Helios Crash
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Frangible I agree with your analysis, changes to checklists and procedures meant to ameliorate design deficiencies belong to the short term during the period when redesign and implementation should take place, they are not a long term panacea. I wonder if Boeing's stubborn refusal to change the pressurization warning system on the 737 might have its roots in type certification issues and/or the potential for increased liability exposure on older models, absent an expensive mandated retrofit.
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Maybe it is just me, but a horn that starts wailing in a pressurised aircraft shortly after passing through 10,000ft is a no-brainer, especially when your ears have also been popping. Yet another give-away is a significantly noisier flight-deck.
I flew the succeeding aircraft off the 73-3 production line to the Helios airframe AND (surprise!) on one occasion also had a total failure of the pressurisation controller (same type fitted). Yes I filed an ASR. Come to mention it, I have also had pressurisation controller faults and the cabin altitude horn on DHC8s - IMHO they leave you in no doubt, whether they sound the same as the takeoff config horn or not.
I am an average airline pilot of average ability - no more experienced than the fated Captain on the Helios, and possibly less. He had issues. The pressurisation controller on 737s is far from perfect - but then none are - as with all systems, vigilance and proper procedure would have prevented this accident. We shouldn't be so hard on Mr Boeing.
I flew the succeeding aircraft off the 73-3 production line to the Helios airframe AND (surprise!) on one occasion also had a total failure of the pressurisation controller (same type fitted). Yes I filed an ASR. Come to mention it, I have also had pressurisation controller faults and the cabin altitude horn on DHC8s - IMHO they leave you in no doubt, whether they sound the same as the takeoff config horn or not.
I am an average airline pilot of average ability - no more experienced than the fated Captain on the Helios, and possibly less. He had issues. The pressurisation controller on 737s is far from perfect - but then none are - as with all systems, vigilance and proper procedure would have prevented this accident. We shouldn't be so hard on Mr Boeing.
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Helios criminal case
Dear colleagues,
We are experiencing a bit of a thread drift.
The deficiency of the B737 press system is well known and discussed in many threads on pprune and elswhere.
Another important info - Boeing settled with a major part of the Helios crash victims' families (but not all) out of court at the cost of almost 40 million EUR.
This is another proof of the above deficiency.
This thread was started to bring attention to the disgusting trend of criminalization of commercial aviation accidents.
Noone claims that the pilots were faultless.
Captain van Zanten of KLM 4805 did not make a mistake. He commited a crime that cost the highest ever number of victims in aviation history. Or did he?
Wiki:
The Dutch authorities were reluctant to accept the Spanish report blaming the KLM captain for the accident. The Netherlands Department of Civil Aviation published a response that, whilst accepting that the KLM aircraft had taken off "prematurely", argued that he alone should not be blamed for the "mutual misunderstanding" that occurred between the controller and the KLM crew, and that limitations of using radio as a means of communication should have been given greater consideration.
So should the courts in Larnaca and Athens put the blame only on Helios management? So should the "limitations of the B737 press system have been given a greater consideration"? Or someone hopes that a criminal verdict should facilitate "another compensation" like the Boeing payout?!
We are experiencing a bit of a thread drift.
The deficiency of the B737 press system is well known and discussed in many threads on pprune and elswhere.
Another important info - Boeing settled with a major part of the Helios crash victims' families (but not all) out of court at the cost of almost 40 million EUR.
This is another proof of the above deficiency.
This thread was started to bring attention to the disgusting trend of criminalization of commercial aviation accidents.
Noone claims that the pilots were faultless.
Captain van Zanten of KLM 4805 did not make a mistake. He commited a crime that cost the highest ever number of victims in aviation history. Or did he?
Wiki:
The Dutch authorities were reluctant to accept the Spanish report blaming the KLM captain for the accident. The Netherlands Department of Civil Aviation published a response that, whilst accepting that the KLM aircraft had taken off "prematurely", argued that he alone should not be blamed for the "mutual misunderstanding" that occurred between the controller and the KLM crew, and that limitations of using radio as a means of communication should have been given greater consideration.
So should the courts in Larnaca and Athens put the blame only on Helios management? So should the "limitations of the B737 press system have been given a greater consideration"? Or someone hopes that a criminal verdict should facilitate "another compensation" like the Boeing payout?!
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I am an average airline pilot of average ability - no more experienced than the fated Captain on the Helios, and possibly less. He had issues. The pressurisation controller on 737s is far from perfect - but then none are - as with all systems, vigilance and proper procedure would have prevented this accident. We shouldn't be so hard on Mr Boeing.
That said, we have to cut Mr. Boeing some slack, after all the aircraft and warning system design is after all over 40 years old by now and should be very well known by all pilots operating this thing, if they are properly trained of course.
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A couple of comments:
One reader notes that a horn above 10,000' in a pressurised a/c is a no brainer. I flew for an operator which had the wailer go off at 29.000'. The captain had been in the sim recently where the SFI had introduced a failure of the ground/air sensor. I don't know the full details of the scenario, but suffise to say the takeoff config wailer went off at altitude. I heard the captain in question leapt into the fray and discussed the problem with the F/O saying he had seen this problem in the sim and it was this & that and this was why and this was what to do about it etc. etc. A few moments later the No.1 one rang to ask why all the O2 masks were hanging down.
In past years many of us will have had an indepth recurrent training on communications. Listen and digest etc. etc. How to ask and answer questions. Advocate your position; be clear what is understood. If there is doubt asl again. If the Discovery Channel re-enactment was accurate, and I assume they used CVR tapes, they alledged that the gound engineer asked the captain "the position of the pressuristaion controller." The captain ignored that and kept insisting to know the position of the recirc fan (or altn cooling) C.B's. They alledged the engineer NEVER had his question answered. Makes you wonder. Another captain who was portrayed as allegedly dominering and un-listening and rushing. Does that remind you of KLM Teneriffe or Spanair Madrid; not to mention the B757 crash in Cali? 4 different nationalities and very different cultural backgrounds. Same impatient actions, same result. No doubt there are 100's more examples of where 'less haste more speed' and listen....... would have caused a different outcome.
Trying to lay the most of the blame on a technical design is short sighted. Same goes for Turkish airlines at AMS. To say the technology is more at fault than the humans will cause the medication to be applied in the worng place; treating the symptoms and not the illness.
One reader notes that a horn above 10,000' in a pressurised a/c is a no brainer. I flew for an operator which had the wailer go off at 29.000'. The captain had been in the sim recently where the SFI had introduced a failure of the ground/air sensor. I don't know the full details of the scenario, but suffise to say the takeoff config wailer went off at altitude. I heard the captain in question leapt into the fray and discussed the problem with the F/O saying he had seen this problem in the sim and it was this & that and this was why and this was what to do about it etc. etc. A few moments later the No.1 one rang to ask why all the O2 masks were hanging down.
In past years many of us will have had an indepth recurrent training on communications. Listen and digest etc. etc. How to ask and answer questions. Advocate your position; be clear what is understood. If there is doubt asl again. If the Discovery Channel re-enactment was accurate, and I assume they used CVR tapes, they alledged that the gound engineer asked the captain "the position of the pressuristaion controller." The captain ignored that and kept insisting to know the position of the recirc fan (or altn cooling) C.B's. They alledged the engineer NEVER had his question answered. Makes you wonder. Another captain who was portrayed as allegedly dominering and un-listening and rushing. Does that remind you of KLM Teneriffe or Spanair Madrid; not to mention the B757 crash in Cali? 4 different nationalities and very different cultural backgrounds. Same impatient actions, same result. No doubt there are 100's more examples of where 'less haste more speed' and listen....... would have caused a different outcome.
Trying to lay the most of the blame on a technical design is short sighted. Same goes for Turkish airlines at AMS. To say the technology is more at fault than the humans will cause the medication to be applied in the worng place; treating the symptoms and not the illness.
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RAT5 :
Very wise comment, but unfortunately not applied . It is quite the opposite we see, almost always putting the" blame" on operators of systems. instead of revisiting the system design.
To say the technology is more at fault than the humans will cause the medication to be applied in the worng place; treating the symptoms and not the illness.
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Trying to lay the most of the blame on a technical design is short sighted. Same goes for Turkish airlines at AMS. To say the technology is more at fault than the humans will cause the medication to be applied in the worng place; treating the symptoms and not the illness.
But here's where I differ with your analysis. Accident investigations should not concern themselves with assigning blame whatsoever. Only in the factual determination of cause/probable cause and contributing factors, be they human failings or technical. The better to prevent the same thing happening again under similar circumstances. Further, I wouldn't claim that design faults were the root cause of either the Helios or Turkish accidents, but they were certainly contributing factors that need to be fixed.
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Greetings and thank you for the replies. I agree, blame is often inferred to identifying persons at fault, and causes to the broader spectrum including systems and any inter-actions with humans. Causes are more important in trying to prevent repetition and to help evolve better designs to aid that end.
However, and this touches on another thread regarding the erosion of basic piloting skills. That subject is addressed very forceably in the NSTB report of the Q400 crash in Buffalo. It draws attention to the modern age where too much reliance is placed by crews on the automatics. They can't go wrong..go wrong..go wrong... Often this is due to the method of training by an operator. I have worked for various opertaors where the attitude from upstairs was very different. Some emphasised and encouraged the continuence of excellent handling skills and multi-tasking while doing so. Others have stifled that approach and turned pilots into robotic trained monkeys in the name of crash prevention. They both had significant failure in command up-grades, but for different reasons. The latter, though, saw a weakness in situational awareness and reacting to non standard non-normal situations. Thinking on your feet and making decisions based on your supposed experience to handle some unusual scenario was missing or confused. Basic command requirements. Especially necessary considering that the total experience in some cockpits can be as little as 3500hrs, when basic command requiremenst alone used to be 5000hrs.
What I am nervous about is the march of technology to remove even further the pilot from the operation. A pilot makes an error in managing a system. There is a knee jerk reaction to blame the system or the human-system interplay. Of all the other 1000's of pilots on same type, how many others have nearly made that same error? Is that researched? I've not heard of it very often. The reaction is to say that the system must have an inherent fault and it is redesigned to be even more automatic. Is the training of that individual ever researched? Is the training philosophy of the airline considered? In some cases, such as the fin failure of the Airbus in the USA due to heavy rudder loads being applied, I believe the training program was questioned. There have been other instances where the training has been improved after an incident. The system was not necessarily automated any more to prevent human interference. There have been some superb enhacements of automation. I've flown the most basic of a/c and some of Boeing's finest, not including FBW. I've not felt out of the loop by EFIS & EICAS. I've felt empowered to do a much better job and easier and more relaxed, helped by the information and level of automation, but not neutered by it. Perhaps that is becasue of my background. I never forgot the basics for older technology. I notice that younger pilots, who grew up on EFIS & EICAS, do tend to let themselves be led by the nose. I hear younger trainers teach them to not interfer but trust the automatics and FLY the F.D.
All I'm saying is that if every time there is a prang due to mis-managing the automatics the answer is to increase the level of automation, I wonder if that is going in the wrong direction for the wrong reason. Perhaps the 1 pilot and a dog cockpit is closer than we think.
However, and this touches on another thread regarding the erosion of basic piloting skills. That subject is addressed very forceably in the NSTB report of the Q400 crash in Buffalo. It draws attention to the modern age where too much reliance is placed by crews on the automatics. They can't go wrong..go wrong..go wrong... Often this is due to the method of training by an operator. I have worked for various opertaors where the attitude from upstairs was very different. Some emphasised and encouraged the continuence of excellent handling skills and multi-tasking while doing so. Others have stifled that approach and turned pilots into robotic trained monkeys in the name of crash prevention. They both had significant failure in command up-grades, but for different reasons. The latter, though, saw a weakness in situational awareness and reacting to non standard non-normal situations. Thinking on your feet and making decisions based on your supposed experience to handle some unusual scenario was missing or confused. Basic command requirements. Especially necessary considering that the total experience in some cockpits can be as little as 3500hrs, when basic command requiremenst alone used to be 5000hrs.
What I am nervous about is the march of technology to remove even further the pilot from the operation. A pilot makes an error in managing a system. There is a knee jerk reaction to blame the system or the human-system interplay. Of all the other 1000's of pilots on same type, how many others have nearly made that same error? Is that researched? I've not heard of it very often. The reaction is to say that the system must have an inherent fault and it is redesigned to be even more automatic. Is the training of that individual ever researched? Is the training philosophy of the airline considered? In some cases, such as the fin failure of the Airbus in the USA due to heavy rudder loads being applied, I believe the training program was questioned. There have been other instances where the training has been improved after an incident. The system was not necessarily automated any more to prevent human interference. There have been some superb enhacements of automation. I've flown the most basic of a/c and some of Boeing's finest, not including FBW. I've not felt out of the loop by EFIS & EICAS. I've felt empowered to do a much better job and easier and more relaxed, helped by the information and level of automation, but not neutered by it. Perhaps that is becasue of my background. I never forgot the basics for older technology. I notice that younger pilots, who grew up on EFIS & EICAS, do tend to let themselves be led by the nose. I hear younger trainers teach them to not interfer but trust the automatics and FLY the F.D.
All I'm saying is that if every time there is a prang due to mis-managing the automatics the answer is to increase the level of automation, I wonder if that is going in the wrong direction for the wrong reason. Perhaps the 1 pilot and a dog cockpit is closer than we think.
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DATE:02/05/10 SOURCE:Flight International
RAeS calls for better balance between accident investigation and the judicial system
By David Learmount
Air accidents will increasingly be treated as criminal events unless aviation authorities can muster a global push to achieve a better balance between the roles of accident investigators and the judiciary, according to a London aviation law specialist.
Delegates to a Royal Aeronautical Society conference on the criminalisation of air accidents in London on 28 April were warned that it is becoming more common for criminal prosecutions almost automatically to follow accidents.
Charles Haddon-Cave QC said that as a consequence the industry is tending to engage in "defensive engineering, not just technical but personal and administrative".
Procedures are now being designed as "a bulwark against criticism" rather than an improved way of doing things, he added.
The conference examined the tension between the need for operators to run an internal voluntary safety reporting system - without which a safety management system cannot operate - and the judiciary's duty to examine data to determine whether a failure was criminal or not, which tends to kill voluntary disclosure.
Haddon-Cave suggested the system's performance would improve through "simplification of process" and a management structure that clearly defines lines of responsibility. He also called for "balance" in national governance between the purposes of accident investigators and the judiciary, suggesting the law should be used for "prosecution, not persecution".
During the conference a consensus appeared to develop that the International Civil Aviation Organisation is the agency through which this should be achieved, and that its recent High Level Safety Conference in Montreal was the first step along that road.
Meanwhile, the controversial European Commission draft proposal for setting up a European "network" of national air accident investigation agencies that could share resources, was advanced as a more legally practical proposal than creating a centralised supra-national one.
Paris-based lawyer Simon Foreman said the draft offered France an opportunity to redress some of the imbalance in its own system by requiring the judiciary to justify any demand to take charge of evidence, rather than the present system that allows the judiciary to remove evidence for its own purposes, thus impeding the task of the accident investigators.
By David Learmount
Air accidents will increasingly be treated as criminal events unless aviation authorities can muster a global push to achieve a better balance between the roles of accident investigators and the judiciary, according to a London aviation law specialist.
Delegates to a Royal Aeronautical Society conference on the criminalisation of air accidents in London on 28 April were warned that it is becoming more common for criminal prosecutions almost automatically to follow accidents.
Charles Haddon-Cave QC said that as a consequence the industry is tending to engage in "defensive engineering, not just technical but personal and administrative".
Procedures are now being designed as "a bulwark against criticism" rather than an improved way of doing things, he added.
The conference examined the tension between the need for operators to run an internal voluntary safety reporting system - without which a safety management system cannot operate - and the judiciary's duty to examine data to determine whether a failure was criminal or not, which tends to kill voluntary disclosure.
Haddon-Cave suggested the system's performance would improve through "simplification of process" and a management structure that clearly defines lines of responsibility. He also called for "balance" in national governance between the purposes of accident investigators and the judiciary, suggesting the law should be used for "prosecution, not persecution".
During the conference a consensus appeared to develop that the International Civil Aviation Organisation is the agency through which this should be achieved, and that its recent High Level Safety Conference in Montreal was the first step along that road.
Meanwhile, the controversial European Commission draft proposal for setting up a European "network" of national air accident investigation agencies that could share resources, was advanced as a more legally practical proposal than creating a centralised supra-national one.
Paris-based lawyer Simon Foreman said the draft offered France an opportunity to redress some of the imbalance in its own system by requiring the judiciary to justify any demand to take charge of evidence, rather than the present system that allows the judiciary to remove evidence for its own purposes, thus impeding the task of the accident investigators.
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RAT5 : Excellent post , fully agree. The same tendency is going on in ATC right now, where complexities and incoherences in the advanced automated systems are mitigated by more automation , leaving the controller further away from understanding what the system is doing. I we combine this with the new young generation which was born with a Nitendo next to the feeding bottle , the results are decrease of situation awareness, repetitive tasks to feed the machine, erosion of basic control skills and very, very poor decision making in abnormal situations and/or when automation fails.
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Swish 266: Is this rush to find a criminal (humans to blame) driven by the compensation society that has evolved? Is it there in comparable industries, I wonder? Is it caused by the massive payouts that can be achieved in aviation, and has it been driven by the legal profession not the legislators? Until we know the cause of the change we can not start to find an antidote. Can the legislators reverse the trend? I'm sure that in the search for truth and prevention the same attitude of blame-free reporting/investigation, as is found in many airlines, needs to feed across into the public arena. Surely any accident should be investigated as just that. They do happen, in innocence, but it is likely there was a trail of minor events that culminated in an unforeseen accident that was outside the scope of the humans involved.That finds a cause. In doing so the root cause is found and addressed, and may indeed involve a mixture of humans & systems. Should negligence, or other culpable human factors be uncovered, then further action might be taken; but to start assuming someone is for the chop is counter productive and could cloud any judgement as to finding real cause. Just look for the finger on the wrong button and, hey presto, a winner. Mega bucks please.
I have come across an attitude supporting rigid SOP adherence. It was not good communications; any crew can fly together philosophy, but rather a back-side covering attitude. "The SOP's are approved. I followed them; S*!t happened. Not my fault. Ask the company and authority." I wonder what will happen when this attitude is questioned after a survivable accident. "Surely, you as an experinced captain, should have realised that the situation called for a different response? Surely you should have realised that the SOP was not appropriate at this time?" "I was only following orders, guv." I wonder.
In history, we have seen too many accidents, especially where the pilots have not survived to defend themselves, where, perhaps for expediancy, perhaps for compensation reduction, pilot error has been the verdict. The trail of little things, including fatigue, lack of or inadequate training/checking, lack of total experience in the cockpit, etc. etc. has never been fully investigated. Maybe touched upon, but given little importance. Perhaps lack of time or resources? I have marvelled at how some accident investigations have unearthed the most minute and bizzare causes. I applaud them. It was years of hard graft and eventually they found the tiniest grain of truth. Real Silent Witness stuff, but usually mechanical, not human failure.
The process needs to change, as does the incessant removal of the pilot from the flying loop, otherwise we'll become earth astronauts on a computer controlled trajectory with TCAS as the final safety net. Afterall, the only thing missing is automatic taxy & takeoff, and taxy after landing. For 20 years, from 400' up to landing, it has been able to pre-program it. However, I suspect the ball will roll much further in its present direction before someone puts their foot on it and looks around to pause and makes a back-pass.
As our friends in ATC and engineering are commenting, it is not isolated to the sharp end. Our world is part of a chain of many links. I wonder if they are all evolving in a coordinated manner? I wonder if isolated technocrats & accountants are too inward looking at their own territory? It is not impossible to imagine an incident being created by one link working out of sinc with another down the chain and catching the latter by surprise. However, I'm sure blame would be attached to the final culprit. It's an extremely complex area for discussion, and as always 10 experts will have 10 opinions. Who decides?
I have come across an attitude supporting rigid SOP adherence. It was not good communications; any crew can fly together philosophy, but rather a back-side covering attitude. "The SOP's are approved. I followed them; S*!t happened. Not my fault. Ask the company and authority." I wonder what will happen when this attitude is questioned after a survivable accident. "Surely, you as an experinced captain, should have realised that the situation called for a different response? Surely you should have realised that the SOP was not appropriate at this time?" "I was only following orders, guv." I wonder.
In history, we have seen too many accidents, especially where the pilots have not survived to defend themselves, where, perhaps for expediancy, perhaps for compensation reduction, pilot error has been the verdict. The trail of little things, including fatigue, lack of or inadequate training/checking, lack of total experience in the cockpit, etc. etc. has never been fully investigated. Maybe touched upon, but given little importance. Perhaps lack of time or resources? I have marvelled at how some accident investigations have unearthed the most minute and bizzare causes. I applaud them. It was years of hard graft and eventually they found the tiniest grain of truth. Real Silent Witness stuff, but usually mechanical, not human failure.
The process needs to change, as does the incessant removal of the pilot from the flying loop, otherwise we'll become earth astronauts on a computer controlled trajectory with TCAS as the final safety net. Afterall, the only thing missing is automatic taxy & takeoff, and taxy after landing. For 20 years, from 400' up to landing, it has been able to pre-program it. However, I suspect the ball will roll much further in its present direction before someone puts their foot on it and looks around to pause and makes a back-pass.
As our friends in ATC and engineering are commenting, it is not isolated to the sharp end. Our world is part of a chain of many links. I wonder if they are all evolving in a coordinated manner? I wonder if isolated technocrats & accountants are too inward looking at their own territory? It is not impossible to imagine an incident being created by one link working out of sinc with another down the chain and catching the latter by surprise. However, I'm sure blame would be attached to the final culprit. It's an extremely complex area for discussion, and as always 10 experts will have 10 opinions. Who decides?
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RAT 5 -
I think it is fairly well appreciated that a devious sim instructor could conjure up any number of failures that could result in a pilot losing his/her S.A. - but there is a very real trap in that doing so introduces the possibility of negative training. I too have had the pleasure of a failue of the air/ground system in a 73-3 sim - the fundamental shortfall of this scenario being the complete absense in your bowels (and ears) that something is VERY wrong with the pressurisation system. In the Helios situation - a typical (but unpressurised) 737 with typical ROC - these visceral clues SHOULD be ringing alarm bells independently of anything Mr Boeing has fitted. They certainly have with me - in stark contrast to what happens in the sim. An experienced pilot might say this is a perfect example of where one has to follow ones gut instinct.
Nevertheless, you raise many very valid points. There are a number of issues here not confined to the aviation industry, and we must work not to let them make our business less safe (like negative sim training). Most pertinently, because the powers and responsibilities of the Commander of an aircraft essentially have their roots in old maritime law, they were not written with the concept of a gratuitously litigious society and law profession in mind. In other words, as you have alluded to, we (and our employers) are far too ripe a target for the avaricious and/or political not to have a pop at. We either need to modify these old laws so that we do not bear responsibility absolute for everything that happens on our flights, or we need to have a bullet-proof get-out-of-jail-free clause that admits the possibility of "honest" human falibility on the flight deck and decriminalises it. The later, of course, still does not negate the possibility of civil lawsuit, hence we really should be carrying professional insurance, like many in the medical profession.
There are parallels here with AF447 inasmuch as design philosphy with Airbus worked towards decreasing the motor-skill levels required to fly the aeroplane, thereby (theoretically) decreasing the likelyhood of mis-handling leading to an accident. But, in accordance with the law of diminishing returns, the human use-it-or-lose-it skill trait in itself introduces a risk that must be carefully balanced. Broadly, AF447 came unstuck because of this and, paradoxically, one other important element of flight safety - a decision of judgement. I cannot see how a manufacturer can design a system that is perfectly fool-proof, 100% safe, and able to accomodate every possible scenario and variable that international passenger air transport involves. There will always be judgement calls to be made and systems that need setting and monitoring, and at least some of that stuff can only be done in-situ .
W.R.T. your other observations, I wholeheartedly agree - the processes of accident investigation, and of judicial process, must be kept very separate. This is clearly not happening in many (most) countries at present and I can't see it changing in a hurry. I suggest whilst we as a profession try to get our laws re-written, we reflect upon what it entails to be a skilled pilot, and what value we place on experience.
I think it is fairly well appreciated that a devious sim instructor could conjure up any number of failures that could result in a pilot losing his/her S.A. - but there is a very real trap in that doing so introduces the possibility of negative training. I too have had the pleasure of a failue of the air/ground system in a 73-3 sim - the fundamental shortfall of this scenario being the complete absense in your bowels (and ears) that something is VERY wrong with the pressurisation system. In the Helios situation - a typical (but unpressurised) 737 with typical ROC - these visceral clues SHOULD be ringing alarm bells independently of anything Mr Boeing has fitted. They certainly have with me - in stark contrast to what happens in the sim. An experienced pilot might say this is a perfect example of where one has to follow ones gut instinct.
Nevertheless, you raise many very valid points. There are a number of issues here not confined to the aviation industry, and we must work not to let them make our business less safe (like negative sim training). Most pertinently, because the powers and responsibilities of the Commander of an aircraft essentially have their roots in old maritime law, they were not written with the concept of a gratuitously litigious society and law profession in mind. In other words, as you have alluded to, we (and our employers) are far too ripe a target for the avaricious and/or political not to have a pop at. We either need to modify these old laws so that we do not bear responsibility absolute for everything that happens on our flights, or we need to have a bullet-proof get-out-of-jail-free clause that admits the possibility of "honest" human falibility on the flight deck and decriminalises it. The later, of course, still does not negate the possibility of civil lawsuit, hence we really should be carrying professional insurance, like many in the medical profession.
There are parallels here with AF447 inasmuch as design philosphy with Airbus worked towards decreasing the motor-skill levels required to fly the aeroplane, thereby (theoretically) decreasing the likelyhood of mis-handling leading to an accident. But, in accordance with the law of diminishing returns, the human use-it-or-lose-it skill trait in itself introduces a risk that must be carefully balanced. Broadly, AF447 came unstuck because of this and, paradoxically, one other important element of flight safety - a decision of judgement. I cannot see how a manufacturer can design a system that is perfectly fool-proof, 100% safe, and able to accomodate every possible scenario and variable that international passenger air transport involves. There will always be judgement calls to be made and systems that need setting and monitoring, and at least some of that stuff can only be done in-situ .
W.R.T. your other observations, I wholeheartedly agree - the processes of accident investigation, and of judicial process, must be kept very separate. This is clearly not happening in many (most) countries at present and I can't see it changing in a hurry. I suggest whilst we as a profession try to get our laws re-written, we reflect upon what it entails to be a skilled pilot, and what value we place on experience.
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gradual/slow depress
I can say from personal experience (in my AF days I did 2 times climb in a baro-chamber to 5000 m at an average rate of 1000f/min) that gradual depress is not even close to a calamity. But the effect of hypoxia is! One can't even imagine the gibberish one puts down on his notepad under the dictation of the people conducting the exercise from the outside!
The Helios 522 crew were in a high workload scenario immediately after t/o. This, of course should have not in itself alone sprung the trap on them, but with the slow onset of hypoxia we could never be so sure!
The prosecution in Larnaca is so sure (remember - prosecution claims the pilots were inadequately trained and wrongfully selected for the job) that they are using as evidence a test flight conducted on an Olympic B737 that didn't even have the same pressurization system.
It had the analogue one...
Nevertheless the Hon Judge allowed above piece of evidence...
The Helios 522 crew were in a high workload scenario immediately after t/o. This, of course should have not in itself alone sprung the trap on them, but with the slow onset of hypoxia we could never be so sure!
The prosecution in Larnaca is so sure (remember - prosecution claims the pilots were inadequately trained and wrongfully selected for the job) that they are using as evidence a test flight conducted on an Olympic B737 that didn't even have the same pressurization system.
It had the analogue one...
Nevertheless the Hon Judge allowed above piece of evidence...
Join Date: Jan 2006
Location: LPFL
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I'm just an SLF but tonight, my wife's washing machine didn't spin the clothes after rinsing them.
Last time the machine didn't do what it was supposed to, I pulled out the filter and found a coin in it after removal of which the machine worked perfectly.
Tonight, I pulled out the filter but found a coin jammed in the hose. I spent about 20 minutes trying to prise it loose but even after I'd got it out, the machine didn't seem to want to spin.
5 minutes later, my wife realised the spin speed dial was set to zero - she reckoned she'd accidentally nudged it from its usual setting while cleaning the machine last night ...
Two points arise from this tedious little tale -
1. Pretty daft of Hoover to design a washing machine with a spin speed setting of zero BUT ...
2. Don't get tunnel vision-ed on the "usual solution" - scan the instrument panel (which Hoover WMs have as well as Boeings!) to see if something's out of place.
Last time the machine didn't do what it was supposed to, I pulled out the filter and found a coin in it after removal of which the machine worked perfectly.
Tonight, I pulled out the filter but found a coin jammed in the hose. I spent about 20 minutes trying to prise it loose but even after I'd got it out, the machine didn't seem to want to spin.
5 minutes later, my wife realised the spin speed dial was set to zero - she reckoned she'd accidentally nudged it from its usual setting while cleaning the machine last night ...
Two points arise from this tedious little tale -
1. Pretty daft of Hoover to design a washing machine with a spin speed setting of zero BUT ...
2. Don't get tunnel vision-ed on the "usual solution" - scan the instrument panel (which Hoover WMs have as well as Boeings!) to see if something's out of place.
Join Date: Jun 2009
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midland 63,
Their first clue was the intermitent horn at 10,000 ft cabin altitude. Hypoxia didn't set in until several minutes later so if they knew their systems at all they should have realized the warning in flight is cabin altitude, not take off warning. It happened to me one day and I figured it out in a few seconds, as we are trained to do, so it was a non event. Blaming Boeing for using the same warning on the ground and in the air seems lame. They should have performed standard procedures to easily handle the situation.
Their first clue was the intermitent horn at 10,000 ft cabin altitude. Hypoxia didn't set in until several minutes later so if they knew their systems at all they should have realized the warning in flight is cabin altitude, not take off warning. It happened to me one day and I figured it out in a few seconds, as we are trained to do, so it was a non event. Blaming Boeing for using the same warning on the ground and in the air seems lame. They should have performed standard procedures to easily handle the situation.
RAT 5,
I am an SLF with a bad cold so you and all the others please feel free to ignore me.
May I argue that the Turkish crew, the KLM in Teneriffe crew, and the Callie crew as well as the captain of Helios all share a common dedication to hierarchy. In the first three cases the FO dared not to talk back or argue to their respective captain and in the Helios case the captain did the talking with his company's maintenance dept instead of letting his FO to discuss the matter in their native tongue. I think this is clearly stated on the report.
No regarding the specific issue most of us would agree that the crew did mis-interpret the warning after having various times failed to set correctly the pressurization controller. PAX on that flight did pay to have a crew correctly trained to operate the flight. Instead they died because the crew failed on this role. Why should the relatives of the crew don't seek a settlement against the airline for failing to meet a basic obligation?
Rwy in Sight
I am an SLF with a bad cold so you and all the others please feel free to ignore me.
May I argue that the Turkish crew, the KLM in Teneriffe crew, and the Callie crew as well as the captain of Helios all share a common dedication to hierarchy. In the first three cases the FO dared not to talk back or argue to their respective captain and in the Helios case the captain did the talking with his company's maintenance dept instead of letting his FO to discuss the matter in their native tongue. I think this is clearly stated on the report.
No regarding the specific issue most of us would agree that the crew did mis-interpret the warning after having various times failed to set correctly the pressurization controller. PAX on that flight did pay to have a crew correctly trained to operate the flight. Instead they died because the crew failed on this role. Why should the relatives of the crew don't seek a settlement against the airline for failing to meet a basic obligation?
Rwy in Sight