Pilots Palermo ATR Crash received 10-year sentences
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Think about the logical conclusion to this argument. BA flight LHR-PEK, the rostered FA who speaks Chinese goes sick at the last minute. What do you do, delay the flight as it has 50/50 English/Chinese speakers as PAX ????
You'll find that all emergency instructions on board are illustrated.
IMHO it makes a lot of sense to have at least one FA speaking the language of departure and arrival airports
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IMHO it makes a lot of sense to have at least one FA speaking the language of departure and arrival airports
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Italian speaking FA
At least one Italian-speaking flight attendant is required for wet-leased-in aircraft, not for scheduled flights from other Countries. In other words, if an Italian airline flies its scheduled flights under its code, with a Foreign aircraft (operated and under control of a Foreign airline), then on board that Foreign airline at least one FA need to be Italian speaking. The solution is frequently found in having on-board a FA of the Italian airline momentarily seconded to the foreigh airline.
D
D
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A usually-just-lurking SLF here.
Thank you to Enrik767 for the Youtube link. I would not normally agree with CVR recordings being leaked like this but I had been sucked into believing the Reuters/BBC version about an unprofessional "praying" crew. Hearing it for myself, nothing could be farther from the truth.
It's pretty clear that this crew is being royally shafted by whoever released the "praying instead of flying" version of the story...likely the Italian authorities.
Bob
Thank you to Enrik767 for the Youtube link. I would not normally agree with CVR recordings being leaked like this but I had been sucked into believing the Reuters/BBC version about an unprofessional "praying" crew. Hearing it for myself, nothing could be farther from the truth.
It's pretty clear that this crew is being royally shafted by whoever released the "praying instead of flying" version of the story...likely the Italian authorities.
Bob
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The italians love to strike for the smallest things. Why on earth is the pilot association of Italy not acting? This ruling will set an example. And it is ridiculous.
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One thing that would've pissed me off something rotten whilst is such a stressful situation was the ATC asking several times whether they were going to make the field and just not adding anything beneficial during the whole 5 mins. I've no knowledge of the ATR but a 20nm glide from 4000ft seems rather hopeful. Not much he could've done about the a/c but stop repeating the same question and maybe show some initiative and tell the pilots that he was sorting out some out of rescue and leave them to concentrate on landing the a/c.
Having now listened to the CVR the point concerning ATC is something that also crossed my mind. Although I can totally understand their willingness to help sometimes you have to know when to keep quite and let the crew do there job.
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Here's the Accident Investigation Final Report...
http://www.ansv.it/cgi-bin/eng/FINAL...20ATR%2072.pdf
Note the cause listed on pages 198 is the maintenance f*ck up. It cites nine contributing factors, 8 of which were totally non-flightcrew related!
http://www.ansv.it/cgi-bin/eng/FINAL...20ATR%2072.pdf
Note the cause listed on pages 198 is the maintenance f*ck up. It cites nine contributing factors, 8 of which were totally non-flightcrew related!
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FYI:
^BC-EU--Italy-Pilots Sentenced,0357<
^Pilots' group blasts Italy over air crash trial<
¶ BRUSSELS (AP) _ The international pilots' association on Wednesday denounced the long prison sentences given to the pilot and co-pilot of a charter flight that crashed off Sicily in 2005 killing 16 people.
¶ "Once again the compulsion to apportion blame has outweighed the greater need to improve the safety of air transport," said a statement released by the London-based International Federation of Airline Pilots' Associations.
¶ The federation said that a court in Palermo, Italy, on Monday convicted the two pilots of manslaughter and sentenced them to 10 years each. It also sentenced five other people, including executives of the Tunisian charter operator, to lesser prison terms.
¶ Italian aviation authorities say the ATR-72 went down Aug. 6, 2005, after running out of fuel, because the fuel gauge on the plane was the wrong model and did not show that the fuel tanks were nearly empty.
¶ The judges determined that the captain lost control of the situation. According to the plane's cockpit voice recorder, he ceded command of the plane to his co-pilot and began praying, Italian media reported.
¶ But the federation said the flight crew reacted to the loss of power in a textbook fashion and completed a successful ditching at sea. Under international accident investigation rules such circumstances would not be grounds for a criminal prosecution.
¶ Italy has been criticized in the past for its stance on accident related prosecutions and "this case provides another example of this policy," said Gideon Ewers, the group's spokesman.
¶ The pilots' federation "calls on the Italian Government to act now to amend the laws which continue to have a detrimental effect on air safety, and in doing so improve the safety of the traveling public," he said.
¶
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Flight Path reconstruction animation?
The official report mentions an enclosed CD-ROM with ...
Has anyone seen that? I cannot find it on the popular internet video services.
(I don't think it will give any new insights, just curious in this case.)
And I also hope that higher court instances will see wisdom and overturn the sentences. This would be ridiculous if it weren't so sad.
Bernd
Animated reconstruction of Flight TUI 1153:
take-off from Bari and final phase of the flight
take-off from Bari and final phase of the flight
(I don't think it will give any new insights, just curious in this case.)
And I also hope that higher court instances will see wisdom and overturn the sentences. This would be ridiculous if it weren't so sad.
Bernd
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¶ The judges determined that the captain lost control of the situation. According to the plane's cockpit voice recorder, he ceded command of the plane to his co-pilot and began praying, Italian media reported.
Take me downwind
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My observations:
The proceedings started off with a rather shameful turf war typical of the Italians. The ditching position (according to my plot) lies 3nm into International Waters so the responsibility for investigation lies with the state of registration. Clearly not content with this situation the Italians muscled in in search of the guilty.
The French BEA, representing the state of manufacture, made several complaints that their participation was impeded by the Italian judiciary. See the letter at the end of the report.
On departure from Tunis the Captain should have verified any fuel uplift discrepancy using a calculation based on the fuel delivery note. For some reason this note was not available and he elected to depart without verification of any uplift discrepancy. Most companies require a manual drip-stick check in these circumstances to manually verify the fuel on board. The FO was not involved in this decision.
There appears to have been no rationalisation of 'Arrival Fuel' against 'Fuel used' on arrival in Bari. Following refuelling another refuel discrepancy occurred that was not explained by any prevailing circumstances. Again, a manual fuel check should have been performed with the participation of the FO in the decision process. The Captain elected to depart without.
I have listened to the CVR recording (shamefully released by the Italians to the media), and I conclude they spent an understandable amount of time attempting to relight an engine before completing the ditching checklist. The No1 CCM spoke Italian and evidently all passengers were wearing life jackets when they hit the water - They were not unprepared for ditching as reported.
The Italians seem to have gone to inordinate lengths in subsequent simulator trials to prove that the crew could have glided to Palermo.... How does this contribute to the investigation and future safety ? In the two trials quoted a pair of very experienced training Captains made it.......just. The second, a regular line crew did not. You might ask yourself if a controlled ditching right next to a likely rescue vessel is preferable to a crash landing as you cross the coast..... you will always have an Italian Judge to tell you that you made the wrong choice.
I don't think I have ever seen a report so bureaucratically verbose that seems intent on showing the world how clever they are. It is clear from the beginning that despite the ICAO preamble of 'not apportioning blame', that is precisely what they have achieved.
The pilots were guilty of not carrying out standard 'fuel-uplift' and 'fuel-used' checks that would have revealed the core problem. The fact that the FO was not involved in either of the fuel discrepancy decision processes might be very telling from a CRM and cultural perspective.
Like many incidents, after the initial cock-ups I believe the subsequent handling and preparation for ditching was handled as well as any line crew might be expected to do.
Negligence.... Yes..... worthy of 10 years in jail...... I don't think so. If you think sitting in the RHS carries little or no responsibility then think again.... Kegworth proved that a long time ago.
Remember, when in Italy..... It's a third world country just waiting to throw you in jail. Make sure your operation is whiter than white, and make sure you are both involved in ALL safety critical decisions.
The proceedings started off with a rather shameful turf war typical of the Italians. The ditching position (according to my plot) lies 3nm into International Waters so the responsibility for investigation lies with the state of registration. Clearly not content with this situation the Italians muscled in in search of the guilty.
The French BEA, representing the state of manufacture, made several complaints that their participation was impeded by the Italian judiciary. See the letter at the end of the report.
On departure from Tunis the Captain should have verified any fuel uplift discrepancy using a calculation based on the fuel delivery note. For some reason this note was not available and he elected to depart without verification of any uplift discrepancy. Most companies require a manual drip-stick check in these circumstances to manually verify the fuel on board. The FO was not involved in this decision.
There appears to have been no rationalisation of 'Arrival Fuel' against 'Fuel used' on arrival in Bari. Following refuelling another refuel discrepancy occurred that was not explained by any prevailing circumstances. Again, a manual fuel check should have been performed with the participation of the FO in the decision process. The Captain elected to depart without.
I have listened to the CVR recording (shamefully released by the Italians to the media), and I conclude they spent an understandable amount of time attempting to relight an engine before completing the ditching checklist. The No1 CCM spoke Italian and evidently all passengers were wearing life jackets when they hit the water - They were not unprepared for ditching as reported.
The Italians seem to have gone to inordinate lengths in subsequent simulator trials to prove that the crew could have glided to Palermo.... How does this contribute to the investigation and future safety ? In the two trials quoted a pair of very experienced training Captains made it.......just. The second, a regular line crew did not. You might ask yourself if a controlled ditching right next to a likely rescue vessel is preferable to a crash landing as you cross the coast..... you will always have an Italian Judge to tell you that you made the wrong choice.
I don't think I have ever seen a report so bureaucratically verbose that seems intent on showing the world how clever they are. It is clear from the beginning that despite the ICAO preamble of 'not apportioning blame', that is precisely what they have achieved.
The pilots were guilty of not carrying out standard 'fuel-uplift' and 'fuel-used' checks that would have revealed the core problem. The fact that the FO was not involved in either of the fuel discrepancy decision processes might be very telling from a CRM and cultural perspective.
Like many incidents, after the initial cock-ups I believe the subsequent handling and preparation for ditching was handled as well as any line crew might be expected to do.
Negligence.... Yes..... worthy of 10 years in jail...... I don't think so. If you think sitting in the RHS carries little or no responsibility then think again.... Kegworth proved that a long time ago.
Remember, when in Italy..... It's a third world country just waiting to throw you in jail. Make sure your operation is whiter than white, and make sure you are both involved in ALL safety critical decisions.
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ANSV
2.13.2 Accident origin and analysis.
The accident originated from the incorrect replacement of the fuel quantity indicator (FQI) performed the day before. However, this should not be considered the main cause.
The event has been analysed not only as a human error performed
· by mechanics/technicians who replaced the FQI not searching for the correct item
· by the aircraft’s crew who, although they had the possibility of notice the incorrect replacement, did not perform any corrective action
but also as a series of organizational errors.
All people involved in the event did not received sufficient aid from the system in which they were operating to avoid the so-called fatal error.
The error that caused the accident has been determined by errors carried out by so-called “front-line” operators, but such errors occurred in a critical operational situation which, if it has not been so, maybe would have prevented the accident itself.
The aetiology of the event shows in fact the presence of multiple factors:
· errors committed by ground mechanics when searching for and correctly identifying the fuel indicator
· errors committed by the flight crew
· non respect of various operational procedures
· lack of adequate control by responsible persons of various sectors of the operator’s organization
· lack of an adequate quality control system
· lack of accuracy of data entered in the spares management system database
· mechanics not adequately trained on use and procedures for spares search with the spares management system
· deficiencies in maintenance and configuration control for the fleet’s aircraft
· procedural deficiencies in technical management and maintenance of the aircraft
· low qualitative standard for maintenance operations
· inadequate surveillance of the operator by the competent Tunisian authority
· lack of Flight Data Monitoring system
· lack of adequate Safety Management System
From the above mentioned considerations, it is possible to affirm that in the event two types of errors (failures) occurred: active and latent failures.
2.13.2 Accident origin and analysis.
The accident originated from the incorrect replacement of the fuel quantity indicator (FQI) performed the day before. However, this should not be considered the main cause.
The event has been analysed not only as a human error performed
· by mechanics/technicians who replaced the FQI not searching for the correct item
· by the aircraft’s crew who, although they had the possibility of notice the incorrect replacement, did not perform any corrective action
but also as a series of organizational errors.
All people involved in the event did not received sufficient aid from the system in which they were operating to avoid the so-called fatal error.
The error that caused the accident has been determined by errors carried out by so-called “front-line” operators, but such errors occurred in a critical operational situation which, if it has not been so, maybe would have prevented the accident itself.
The aetiology of the event shows in fact the presence of multiple factors:
· errors committed by ground mechanics when searching for and correctly identifying the fuel indicator
· errors committed by the flight crew
· non respect of various operational procedures
· lack of adequate control by responsible persons of various sectors of the operator’s organization
· lack of an adequate quality control system
· lack of accuracy of data entered in the spares management system database
· mechanics not adequately trained on use and procedures for spares search with the spares management system
· deficiencies in maintenance and configuration control for the fleet’s aircraft
· procedural deficiencies in technical management and maintenance of the aircraft
· low qualitative standard for maintenance operations
· inadequate surveillance of the operator by the competent Tunisian authority
· lack of Flight Data Monitoring system
· lack of adequate Safety Management System
From the above mentioned considerations, it is possible to affirm that in the event two types of errors (failures) occurred: active and latent failures.
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The 'praying'....
which in any case is minimal, is perfectly understandable in the cultural context of the pilots' origins, as natural to them as a westerner imprecating his own secular or other divinities with swear words, pleas or curses.
Psychologically it is just as likely to be helpful as it is to be hurtful to the pilots' efforts, allowing an excess of tension and anxiety to be expended as they focus their efforts on the relight attempt and the ditching procedures, while all the time the useless ATC voice booms distractingly in the background.
For Reuters to make a 'story' out of this element is totally shameful. But 'technical problems contribute to crash' is so less attractive a headline to the entertainers (sorry, I mean editors) of that once-upon-a-time renowned news organisation.
Psychologically it is just as likely to be helpful as it is to be hurtful to the pilots' efforts, allowing an excess of tension and anxiety to be expended as they focus their efforts on the relight attempt and the ditching procedures, while all the time the useless ATC voice booms distractingly in the background.
For Reuters to make a 'story' out of this element is totally shameful. But 'technical problems contribute to crash' is so less attractive a headline to the entertainers (sorry, I mean editors) of that once-upon-a-time renowned news organisation.
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Really poor performance by ATC. I can also see the mistakes on pilots part and praying is not it. Manually checking the fuel should be mandatory. Ground mechanics are, without a doubt, the ones to be blamed here. The pilots, in this case, deserve no more than a wrist slap and a ban from commercial aviation.
But on the other hand, to contradict myself, the PIC must carry out all the relevant checks prior to departure and should be held responsible in failure to do so.
OFF TOPIC.
(note to self) so that`s what level 4 English sounds like. Phew, that`s a stone off my chest.
But on the other hand, to contradict myself, the PIC must carry out all the relevant checks prior to departure and should be held responsible in failure to do so.
OFF TOPIC.
(note to self) so that`s what level 4 English sounds like. Phew, that`s a stone off my chest.
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The delegates to the 64th Conference of the International Federation of Air Line Pilots’ Associations (IFALPA) unanimously voiced their dismay yesterday when informed that once again the compulsion to apportion blame has outweighed the greater need to improve the safety of air transport. In Palermo yesterday sentences, totaling 62 years, were handed down against the flight crew and management of Tuninter in connection with the August 2005 ditching of an ATR72 off the coast of Sicily.
The technical investigation into the circumstances leading to the crash revealed that it happened because an incorrect fuel gauge sensor was fitted to the aircraft which, in turn, lead to a double engine failure due to fuel exhaustion. The flight crew reacted to the loss of power in a textbook fashion and completed a successful ditching at sea. Under the internationally accepted approach to accident investigation such circumstances would not be grounds for a criminal prosecution.
IFALPA strongly believes that this prosecution was totally unwarranted given the facts of the accident and furthermore once again calls into question its commitment to the improvement of air safety. Italy has been criticized in the past for its stance on accident related prosecutions and this case provides another example of this policy.
IFALPA calls on the Italian Government to act now to amend the laws which continue to have a detrimental effect on air safety and in doing so improve the safety of the travelling public.
The technical investigation into the circumstances leading to the crash revealed that it happened because an incorrect fuel gauge sensor was fitted to the aircraft which, in turn, lead to a double engine failure due to fuel exhaustion. The flight crew reacted to the loss of power in a textbook fashion and completed a successful ditching at sea. Under the internationally accepted approach to accident investigation such circumstances would not be grounds for a criminal prosecution.
IFALPA strongly believes that this prosecution was totally unwarranted given the facts of the accident and furthermore once again calls into question its commitment to the improvement of air safety. Italy has been criticized in the past for its stance on accident related prosecutions and this case provides another example of this policy.
IFALPA calls on the Italian Government to act now to amend the laws which continue to have a detrimental effect on air safety and in doing so improve the safety of the travelling public.
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If this crew are guilty then so are two other parties. The goons from the "Hang 'em high" squad from the Italian justice department (Justice? My RRrr's) and the plonkers from the ANSV. The report will be used by other investigators, but only as an example of how not to write one. The Italians should be ashamed of themselves. Little will be learnt from this debacle other than to install paper shredders and disk erasers on all aircraft that fly near Italian airspace.
We deserve more from the Italians than this.
PM
We deserve more from the Italians than this.
PM
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....................
Prosecutors say that after both the plane's engines cut out, the pilot succumbed to panic, praying out loud instead of following emergency procedures and then opting to crash-land in the Mediterranean instead of trying to reach the nearest airport.
............................
quote from: http://news.bbc.co.uk/2/hi/europe/7962082.stm
Prosecutors say that after both the plane's engines cut out, the pilot succumbed to panic, praying out loud instead of following emergency procedures and then opting to crash-land in the Mediterranean instead of trying to reach the nearest airport.
............................
quote from: http://news.bbc.co.uk/2/hi/europe/7962082.stm
On this cvr recording, no panic or long prayers are heard. Could it be possible that this cvr recording isn't complete, or where long prayers removed by editing the sound?
Or are the prosecutors lying?
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SLF here again.
I've had a skim through the ANSV report and notice that it gets pretty political at times, with complaints (probably justified) about the police hanging onto the CVR and FDR for a couple of weeks before letting the proper crash investigators get access. The report is actually used at one point to call for changes in legislation to remove police and judicial powers during the investigation.
Knowing a bit about the Italian system, my fear is that politicising a report like this "got up the noses" of the police and prosecutor's office and they decided they needed a show trial to prove that ANSV is "soft on the industry". The "praying not flying" allegations, as far as I can see, come from the prosecutor whose job it is to paint the accused as badly as possible.
So, if I'm right, the poor crew got caught in the middle of an Italian political power struggle.
Bob
I've had a skim through the ANSV report and notice that it gets pretty political at times, with complaints (probably justified) about the police hanging onto the CVR and FDR for a couple of weeks before letting the proper crash investigators get access. The report is actually used at one point to call for changes in legislation to remove police and judicial powers during the investigation.
Knowing a bit about the Italian system, my fear is that politicising a report like this "got up the noses" of the police and prosecutor's office and they decided they needed a show trial to prove that ANSV is "soft on the industry". The "praying not flying" allegations, as far as I can see, come from the prosecutor whose job it is to paint the accused as badly as possible.
So, if I'm right, the poor crew got caught in the middle of an Italian political power struggle.
Bob