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Pilot criticised over Puma crash

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Pilot criticised over Puma crash

Old 28th Oct 2009, 16:44
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Not. You answer your own question, SafetyCase.

This all comes from a Coroner's Inquest. What makes you think the release of evidence (the CVR recordings in this case) required by a Coroner needs to be authorised for release by those that hold it. Even the military are accountable to one of the oldest legal offices in the world, old chap. Or are you suggesting they should have smothered it?... No, surely not.

Once in the hands of the Coroner it, and all the other evidence 'heard' at the inquest, is in the public domain. Inquests are generally open to the public.

The editorial decision to broadcast any or all of the evidence is another question altogether, but in this case I see relatively little harm in doing so. The plus side of doing so with the CVR recordings was, to best explain to the public what happened, ie: that the pilot was wazzing about when he should not have been. There is a clear public interest here: That was the their expensive hardware that got trashed at a time when helicopters are in short supply in a real war and they, the public, are paying for the clean-up. Also, civil action may follow from civilian family members and that may be fuelled in the first instance by public money in the form of Legal Aid.


Dan
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Old 28th Oct 2009, 17:16
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Safety Case

Seeing as you've edited your most recent post twice already, you couldn't just edit the whole lot could you?

There's no need to have a pop at Crab just because everyone else does. What he wrote seemed quite balanced really. It'll probably be open season on him when the SAR-H contract winner is announced. Cut the man some slack - what he wrote wasn't inflammatory in any way.
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Old 28th Oct 2009, 17:31
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Yes I edit my posts all the time as English is not my first language. Hope you can bear with me,
I guess that your language being french(?) is better than mine.

I totally disagree with you
CVR should never ever be released like in this case.
I think that CVR recordings are privileged information, not necessary to distribute freely. How you think the families feel? And one more thing maybe more important than you think: the recording does not help the investigation at all. It is published only to keep the interest up.

Last edited by SafetyCase; 28th Oct 2009 at 18:00.
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Old 28th Oct 2009, 17:38
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I have the greatest respect for Crab. However, we all need to be able to take a little bit of flak now and then. And I think Crab can take care of himself without your help.
And SAR H was not what we were discussing, was it??
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Old 28th Oct 2009, 17:53
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Not. You answer your own question, SafetyCase.

This all comes from a Coroner's Inquest. What makes you think the release of evidence (the CVR recordings in this case) required by a Coroner needs to be authorised for release by those that hold it. Even the military are accountable to one of the oldest legal offices in the world, old chap. Or are you suggesting they should have smothered it?... No, surely not.

Once in the hands of the Coroner it, and all the other evidence 'heard' at the inquest, is in the public domain. Inquests are generally open to the public.

The editorial decision to broadcast any or all of the evidence is another question altogether, but in this case I see relatively little harm in doing so. The plus side of doing so with the CVR recordings was, to best explain to the public what happened, ie: that the pilot was wazzing about when he should not have been. There is a clear public interest here: That was the their expensive hardware that got trashed at a time when helicopters are in short supply in a real war and they, the public, are paying for the clean-up. Also, civil action may follow from civilian family members and that may be fuelled in the first instance by public money in the form of Legal Aid.
Dan

You are not not a person who makes his living by flying are you?

Have you ever heard about the Flight Safety Foundation??

Have you ever heard about IFALPA??

Do you know about EASA and FDM??


I thought so

Have a read on what they think about CVR porn

CVR should never be released to the press!
Actually there are countries that protect this information by law, but I guess you don't agree with that.

Last edited by SafetyCase; 28th Oct 2009 at 18:17.
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Old 28th Oct 2009, 18:08
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While it might sound slightly distasteful on the telly, I think being able to hear the CVR in this case could actually be a deterrent to the next young'un. A stark reminder that all banter is evidence in the subsequent enquiry.

Seems to me that a disproportionate number of Pumas crash compared to the rest of the helo force. Their tasking doesn't seem any more arduous than the rest so what's the problem? An engrained culture of cowboyism? How are 60(R) streaming the pilots into the Puma force? Haven't they just finished a close look at Puma SF ops?

This kid was flying like an idiot - no question. But - it's hard to believe the Sqn/Station exec's hadn't engaged in the same bufoonery at some point earlier in their careers and therefore armed with this knowledge could have helped nip this sort of thing in the bud as the culture has surely moved on these days - we just can't tolerate this kind of flying. The pilot was ultimately responsible for his actions (he certainly paid for them - along with the rest) but the leadership is almost certainly just as much to blame.
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Old 28th Oct 2009, 18:28
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Really - I think is disgusting for TV or radio to transmit the last words of people about to die.
It is all about selling more news.
And the terrible thing: did it help to find the cause? NO

Last edited by SafetyCase; 29th Oct 2009 at 04:20.
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Old 28th Oct 2009, 19:26
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Guys,

I'm not saying that there are not lessons to learn from this tradegy.

However hard you try, however many rules you have in place, if someone doesn't keep a good lookout/ignores proceedure/shows off/ignores authorisations - a crash can result. (I am not saying the Puma crash was caused by ANY of the above!)

It is all to easy to jump and say 'Things must change so this can never happen again!' BUT Gents, just adding to the rules is not always the safest way forward. Making sure that the risks are reduced to As low as reasonably practicable- through orders/education/authorisations is the perfect ideal to which we should all aspire. It still needs the man in the seat to follow them, and use sound airmanship and judgement.
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Old 28th Oct 2009, 20:39
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Safety Case - the fact that the people in the USN Fighter Weapons School feel the need to refer to it as Top Gun is exactly the attitude I mean - the 'I'm better than you' arrogance requires a level of egotism that is not healthy in a cockpit but is common place in the military - unfortunately.

Since this supreme self-belief is not only condoned but encouraged by the upper echelons it is not surprising that some pilots will take it to the limit and venture beyond theirs.

I am certainly not going to defend the RAF in this tragic case, many events had conspired to leave the Puma force with a high dilution of experience and a catch 22 situation where new boys couldn't be trained up enough to do the operational tasking because the rest were working too hard on Ops to spare hours or people.

So some inexperienced guys were left in UK to do noddy tasking, unfortunately with inadequate supervision. It all comes down to poor leadership and a system that promotes the wrong people who seem
incapable of leading by good example.

I do believe that if the release of the CVR tapes helps the other junior pilots out there to realise what is and isn't acceptable and prevents another sensless loss of life then it will have been justified. It's not nice for the families but I expect they wish someone had played the crew a similar tape at some point in their training.
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Old 28th Oct 2009, 22:54
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Perspectives

I've just been looking through my first logbook. On an average month in a peacetime Navy, on my first operational Squadron I was averaging 20-25 hours a month. In one sample month those hours comprised Winching, Close and Tactical formation flying, troop lifts, confined area work, low-level Navexs, Parachute dropping, Night load lifting, Night Navexs, Instrument flying and Tactical 2" RP firing. Most flights were two-pilot plus crewman. I was P1 about 40% of the time by this stage.

The point is I was 22 years old with 400 hours total time. In the RN we got responsibility early, having been properly assessed by the senior guys, and then got on with it.

Now, I'm sure that defence expenditure cutbacks contribute to a lack of good quality training time but I believe that the RAF have never delegated responsibility to their younger pilots effectively and Senior Officers tended to hide behind rulebooks to protect their backs on the slippery promotion ladder. (Incidentally, one of the finest pilots I have known was a grizzled, grumpy old Crab on exchange to us)

If this pilot was a habitual hot-dogger, who failed to spot it and act on it? If he wasn't up to standard why was he self-authorising? Are RAF crewman encouraged to comment during training-flight debriefs? Which half-wit considered playing the "Top Gun" soundtrack through the intercom was ever a good idea?
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Old 29th Oct 2009, 03:58
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Safety Case - the fact that the people in the USN Fighter Weapons School feel the need to refer to it as Top Gun is exactly the attitude I mean - the 'I'm better than you' arrogance requires a level of egotism that is not healthy in a cockpit but is common place in the military - unfortunately.
Sorry, but that is not my experience with the USN Fighter Weapons School. Their emphasis on safety and professionalism was very real. But maybe you have different experiences with them.

You might have noticed that I have not said a bad word of any pilot or crewmember during this discussion.
What I am concerned about is the apparent lack of operational management control and oversight in the RAF. Crab has repeatedly bashed away at the management of a certain company that is tendering for the UK SAR contract (without bringing that issue into this thread) so I think it is only fair to point at the total lack of leadership and operational control that was demonstrated during this accident. I am sorry I used the term "Corporate Liability" in an earlier post. what I meant was "Corporate Killing" Yes, it is a legal term, google it. And this is what this case is about in my opinion.

Could this happen in a civilian company? Certainly, however, I don't think so if we are talking about a professional offshore operator, with FDM (HOMP) and proper safety culture, policies, training, hands-on monitoring etc. There are many opportunities for those who would like to break or bend the rules in these companies too: test flights, ferry flights, training flights etc.

So some inexperienced guys were left in UK to do noddy tasking, unfortunately with inadequate supervision. It all comes down to poor leadership and a system that promotes the wrong people who seem incapable of leading by good example.
You are most likely right on this

I do believe that if the release of the CVR tapes helps the other junior pilots out there to realise what is and isn't acceptable and prevents another sensless loss of life then it will have been justified. It's not nice for the families but I expect they wish someone had played the crew a similar tape at some point in their training
I strongly disagree that it was right to release the recording to the public and the tabloid press for entertainment purposes, that is what it really is. The recording was not crucial in establishing the causes of this accident.
In cases like this, the public does not have the right to know. As I said in an earlier post, information gathered by an investigation body is privileged information in certain countries, Denmark for one.
Release for internal use only? Yes, that would have been acceptable.

I have seen pictures of the results of accidents during my accident/incident investigation training. Would I release these to the public? Hardly.
Almost the same thing isn't it?

Last edited by SafetyCase; 29th Oct 2009 at 06:05.
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Old 29th Oct 2009, 11:54
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Oh SafetyCase...where do I begin with you?

Oh SafetyCase...where do I begin with you?

Am I a person who makes his living by flying?...not now, but in the past, yes. Why do you ask? Is that relevant? Perhaps by not being an aviator I am able to consider the issues with more objectivity than you seem to be able to muster this fine morning.

As you ask, mostly I make my living by gathering facts and knowledge, assembling them into reasoned argument that can be supported by evidence, and then I publish. If I am publishing an opinion I try to build a foundation of evidence around that opinion to support its bearing.

Have I heard of FSP, IFALPA et al?..yes, more than you know. It is not clear how you know, or think you know, that I have not. Please do not try to put words into my mouth, or try to guess what I agree with. If you want to know, simply ask. It is far more polite, not to mention successful.

Above all, calm down chap. You really should not dismiss the views of others like Crab so glibly, especially when you do not know who they are, and particularly when most of the others in here do. Therein lies the potential for face, egg and a combination of the two.

That CVR recordings should never be released to the media is OPINION.
That CVR recordings assist the public’s understanding of this particular case is FACT.
I see no gain in confusing the two, as you repeatedly insist on doing.

As for ‘CVR porn,’ as you call it, the organizations you refer to tend to agree with me...that gratuitous publication serves no purpose and can be upsetting to some, while selective publication is sometimes justified to serve a greater good. Don’t generalize.

As I have said, I think broadcasting this particular tape for a specific and helpful purpose (public explanation, in this case) was justifiable. Gratuitous publication is wrong in my book, you will be glad to hear, but that is not what is happening in this case. That is what you fail to recognize.

I commend your grasp of English, it being your second language, and all. I myself am struggling miserably to learn German, but I have found the trick is to get yourself a German girlfriend. And do keep on editing as much as you like, I say. Editing is a good thing. Don’t let anyone tell you otherwise.

Dan

Last edited by Dantruck; 29th Oct 2009 at 11:56. Reason: because editing is a GOOD thing
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Old 29th Oct 2009, 12:25
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The question is `Cowboy Outfit` or one rotten apple. Perhaps now is a good moment to reconsider the re-allocation of responsibility for all flying operations within the MOD to the two services best suited to the modern requirement, namely the Royal Naval Air Service and the Army Air Corps. The arguments are compelling.
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Old 29th Oct 2009, 13:28
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Dantruck:
As for ‘CVR porn,’ as you call it, the organizations you refer to tend to agree with me...that gratuitous publication serves no purpose and can be upsetting to some, while selective publication is sometimes justified to serve a greater good. Don’t generalize
The organizations agree? Don't think so. Read this from IFALPA:

IFALPA deplores the use of Cockpit Voice Recordings for entertainment

CHERTSEY 8 December: The International Federation of Air Line Pilots’ Associations (IFALPA) is outraged to learn that once again the Cockpit Voice Recordings (CVR) of aircraft involved in a fatal accident have been leaked and are being used by a media provider for public entertainment.
CVRs are intended for one purpose, to help investigators determine the factors that led to an accident with the aim of preventing an accident of the same type in the future. This idea is enshrined in the international principles set down in ICAO Annex 13 which states in Attachment E (Chapter 3.4) “Safety information should not be used in a way different
from the purposes for which it was collected”.
Publishing the content of CVRs outside the context of an Accident Investigation report does nothing to improve air safety. Accordingly, IFALPA calls on States to institute legislation which will prevent publication of the actual recordings of CVRs in the public domain.

And I do not put Crab down, I have respect for his opinions, but I do reserve the right to discuss, even if the words can seem harsh at times.
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Old 29th Oct 2009, 14:32
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That's entertainment

Yes...IFALPA is specifically talking about use for entertainment purposes, as you will see if you actually stop and read it.

I said: "the organizations you refer to tend to agree with me...that gratuitous publication serves no purpose and can be upsetting..." You are pushing at an open door my friend.

However, all this is not the same as my "...selective publication sometimes justified to serve a greater good" is it?

Show me that clipping and I might change my mind.
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Old 29th Oct 2009, 14:42
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Snarlie - you imply the other two services have unblemished records and act in a disciplined way at all times? After 40 yrs of working with all three, I beg to differ!
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Old 29th Oct 2009, 14:58
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I think the CVR porn issue is mute. It was used as evidence and therefore in the public domain. If you fly like a dough bag and stuff it in without just cause I think you deserve all you get.

Why should we be above the law and when paid by the tax payer - not accountable to him. The public and the family deserve to know what happened on that flight....and sadly the press sensationalism is probably the only way to change some die-hard attitudes in the military management.

If you have an accident or serious whoopsie expect the CVR to be played!!! If it contains clear statements of intent to endanger other people, as this one did (lets scare the *** out of this taxi driver)) I would expect to see a custodial sentence.
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Old 29th Oct 2009, 15:19
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DB
Are you actually saying that all information gathered by f.ex the AAIB after an accident is public property for all to see?
Would you accept that a transcript of an interview of you, or maybe a recording of that interview should be published by the BBC?
This is the direction some of you are going.
There are good reasons for Denmark, Norway and other countries to prohibit the use of information gathered by an investigation body to be used for any other purpose than establishing the cause of an accident and preventing new accidents. The main one is to ensure that the reporters can be assured of some kind of protection. If not, there will be a marked drop in reporting, and this is not what we want.
Please read the ICAO Annex 13, it is available on the internet.

Last edited by SafetyCase; 29th Oct 2009 at 15:30.
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Old 29th Oct 2009, 15:58
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It is sad and a tragic shame that people have lost their lives, my thoughts are with the family and friends of those who have perished.

I do, however, agree with Crab, and others, that a safety margin imposed by oneself for when one runs out of talent is the saviour of many a "young gun".It is a shame that this particular pilot failed to apply the "10% for the wife and kids" maxim, another tried and tested safety system.
He made the decisions on that day and flew the aircraft in such a way as to lead to the demise of innocent people including crew members, who though complicit in what went on, were not in command.
A no blame culture is all well and good, but responsibility has to be taken by someone and the buck stops with the person holding the cyclic.
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Old 29th Oct 2009, 16:53
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All in all, I agree with most of what you are saying.
I am not advocating a "no blame" culture at all, what I would like to see in any company, RAF included, is a "just and learning" culture. To put the cause of this accident on the shoulders of the crew only, and to use the recording of the CVR to support this really upsets me. That will not facilitate the learning which this institution obviously needs. The crew should not have been put in the situation where they thought it was all right to do what they did during this flight. They should have been told in very clear terms, long before the accident, that this kind of flying leads to severe consequences. This is about Squadron Safety Culture.
There seems to have been a serious flaw in the safety culture in that squadron or wing or station. I don't know where the root cause lies, but it there is certainly a serious problem there..

Last edited by SafetyCase; 29th Oct 2009 at 17:08.
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