into a loose article, and then causing harm to his passengers through his actions, deserves punishment.
The fact he wanted to make a technical manual is neither here nor there.
As a member of the "SLF" and not the 2 winged PAS master race, I feel safer for him not flying me any more.
The fact he wanted to make a technical manual is neither here nor there.
As a member of the "SLF" and not the 2 winged PAS master race, I feel safer for him not flying me any more.
Dog Tired
From post #748
As a (slight) aside, the captain's armrest - if accurately shown - is at an absurd position.
As a 330 instructor and examiner for very many years, I have only seen one captain have the armrest in a similar position and we had a very comprehensive conversation about it.
The armrest is to support the arm, to allow the wrist and hand free movement, not to act as an elbow fulcrum.
It should be about horiz with a bit of nose-down and as high or low as you like.
If he had been taught properly, or listened if he were, this accident would never have happened.
Was an Airbus expert at the CM to confirm this?
As a (slight) aside, the captain's armrest - if accurately shown - is at an absurd position.
As a 330 instructor and examiner for very many years, I have only seen one captain have the armrest in a similar position and we had a very comprehensive conversation about it.
The armrest is to support the arm, to allow the wrist and hand free movement, not to act as an elbow fulcrum.
It should be about horiz with a bit of nose-down and as high or low as you like.
If he had been taught properly, or listened if he were, this accident would never have happened.
Was an Airbus expert at the CM to confirm this?
The following users liked this post:
Alfred
Well said
.
The amount of hand-wringing by multi-engined Captains with the implied "how very dare you he is multi-engine Captain with 5,000hrs, don't you know?" attitude is an example of closing ranks if I ever saw one! Just like the Shoreham pilot, this guy scr3w3d up and hurt a lot of people (thankfully no one was killed). I find it laughable that he could not notice that a friggin' mahoosive camera was pushing his control stick forward at some point during the bunt manoeuvre whilst his poor co-pilot was doing the Apollo 13 - was he still looking outside at the stars???
Standing by for more "rubbish" accusations of my posts.
iRaven
Well said
. The amount of hand-wringing by multi-engined Captains with the implied "how very dare you he is multi-engine Captain with 5,000hrs, don't you know?" attitude is an example of closing ranks if I ever saw one! Just like the Shoreham pilot, this guy scr3w3d up and hurt a lot of people (thankfully no one was killed). I find it laughable that he could not notice that a friggin' mahoosive camera was pushing his control stick forward at some point during the bunt manoeuvre whilst his poor co-pilot was doing the Apollo 13 - was he still looking outside at the stars???
Standing by for more "rubbish" accusations of my posts.
iRaven
Join Date: Apr 2000
Location: UK
Posts: 608
Likes: 0
Received 0 Likes
on
0 Posts
Just Culture
Which definition do the military use?
"Just Culture" is a culture in which front-line operators and others are not punished for actions, omissions or decisions taken by them which are commensurate with their experience and training, but where gross negligence, wilful violations and destructive acts are not tolerated.- (Eurocontrol definition)
I guess we all accept the Capt had the experience. Training; Was that questionable? Wilful violation? Gross negligence?
Sad to see a competent person with lots of proven ability and skill to lose it all - but hard to see any other outcome, IMHO.
"Just Culture" is a culture in which front-line operators and others are not punished for actions, omissions or decisions taken by them which are commensurate with their experience and training, but where gross negligence, wilful violations and destructive acts are not tolerated.- (Eurocontrol definition)
I guess we all accept the Capt had the experience. Training; Was that questionable? Wilful violation? Gross negligence?
Sad to see a competent person with lots of proven ability and skill to lose it all - but hard to see any other outcome, IMHO.
Nice
Join Date: Oct 2003
Location: All Over
Posts: 322
Likes: 0
Received 0 Likes
on
0 Posts
My brother in law was on this particular trip and remains rather pissed off at being pinned to the ceiling wondering whether he was even going to make it to Afghan at all. He is a reasonable, amicable man, he also significantly outranks the Captain of this aircraft. The RAF pilot sat next to him wasn't that impressed either.
When I last had a chat with him I suggested some remedial training might resolve this issue. He still wanted to tear the Captain a new one. They went through 27 seconds of hell. Brother in law would rather be in a contact than that unknown. He **** out and cost the tax payer a million quid. Unfortunate end to an unfortunate situation. But ultimately correct. The old boys network went years ago.
When I last had a chat with him I suggested some remedial training might resolve this issue. He still wanted to tear the Captain a new one. They went through 27 seconds of hell. Brother in law would rather be in a contact than that unknown. He **** out and cost the tax payer a million quid. Unfortunate end to an unfortunate situation. But ultimately correct. The old boys network went years ago.
Join Date: Oct 2005
Location: Closer than you think...
Age: 65
Posts: 390
Received 0 Likes
on
0 Posts
Moving away from the CM verdict for a moment, one thing leaps to my mind is to question why the seat/armrest/control stick was designed in such a way that allowed something to get jammed between the arm rest and the control stick in the first place?
Join Date: Dec 2007
Location: UK
Posts: 27
Likes: 0
Received 0 Likes
on
0 Posts
The negligence is based on the fact that, although being the sole person on the flight deck, he decided to direct his attention to taking happy snaps instead of flying the aircraft and taking responsibility for his crew and passengers. Try telling the military personnel who are stil too traumatised to fly on the Voyager that he was a bloody nice bloke who has been hard done by.
I presume the eating of meals is in the RTS, and there are appropriate SOPs to ensure that if one of the pilots drops their fork, the aircraft doesn't go into a dive and seriously injure people, with the chance of killing all 200 onboard.
"how very dare you he is multi-engine Captain with 5,000hrs, don't you know?
As a member of the "SLF" and not the 2 winged PAS master race, I feel safer for him not flying me any more.
I think discussions on just culture are futile now. The moment this went to a CM it effectively divorced itself from the flight safety world and set a trap which has now been sprung. I doubt the powers that be ever intended to string him up just for negligence, they wanted perjury and to nail him on integrity as its integrity that is held the most dearest of all in the military.
I hope the passengers onboard, particularly those that were injured can overcome what must have been a truly terrifying ordeal. I would be interested to see how this would have played out if the pilot had not pleaded guilty to negligence. Its probably the measure of the man that he pleaded so and a sign of how seriously he took his responsibilities that most likely weighed on him long after the aircraft was safely on the ground.
I do not know the pilot but on the presentation of the facts that are publicly known I disagree with the level of punishment and hope this goes to appeal. Nobody has won in this situation and the service has lost a highly valuable and experienced pilot. Given his otherwise unblemished record I would be more than happy to sit in the back of an aircraft he was in command of.
I hope the passengers onboard, particularly those that were injured can overcome what must have been a truly terrifying ordeal. I would be interested to see how this would have played out if the pilot had not pleaded guilty to negligence. Its probably the measure of the man that he pleaded so and a sign of how seriously he took his responsibilities that most likely weighed on him long after the aircraft was safely on the ground.
I do not know the pilot but on the presentation of the facts that are publicly known I disagree with the level of punishment and hope this goes to appeal. Nobody has won in this situation and the service has lost a highly valuable and experienced pilot. Given his otherwise unblemished record I would be more than happy to sit in the back of an aircraft he was in command of.
Always a Sapper
The answer is in Alfred the Great's earlier post....
One must be able to reconcile the Statement of Operating Intent and Usage, Aircraft Specification, Safety Case and RTS. In this case, you couldn't. According to previous reporting, it seems this subject came up in court, because he stated that it was known he took photographs, and some were on open display. Perhaps he concluded there was tacit approval; and it would seem nobody challenged him. After all, very few Aircraft Document Sets can be reconciled, and many RTSs are, frankly, nonsense. It works both ways. There is a duty to ensure the ADS is correct. At the risk of repeating myself, we have discussed many here that were not, including Chinook Mk2 and Sea King ASaC (the latter was a lazy copy of the old AEW Mk2, to such an extent it could be characterised as dangerous). There is an organisational fault here, and the pilot is the latest victim. He may have erred, but prior negligence occurred, only for the pilot to be hammered for the final act.
The answer is in Alfred the Great's earlier post....
In knowingly taken an article not on the RTS into the cockpit
I don't own this space under my name. I should have leased it while I still could
So deleting the pictures from the camera was a red herring.
he stated that it was known he took photographs, and some were on open display.
Join Date: Feb 2017
Location: Lyneham
Posts: 12
Likes: 0
Received 0 Likes
on
0 Posts
If you are going to say he's negligent for taking the camara into to flightdeck against what the RTS says, then based on that thoery the entire Voyager fleet of pilots are negligent as they all take iPads etc on the flightdeck for use during the flight and the RTS says nothing about them either.
The court passed comment on the deleted photos saying while they don't believe he did it to cover any thing up, they believe he did it to save himself looking unprofessional. It fact he did himself no favours there but ultimately the court believes there was no intent to deceive in doing so.
Considering the Captain admitted negligence some 2 years the MOD need to answer why it took so long to go to court martial. Interestingly according to reports coming out, the judge asked the same question and also was less then happy with the prosecution for the near lack of evidence presented for the 3 charges he was found not guilty of.
The court passed comment on the deleted photos saying while they don't believe he did it to cover any thing up, they believe he did it to save himself looking unprofessional. It fact he did himself no favours there but ultimately the court believes there was no intent to deceive in doing so.
Considering the Captain admitted negligence some 2 years the MOD need to answer why it took so long to go to court martial. Interestingly according to reports coming out, the judge asked the same question and also was less then happy with the prosecution for the near lack of evidence presented for the 3 charges he was found not guilty of.
So deleting the pictures from the camera was a red herring.
Back in the days of Ektachrome, I wouldn't keep all my slides either. Keep the good ones, throw out the rest.
Quite which numpty tried to make something of the fact that Andy had deleted images from his camera, I don't know. But it was a total red herring.
Those who haven't seen Andy's art have missed some truly excellent photography; his prowess as a photographer is well known.
I see that it is now over 10 years since I joined here as a PPRuNe member. I remember that what motivated me to do so was the Mull "hitting back" thread, calling for the RAF BoI review finding against the deceased pilots to be scrapped. It was simply a sense of injustice at that stage, it was only later that it emerged that there was in fact proven Gross Negligence, it had simply been by VSOs, rather than the JO pilots that were their scapegoats.
I have that same feeling of injustice at this sentence. This JO has been found Not Guilty of Perjury and Lying. He has pleaded guilty to negligently performing a duty (by allowing his camera to jam the control stick), but the sentence for that seems vindictive to me (just as it did for the Mull pilots).
I would add that many of the FJ comments posted here about Multi engine pilots are equally biased in my view. They seem to imply that military justice should be more severe for those who are negligent, the larger their aircraft and the more the occupants. The corollary of course is that those in small single or dual seaters should be treated more lightly in contrast. That was certainly the apparent attitude of the CinC Strike Command in his treatment of Chinook and Tornado accidents under his command. With all due respect I think that he was gravely in error, despite his lack of consistency being blamed on a certain Legal Services Sqn Ldr.
Malevolence and Vindictiveness is no way to run an Air Force, it requires leadership. There appears to be a great dearth of that these days.
I have that same feeling of injustice at this sentence. This JO has been found Not Guilty of Perjury and Lying. He has pleaded guilty to negligently performing a duty (by allowing his camera to jam the control stick), but the sentence for that seems vindictive to me (just as it did for the Mull pilots).
I would add that many of the FJ comments posted here about Multi engine pilots are equally biased in my view. They seem to imply that military justice should be more severe for those who are negligent, the larger their aircraft and the more the occupants. The corollary of course is that those in small single or dual seaters should be treated more lightly in contrast. That was certainly the apparent attitude of the CinC Strike Command in his treatment of Chinook and Tornado accidents under his command. With all due respect I think that he was gravely in error, despite his lack of consistency being blamed on a certain Legal Services Sqn Ldr.
Malevolence and Vindictiveness is no way to run an Air Force, it requires leadership. There appears to be a great dearth of that these days.
Is taking a camera onto the flight deck negligent when it is considered perfectly normal to eat a meal whilst sat in the same seat, cutlery and all?
Was the camera in the RTS? No idea, but this isn't a FJ or similar, do people think every single type of or every combination of nav bags/pilot bags is listed in the civvie equivalent of the RTS, plus allowable Knives, forks, plates etc? I do appreciate it's your trainset but in the civvie world every single item allowable on the Flight Deck won't be listed in every civvie Ops Manual or FCOM (pilots notes), but there will be generic statements in the Ops Manual about the risks of loose articles.
As for comments and in some cases it appears criticism over the length of time the P2 was off the flight deck...Longhaul Flight: there are physiological risks of being sat in the seat for hours on end. Aircraft/Flight decks are designed with single pilot ops in mind. As long as a break is coordinated between the pilots involved there shouldn't be a problem.
Just my two pence worth, now back in my box.
Last edited by wiggy; 5th Mar 2017 at 08:10.
I see that it is now over 10 years since I joined here as a PPRuNe member. I remember that what motivated me to do so was the Mull "hitting back" thread, calling for the RAF BoI review finding against the deceased pilots to be scrapped. It was simply a sense of injustice at that stage, it was only later that it emerged that there was in fact proven Gross Negligence, it had simply been by VSOs, rather than the JO pilots that were their scapegoats.
I have that same feeling of injustice at this sentence. This JO has been found Not Guilty of Perjury and Lying. He has pleaded guilty to negligently performing a duty (by allowing his camera to jam the control stick), but the sentence for that seems vindictive to me (just as it did for the Mull pilots).
I would add that many of the FJ comments posted here about Multi engine pilots are equally biased in my view. They seem to imply that military justice should be more severe for those who are negligent, the larger their aircraft and the more the occupants. The corollary of course is that those in small single or dual seaters should be treated more lightly in contrast. That was certainly the apparent attitude of the CinC Strike Command in his treatment of Chinook and Tornado accidents under his command. With all due respect I think that he was gravely in error, despite his lack of consistency being blamed on a certain Legal Services Sqn Ldr.
Malevolence and Vindictiveness is no way to run an Air Force, it requires leadership. There appears to be a great dearth of that these days.
I have that same feeling of injustice at this sentence. This JO has been found Not Guilty of Perjury and Lying. He has pleaded guilty to negligently performing a duty (by allowing his camera to jam the control stick), but the sentence for that seems vindictive to me (just as it did for the Mull pilots).
I would add that many of the FJ comments posted here about Multi engine pilots are equally biased in my view. They seem to imply that military justice should be more severe for those who are negligent, the larger their aircraft and the more the occupants. The corollary of course is that those in small single or dual seaters should be treated more lightly in contrast. That was certainly the apparent attitude of the CinC Strike Command in his treatment of Chinook and Tornado accidents under his command. With all due respect I think that he was gravely in error, despite his lack of consistency being blamed on a certain Legal Services Sqn Ldr.
Malevolence and Vindictiveness is no way to run an Air Force, it requires leadership. There appears to be a great dearth of that these days.
And no, "grounding him" wasn't good enough: we're paying £++ to fly, that's the only reason he had a job in the RAF - taking his wage down by 2 increment points and then letting him sit on his arse doing nothing doesn't strike me as reasonable. It sounds like a reward frankly.