Turkish airliner crashes at Schiphol
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Report?
Copy of a message I just posted in another forum:
1. Accidents are devastating to those directly involved and costly to many others.
2. Accidents should be prevented ahead of time by proper operations risk management (ORM).
3. Accident investigations should be performed professionally, and their reports written such that the knowhow obtained is useful and properly communicated to prevent them from recurring.
I am writing the following with a background including chairman of air accident investigation boards, authorized investigator of a certain state CAA, and have completed US postgraduate technical report writing studies.
4. Without prejudice, the report is written such that it deviates from what I view as acceptable standards in this important line of business. In doing so it is my impression that it fails to pass a clear message to decision makers. A proper format of accident report is for example used by the US Dept. of Transportation NTSB.
5. Excuse me for not reading throughall of it, a decision maker needs to read the main conclusions and recommendations in a one page introductory summary. I closed the report on page 7 and might have missed some info.
BUT- the inverstigation in my humble opinion failed to pinpoint the primary cause of the accident. The primary cause of the accident was the failure of the crew to make a safe approach to landing, while flying with a failed RA. A main secondary contributor to the accident is the RA system failure, but the RA or the AFCS isn't the captain, whose primary responsibility I mentioned.
6. This adds to a number of essay messages I wrote about cockpit automation problematics.
1. Accidents are devastating to those directly involved and costly to many others.
2. Accidents should be prevented ahead of time by proper operations risk management (ORM).
3. Accident investigations should be performed professionally, and their reports written such that the knowhow obtained is useful and properly communicated to prevent them from recurring.
I am writing the following with a background including chairman of air accident investigation boards, authorized investigator of a certain state CAA, and have completed US postgraduate technical report writing studies.
4. Without prejudice, the report is written such that it deviates from what I view as acceptable standards in this important line of business. In doing so it is my impression that it fails to pass a clear message to decision makers. A proper format of accident report is for example used by the US Dept. of Transportation NTSB.
5. Excuse me for not reading throughall of it, a decision maker needs to read the main conclusions and recommendations in a one page introductory summary. I closed the report on page 7 and might have missed some info.
BUT- the inverstigation in my humble opinion failed to pinpoint the primary cause of the accident. The primary cause of the accident was the failure of the crew to make a safe approach to landing, while flying with a failed RA. A main secondary contributor to the accident is the RA system failure, but the RA or the AFCS isn't the captain, whose primary responsibility I mentioned.
6. This adds to a number of essay messages I wrote about cockpit automation problematics.
Rotate on this!
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"5. Excuse me for not reading throughall of it, a decision maker needs to read the main conclusions and recommendations in a one page introductory summary. I closed the report on page 7 and might have missed some info."
[ ] Makes sense
[x] Fail
[ ] Makes sense
[x] Fail
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Opherben :
Something is not quiet right here.. because I read many accident reports since many years , and this one is very good I'd say.
Again, if you are who you claim you are and you do not read it through, who else will ? and how can you state that its contents are not acceptable standards if you did not read it all ?
I am writing the following with a background including chairman of air accident investigation boards,....... the report is written such that it deviates from what I view as acceptable standards
Excuse me for not reading throughall of it
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To Opherben
As an experienced investigator, then, you should know that not all investigation agencies, including some of the world's most respected, and no researchers into causality of accidents whom I know, think an assignment of "primary cause" is appropriate.
Indeed, all those professional researchers researching failures and accidents causally whom I know consider that most accidents result from a conjunction of many causes.
There are many ways of selecting one cause to "put on a pedestal". My view is that, if one wants to do this, one should explain and justify one's selection criteria in the report.
I know the senior researcher, who has a world-wide reputation, who prepared the human factors report on this accident. I regard the insights in his report as very high quality, and some of those insights made it into the final report.
It will be obvious to you, having admittedly read only what we might call the "Executive Summary", that the investigators were reporting on all the safety issues which they found, not just those which were causally related to the accident.
PBL
Indeed, all those professional researchers researching failures and accidents causally whom I know consider that most accidents result from a conjunction of many causes.
There are many ways of selecting one cause to "put on a pedestal". My view is that, if one wants to do this, one should explain and justify one's selection criteria in the report.
I know the senior researcher, who has a world-wide reputation, who prepared the human factors report on this accident. I regard the insights in his report as very high quality, and some of those insights made it into the final report.
It will be obvious to you, having admittedly read only what we might call the "Executive Summary", that the investigators were reporting on all the safety issues which they found, not just those which were causally related to the accident.
PBL
Primary cause, probable cause, etc. etc. confuses many readers. However it does not confuse safety professionals (who read right by those words). The meat in a report is the linkage of the contributing facts with recommendations for prevention.
In my initial read of the posts above I sensed that the words "primary cause" was simply assigned to the last link in the chain of swiss cheese.
In other examples of the use of the words, it might refer to the most effective link in the chain to assign preventive action that addresses other combinations as well.
In my initial read of the posts above I sensed that the words "primary cause" was simply assigned to the last link in the chain of swiss cheese.
In other examples of the use of the words, it might refer to the most effective link in the chain to assign preventive action that addresses other combinations as well.
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Hi,
Emphasis put on experts (what some are telling or how they tell) .. not about another accident ..
This expert have the idea that witnesses accounts are peanut for a investigation.
So when this expert begin a investigation work he have already some prejudice who will give a orientation to the investigation (get rid of the witnesses accounts)
Was about this message:
Of course if one of you can produce a better translation than Google .. this is welcome.
Emphasis put on experts (what some are telling or how they tell) .. not about another accident ..
This expert have the idea that witnesses accounts are peanut for a investigation.
So when this expert begin a investigation work he have already some prejudice who will give a orientation to the investigation (get rid of the witnesses accounts)
Was about this message:
To Opherben
As an experienced investigator, then, you should know that not all investigation agencies, including some of the world's most respected, and no researchers into causality of accidents whom I know, think an assignment of "primary cause" is appropriate.
Indeed, all those professional researchers researching failures and accidents causally whom I know consider that most accidents result from a conjunction of many causes.
There are many ways of selecting one cause to "put on a pedestal". My view is that, if one wants to do this, one should explain and justify one's selection criteria in the report.
I know the senior researcher, who has a world-wide reputation, who prepared the human factors report on this accident. I regard the insights in his report as very high quality, and some of those insights made it into the final report.
It will be obvious to you, having admittedly read only what we might call the "Executive Summary", that the investigators were reporting on all the safety issues which they found, not just those which were causally related to the accident.
PBL
As an experienced investigator, then, you should know that not all investigation agencies, including some of the world's most respected, and no researchers into causality of accidents whom I know, think an assignment of "primary cause" is appropriate.
Indeed, all those professional researchers researching failures and accidents causally whom I know consider that most accidents result from a conjunction of many causes.
There are many ways of selecting one cause to "put on a pedestal". My view is that, if one wants to do this, one should explain and justify one's selection criteria in the report.
I know the senior researcher, who has a world-wide reputation, who prepared the human factors report on this accident. I regard the insights in his report as very high quality, and some of those insights made it into the final report.
It will be obvious to you, having admittedly read only what we might call the "Executive Summary", that the investigators were reporting on all the safety issues which they found, not just those which were causally related to the accident.
PBL
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Originally Posted by lomapaseo
Primary cause, probable cause, etc. etc. confuses many readers. However it does not confuse safety professionals (who read right by those words).
Most safety professionals, not necessarily those in aviation, analyse mishaps with techniques such as «Root Cause Analysis», which is,
as Wikipedia suggests here, a collection of techniques (I would put «techniques» in quotes; I don't think much of most of them). Take a look at what Wikipedia says are the «General Principles of Root Cause Analysis»:
Originally Posted by Wikipedia on Root Cause Analysis
1. The primary aim of RCA is to identify the root cause of a problem in order to create effective corrective actions that will prevent that problem from ever re-occurring, otherwise known as the '100 year fix'.
2. To be effective, RCA must be performed systematically as an investigation with conclusions and the root cause backed up by documented evidence.
3.There is always one true root cause for any given problem, the difficult part is having the stamina to reach it.
........
2. To be effective, RCA must be performed systematically as an investigation with conclusions and the root cause backed up by documented evidence.
3.There is always one true root cause for any given problem, the difficult part is having the stamina to reach it.
........
(I will spare the forum another few hundred references, since most can use Google.)
And, most obviously, opherben, who self-identified as an aviation safety professional, didn't «read right by those words» either; indeed, he suggests they are very important! I think you will also find investigators at the NTSB who think there is such a thing as a «primary cause» sitting in the facts of the matter, rather than in their own selection procedures.
And if you look back at the discussion in this very forum, you will find Contributor A talking about the pilots not minding the store and saying «that is the real issue here», and Contributor B talking about the anomalous behavior of the autothrust as a consequence of a single point of failure, and proposing that as the «real issue». And A and B are thinking they are disagreeing with each other. The most obvious way of interpreting that disagreement is that each thinks heshe is proposing his selection as «primary».
So I don't buy your contention that people «read right by those words».
Just to be clear, I don't think there is anything inherently wrong with focusing on one, or a few, causes. Indeed, I sometimes think it is necessary. When talking to the airline, for example, I would likely have more to say about crew behavior than I would about automation behavior, for obvious reasons (connected with your second selection criterion below). But, as I said, when one does so it is important to make one's selection criterion explicit.
Originally Posted by lomapaseo
The meat in a report is the linkage of the contributing facts with recommendations for prevention.
Originally Posted by lomapaseo
In my initial read of the posts above I sensed that the words "primary cause" was simply assigned to the last link in the chain of swiss cheese.
In other examples of the use of the words, it might refer to the most effective link in the chain to assign preventive action that addresses other combinations as well.
In other examples of the use of the words, it might refer to the most effective link in the chain to assign preventive action that addresses other combinations as well.
Your first criterion, though, runs into a problem. If one uses the «Swiss Cheese» model, then it might be tempting to think, as apparently you do, that the layers are ordered, so that there is a «last» one. But I don't think Jim intended them to be ordered. It is just an artifact of the picture. Indeed, the ATSB used the «Reason Model» for well over a decade, and they neither pick a «primary cause» nor linearly-order the causal factors.
If one uses the Rasmussen Accimap model, as the ATSB now does, the causes are divided into classes, but they are not ordered. They are also not ordered in the Rasmussen-Svedung approach which Leveson uses in STAMP (used by NASA). Every level in STAMP is modelled as a feedback control system, and causal factors are identified (I put it crudely) as missing feedback loops. Neither are factors ordered in the SHEL model. They are not linearly ordered in Why-Because Graphs (used by Siemens RA and MT) either, although they are partially ordered.
Where they are ordered in is Layers of Protection Analysis, used in the process industries. That is because one works there with inherently dangerous behavior (stuff at high temperatures and pressures, and reactions, which is why in these domains one defines an accident as «an uncontrolled release of energy») which is mitigated using specific added protection functions, so it fits with the system architecture. That is not the way things are in transportation accidents. No one uses LOPA there.
Concerning
Originally Posted by lomapaseo
...the most effective link in the chain to assign preventive action that addresses other combinations as well.
I won't respond in this forum to any reply. I am very happy to continue discussion of these issues, with you or anyone else interested in them, but please rather by email than here. I am no PJ2 and don't want to be the target of responses such as those of jcjeant to my comment.
PBL
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Unfortunately:
Three universal root causes:
The airplane was invented by humans.
The airplane was designed and built by humans.
The airplane was operated and maintained and managed by humans.
Yes I know, the investigator tries to be more specific, and variables such as the state of the art are considered. But aren't the above comprehensive?
The airplane was invented by humans.
The airplane was designed and built by humans.
The airplane was operated and maintained and managed by humans.
Yes I know, the investigator tries to be more specific, and variables such as the state of the art are considered. But aren't the above comprehensive?
Last edited by barit1; 14th May 2010 at 14:29.
Everything is under control.
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An item in today's Wall Street Journal on NTSB criticism of the draft report . . .
Safety Board Slams Dutch for Airline Crash Report - Washington Wire - WSJ
In the tight-knit world of aviation-crash investigators, experts from one country rarely go public with criticism of another government’s experts.
But in a recent breach of that tradition, the National Transportation Safety Board slammed its Dutch counterpart for preparing an allegedly mistake-riddled draft report of a probe into a Turkish airliner that crashed last year , killing nine people, while approaching Amsterdam’s Schiphol airport.
But in a recent breach of that tradition, the National Transportation Safety Board slammed its Dutch counterpart for preparing an allegedly mistake-riddled draft report of a probe into a Turkish airliner that crashed last year , killing nine people, while approaching Amsterdam’s Schiphol airport.
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Safety Board Slams Dutch for Airline Crash Report - Washington Wire - WSJ
A draft report is just that: a draft. The NTSB should not be making ridiculous public statement about such a thing. If find it very positive that the Dutch ask for input before publishing the final report. A good example of resource management, I would say! 
The Dutch board even included an appendix B into the final report, where you can find the comments and suggestions made by the concerned parties and why (or not) these comments were incorporated in the final report.
I think that the final report is a very nice and well made document resulting from a synergy off all parties involved.
off-topic: looking forward to the accident report from the Lybian safety board about the Afriqiyah crash in Tripoli....
Originally Posted by Eboy
An item in today's Wall Street Journal on NTSB criticism of the draft report . . .
Originally Posted by the article linked to by Eboy
"The final report, issued this month, however, fixed the factual errors and incorporated most of the FAA’s additional suggestions."
The Dutch board even included an appendix B into the final report, where you can find the comments and suggestions made by the concerned parties and why (or not) these comments were incorporated in the final report.I think that the final report is a very nice and well made document resulting from a synergy off all parties involved.
off-topic: looking forward to the accident report from the Lybian safety board about the Afriqiyah crash in Tripoli....
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Absolutely Sabena Boy, I also find this "Dutch" apppoach to accident reporting very healthy . A good report .
me too, with the French BEA in charge , Afriqiyah having 23 Airbus orders on the pipeline, and with Lybian leaders being very sensitive to their National pride, the final version will be an interesting read !
off-topic: looking forward to the accident report from the Lybian safety board about the Afriqiyah crash in Tripoli....
Cause or contribution
The objective of accident reports is to prevent future accidents or incidents, not for academic interest, lawyers, or insurance.
Primary cause etc, might make easy reading for the ‘decision makers’, but does not provide the ‘sharp end’ with an effective means to maintain / improve safety, i.e. what do we have to fix (why), and how.
This report and that for Congonhas, are above average (even if they are difficult to read); Congonhas has greater practicality due to the discussion of human factors (although this was not factual evidence) and that the recommendations aligned with the contributions.
In comparison, the Buffalo report might be more readable, but I doubt that it will have the same effectiveness as the other two. The object is not just to prevent a repeat of the reported accident; it’s the prevention of future ones which should dominate our thoughts.
James Reason provides this view of the elements in accidents (The Human Contribution).
So what are the conditions …. tools and equipment, safety culture, design and construction, workarounds, management and supervision … ”.
Most if not all of Reason’s Universals and Conditions can be found in the ‘contributions’ of accident reports. Concentration on ‘cause’ ultimately leads to a solution of ‘not being there’ just to avoid an accident, which is self-defeating and impracticable. However, focus on contributions, the links, and variability in these, provide everyone with a means of improving safety.
Reason’s solution requires checks on the ‘vital signs’ of an operation (SMS?). IMHO this is not a process of analysis of what can / has to be changed; instead there is a need to look at what has changed – the contributions in accidents and the links between them.
Ask what has been overlooked, what has gradually changed and become the norm, what has been accepted as routine, except that it should not be routine.
Many of those small and insignificant changes are the contributions listed in accident reports. These everyday norms are not the ‘cause’ of accidents, but they are the weaknesses in our safety defenses.
Primary cause etc, might make easy reading for the ‘decision makers’, but does not provide the ‘sharp end’ with an effective means to maintain / improve safety, i.e. what do we have to fix (why), and how.
This report and that for Congonhas, are above average (even if they are difficult to read); Congonhas has greater practicality due to the discussion of human factors (although this was not factual evidence) and that the recommendations aligned with the contributions.
In comparison, the Buffalo report might be more readable, but I doubt that it will have the same effectiveness as the other two. The object is not just to prevent a repeat of the reported accident; it’s the prevention of future ones which should dominate our thoughts.
James Reason provides this view of the elements in accidents (The Human Contribution).
- Universals: the ever present tensions between production and protection.
- Conditions: latent factors that collectively produce defensive weaknesses.
- Causes permit the chance conjunctions of local triggers and active failures to breach all the barriers and safeguards.
So what are the conditions …. tools and equipment, safety culture, design and construction, workarounds, management and supervision … ”.
Most if not all of Reason’s Universals and Conditions can be found in the ‘contributions’ of accident reports. Concentration on ‘cause’ ultimately leads to a solution of ‘not being there’ just to avoid an accident, which is self-defeating and impracticable. However, focus on contributions, the links, and variability in these, provide everyone with a means of improving safety.
Reason’s solution requires checks on the ‘vital signs’ of an operation (SMS?). IMHO this is not a process of analysis of what can / has to be changed; instead there is a need to look at what has changed – the contributions in accidents and the links between them.
Ask what has been overlooked, what has gradually changed and become the norm, what has been accepted as routine, except that it should not be routine.
Many of those small and insignificant changes are the contributions listed in accident reports. These everyday norms are not the ‘cause’ of accidents, but they are the weaknesses in our safety defenses.
Denti asks a good question. If I may "ponder out loud" on his thought ...
If the aural alert goes off during a time when the crew is close to task saturation, particularly tasks heavy with comms/hearing/talking, will an added aural input likely to be edited out, left in the background noise, or pushed to the front of the line for cues to perform an unplanned action?
Why do I say unplanned?
The fraction of a second before the aural cue goes off, the crew are doing something else, and taking other actions (some of them possibly wrong or in wrong priority) when the cue to "do something else" arrives.
If the core problem is that of getting behind the aircraft, and having to catch up, are you as likely to respond to the alert with unsuitable action as with suitable action?
Does this not point to training and proficiency?
If the aural alert goes off during a time when the crew is close to task saturation, particularly tasks heavy with comms/hearing/talking, will an added aural input likely to be edited out, left in the background noise, or pushed to the front of the line for cues to perform an unplanned action?
Why do I say unplanned?
The fraction of a second before the aural cue goes off, the crew are doing something else, and taking other actions (some of them possibly wrong or in wrong priority) when the cue to "do something else" arrives.
If the core problem is that of getting behind the aircraft, and having to catch up, are you as likely to respond to the alert with unsuitable action as with suitable action?
Does this not point to training and proficiency?
I read the report, a few months back.
And all the time, there has been a uncomfortable feeling lurking in the back of my mind. And it is all about ONE word, one key word, that I found in the report:
HOCAM....
You can find it in the CVR transcript, on numerous places. Apparently it means "instructor" in Turkish, and it is used by the two other pilots on the flight deck whenever they had something to say to their captain. And they never used any other name/title/word to get something across.
To me, that smells like a very, very steep cockpit gradient. one Hocam and two zero's.
But it doesn't end there, unfortunately. The report looks pretty complete, exept that it does not adress this "little" problem. Why not? Is it too sensitive? Some sort of Pandora's Box?
Are the Dutch investigators too afraid to include it in the report?
Remember that the Netherlands is a society that thrives by means of concensus-building. I am a Dutch citizen myself and I know what "damage" it can do. --> Just keep on talking until everyone can be sort of happy with some part of the report.
This is the essence of Dutch politics/problem solving, but it does mean that an investigative report might not include everything that should be in it.
And all the time, there has been a uncomfortable feeling lurking in the back of my mind. And it is all about ONE word, one key word, that I found in the report:
HOCAM....
You can find it in the CVR transcript, on numerous places. Apparently it means "instructor" in Turkish, and it is used by the two other pilots on the flight deck whenever they had something to say to their captain. And they never used any other name/title/word to get something across.
To me, that smells like a very, very steep cockpit gradient. one Hocam and two zero's.
But it doesn't end there, unfortunately. The report looks pretty complete, exept that it does not adress this "little" problem. Why not? Is it too sensitive? Some sort of Pandora's Box?
Are the Dutch investigators too afraid to include it in the report?
Remember that the Netherlands is a society that thrives by means of concensus-building. I am a Dutch citizen myself and I know what "damage" it can do. --> Just keep on talking until everyone can be sort of happy with some part of the report.
This is the essence of Dutch politics/problem solving, but it does mean that an investigative report might not include everything that should be in it.
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fox niner,
You have a point there, but I'ld like to defend the investigators by asking the rhetorical question: how much speculation should be allowed into accident investigations?
In my opinion, the best lesson for the co-pilot would have been a go-around at 1000ft: "You're not ready with your checklists, try again!" Why that didn't happen, steep cockpit gradient and airline procedures (only the captain can decide to abort approach) played a part. Crew error, yes.
However, I still have doubts about whether the captain was aware of his altitude (that radar failure ment he lost an instrument.)
You have a point there, but I'ld like to defend the investigators by asking the rhetorical question: how much speculation should be allowed into accident investigations?
In my opinion, the best lesson for the co-pilot would have been a go-around at 1000ft: "You're not ready with your checklists, try again!" Why that didn't happen, steep cockpit gradient and airline procedures (only the captain can decide to abort approach) played a part. Crew error, yes.
However, I still have doubts about whether the captain was aware of his altitude (that radar failure ment he lost an instrument.)
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(that radar failure ment he lost an instrument.)
Engineers at the airframes and component manufacturers go to great lengths to avoid erroneous indications. It's calculated to be on the order of ten to the minus ninth for Cat III autoland.
I'm not intending to excuse the crew for stalling the plane, but pointing out in this case the hazard of avionics with undetected failures.
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The <root cause> is pretty simple...
The plane hit the ground because it was going to slowly. Since there is a guy in the pointy end generically identified as the "PF" who was functioning as a "PP" {pilot passenger} things went south. The rest of it is secondary since a proper scan would have easily identified the decaying speed.
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Lonewolf is absolutely correct in pointing out the fallacy of adding yet more bells and whistles to a cockpit where bells and whistles are already sounding.
The radalt problem really has only one involvement in this accident - it is not normally 'in scan' on the sort of approach being flown there and thus not noticing the 'invalid' indication is quite understandable. Its involvement was the 'secondary effect' of commanding throttles closed. An a/c with a defunct radalt is so easily flyable, safely and efficiently.
The focus on preventing this accident from recurring is, in my opinion, to focus on training and the quality of the training personnel and system. The Dutch may not say it but as I see it the TC failed badly in his duties and that is where 'repair' is needed. I suggest forgetting about software and automatic systems and concentrating on the 'pink bits' is the priority.
We need to address also the point of having a 'safety pilot' on the flight deck - was he there merely to satisfy a regulatory requirement or was the 'C(ockpit)RM' being properly addressed?
The radalt problem really has only one involvement in this accident - it is not normally 'in scan' on the sort of approach being flown there and thus not noticing the 'invalid' indication is quite understandable. Its involvement was the 'secondary effect' of commanding throttles closed. An a/c with a defunct radalt is so easily flyable, safely and efficiently.
The focus on preventing this accident from recurring is, in my opinion, to focus on training and the quality of the training personnel and system. The Dutch may not say it but as I see it the TC failed badly in his duties and that is where 'repair' is needed. I suggest forgetting about software and automatic systems and concentrating on the 'pink bits' is the priority.
We need to address also the point of having a 'safety pilot' on the flight deck - was he there merely to satisfy a regulatory requirement or was the 'C(ockpit)RM' being properly addressed?