Pilots Palermo ATR Crash received 10-year sentences
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Well it seams their prayers have been answered, they survived the crash. On a more serious note there is no difference between saying "god help us" or "holly sh*t". They still carried out the relevant check list before impact.
Are you people trying to say that more lives would have been saved if the pilots were not religious and had not prayed?
Are you people trying to say that more lives would have been saved if the pilots were not religious and had not prayed?
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Having read the very comprehensive accident report, it seems to me that the Swiss cheese was running in overdrive but there were also a number of culpable errors (fuel mis-management) by ground ops personnel and aircrew. The 'praying' bit is merely a headline grabbing element.
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Michael, maybe it's actually a good thing that the CVR was leaked. 
Imagine if it wasn't and all we had to go on were the media reports....what hope would the crew have of support from you pro pilots in their appeal? Very slim at best. At least now you've all heard the real story and can put your weight behind it to turn around this disgraceful decision. 
Imagine if it wasn't and all we had to go on were the media reports....what hope would the crew have of support from you pro pilots in their appeal? Very slim at best. At least now you've all heard the real story and can put your weight behind it to turn around this disgraceful decision.
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True, but if the CVR were not available it would not have been used in the case against them - it's a double edge sword.
It's an argument for not having FDR's and CVR's - which is not a good thing in itself, at least not when anywhere near Italian airspace anyway.
It's an argument for not having FDR's and CVR's - which is not a good thing in itself, at least not when anywhere near Italian airspace anyway.
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Listening to the last few minutes of cockpit conversation there is obviously a lot of professional work being carried out. But do we know who was talking and have we any indication that the captain was involved in this or was he the person mumbling "Oh God" in the background? - in which case he had lost authority.
Surely the main failure was the lack of fuel checks prior to departure. Calculate flight time plus additional times, check fuel uplifted, stick your nose (or something) in the fuel tank. I would hope that this procedure is mandatory before each flight.
Fuel is one of the few things that can cause an aircraft to stop in the air under normal circumstances, to not have enough at any time is unforgivable.
Surely the main failure was the lack of fuel checks prior to departure. Calculate flight time plus additional times, check fuel uplifted, stick your nose (or something) in the fuel tank. I would hope that this procedure is mandatory before each flight.
Fuel is one of the few things that can cause an aircraft to stop in the air under normal circumstances, to not have enough at any time is unforgivable.
The official report does not support the thesis that
It was contributory factor, but main factor was installing the improper FQI. Also being former ATR driver, acquainted with the peculiarities of ATRs electric system, I strongly believe that captain was flying the aeroplane and F/O was reading the checklist after the engines quit. Sticking maintenance noses up the fuel tanks caries a delay penalty and it's done only if the crew suspects something is wrong with fuel gauges. Not making fuel checks on the leg to Bari or checking the uplift against the FQI were mistakes that turned to be lethal but they were mistakes, not something you'd get convicted for in civilized country as mens rea was definitively absent.
EDIT: Rephrased for clarification.
the main failure was the lack of fuel checks prior to departure.
EDIT: Rephrased for clarification.
Last edited by Clandestino; 28th Mar 2009 at 05:23.
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A gross error check would have stopped the problem on the ground.
The vile 'tabloid' headlines are a disgrace and shows the weakness of syndicated news.
If one paper reports it, the others report the reports, it must therefore be true
The vile 'tabloid' headlines are a disgrace and shows the weakness of syndicated news.
If one paper reports it, the others report the reports, it must therefore be true
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this accident is to be broadcast on national geographics "air accident investigations" next monday. It will be interesting to see how the flight crew are portrayed in the film.
Can someone familiar with the ATR 72 tell me why they did not get a low fuel warning? Surely there should be a low fuel indication directly activated by low fuel level and separate from the FQI?
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Based on the National Geographic programme information, it appears the low fuel warning was not applicable. If the low warning is taken from the FQI, then because the wrong FQI was installed it still read 1800Kg with the tanks dry! Maybe an ATR tech can confirm if its taken from the FQI or a tank unit.
Last edited by Flightmech; 7th Apr 2009 at 00:24. Reason: Info added
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I have read the investigation report (not in depth, it's a bit too turgid).
From the facts in the report, my view is that the captain was seriously negligent, although a 10 year jail sentence appears extreme. I don't have the competence to comment upon the flying ability displayed but the serious fault that, imo, amounted to gross negligence was the fact that he noted the anomaly in the fuel upload record but dismally failed to follow through.
Having identified the anomaly, the captain had several choices - he could have delayed departure until the 'missing' (in fact, non-existent) docket was found. Or he could have performed a 'drip-stick' measurement. If he had done either of these, the 'fuel remaining' misreading and incorrect FQI would have been identified. He also had a second (or third) opportunity to trap the original error (incorrect FQI) by performing the fuel used reconciliation at the intermediate stop (I'm not sure whether this is mandated or simply recommended/advised).
If I understand correctly, the reconciliation of previous fuel reading + fuel upload (as per the upload docket(s)) to current fuel reading is the first and last line of defence against an erroneous FQI indication. The entire purpose of that cross-check must be to trap errors and/or faults. As someone posted above, insufficient fuel is one of the few things that is will certainly result in an otherwise serviceable a/c making an early landing. In this case, the failure to apply unexceptional due diligence, on a matter that required no knowledge or training other than the ability to perform simple arithmetic, set at naught the inherently sound purpose and outcome of the cross-check procedure.
The captain's failure in this case is more serious and inexplicable because this was the first flight of the a/c after the FQI had been replaced; a fact that (I suppose) was noted in the technical log which the captain had (or should have) examined.
The other (to my mind) very serious fault that is mentioned but not given sufficiant prominence in the report is the absence in the procedure for replacing the FQI of a simple check to validate that the unit is functioning correctly. All that the manufacturer's procedure guide requres, it seems, is a visual confirmation that the LEDs on the unit illuminate. Well - that's no more than confirmation it has a power supply and is completely inadequate for validating its performance. How the hell is it possible for that procedure to be carried out without (at least) some 'sanity test' type of check that it is giving a more or less correct indication?
However, serious as that fault is, my view is that the captain's was more serious because his check was the last (and only) line of defence against a faulty FQI. Even the right FQI (new or not) could have been giving an erroneous reading.
In my job, I deal with financial calculations. I NEVER assume any calculation I perform is correct until I've done it at least twice and got the same answer each time. If I make a mistake, my employer may lose money (and so, as a result, may I), but nobody dies.
From the facts in the report, my view is that the captain was seriously negligent, although a 10 year jail sentence appears extreme. I don't have the competence to comment upon the flying ability displayed but the serious fault that, imo, amounted to gross negligence was the fact that he noted the anomaly in the fuel upload record but dismally failed to follow through.
Having identified the anomaly, the captain had several choices - he could have delayed departure until the 'missing' (in fact, non-existent) docket was found. Or he could have performed a 'drip-stick' measurement. If he had done either of these, the 'fuel remaining' misreading and incorrect FQI would have been identified. He also had a second (or third) opportunity to trap the original error (incorrect FQI) by performing the fuel used reconciliation at the intermediate stop (I'm not sure whether this is mandated or simply recommended/advised).
If I understand correctly, the reconciliation of previous fuel reading + fuel upload (as per the upload docket(s)) to current fuel reading is the first and last line of defence against an erroneous FQI indication. The entire purpose of that cross-check must be to trap errors and/or faults. As someone posted above, insufficient fuel is one of the few things that is will certainly result in an otherwise serviceable a/c making an early landing. In this case, the failure to apply unexceptional due diligence, on a matter that required no knowledge or training other than the ability to perform simple arithmetic, set at naught the inherently sound purpose and outcome of the cross-check procedure.
The captain's failure in this case is more serious and inexplicable because this was the first flight of the a/c after the FQI had been replaced; a fact that (I suppose) was noted in the technical log which the captain had (or should have) examined.
The other (to my mind) very serious fault that is mentioned but not given sufficiant prominence in the report is the absence in the procedure for replacing the FQI of a simple check to validate that the unit is functioning correctly. All that the manufacturer's procedure guide requres, it seems, is a visual confirmation that the LEDs on the unit illuminate. Well - that's no more than confirmation it has a power supply and is completely inadequate for validating its performance. How the hell is it possible for that procedure to be carried out without (at least) some 'sanity test' type of check that it is giving a more or less correct indication?
However, serious as that fault is, my view is that the captain's was more serious because his check was the last (and only) line of defence against a faulty FQI. Even the right FQI (new or not) could have been giving an erroneous reading.
In my job, I deal with financial calculations. I NEVER assume any calculation I perform is correct until I've done it at least twice and got the same answer each time. If I make a mistake, my employer may lose money (and so, as a result, may I), but nobody dies.
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However, serious as that fault is, my view is that the captain's was more serious because his check was the last (and only) line of defence against a faulty FQI. Even the right FQI (new or not) could have been giving an erroneous reading.
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Well, if the airplane was released to service, why should the captain NOT believe the gauges, as everyone does until they are written up for rectification?
Why not?
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Well, if the airplane was released to service, why should the captain NOT believe the gauges, as everyone does until they are written up for rectification?
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Dear Crossfitter,
Could you please tell us what is your flight experience? Where do you get conclusion?
Did you ever study history?
As somebody already said, we had the Senate and the Coliseum. We invented military tactics that are still used nowdays.....while you were dancing around fires.
And probably planes wouldn't fly without technologies invented by italians. eg. battery - Volta, radio - Marconi.
Signed: An Italian Flight Instructor.
Could you please tell us what is your flight experience? Where do you get conclusion?
[..]...dealing with a primitive form of life on earth.
As somebody already said, we had the Senate and the Coliseum. We invented military tactics that are still used nowdays.....while you were dancing around fires.
And probably planes wouldn't fly without technologies invented by italians. eg. battery - Volta, radio - Marconi.
Signed: An Italian Flight Instructor.
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Gents,
Can we leave the standard pprune petty arguments about which country in Europe is best and get back to the topic in hand?
Ultimately, I think the flight crew have been very harshly treated by the Italian authorities. Which one of you is completely immune to making any sort of human error? The point is, that when they ended up flying a glider, they did their best under the circumstances, with the information they had.
I think the sentence they received could influence a flight crew's decision making in similar situations in the future, in that part of the world. Would you be motivated to try your utmost in a similar scenario, knowing that if you do survive you can expect a long prison sentence if any blame can be attributed to you or your colleagues?
Can we leave the standard pprune petty arguments about which country in Europe is best and get back to the topic in hand?
Ultimately, I think the flight crew have been very harshly treated by the Italian authorities. Which one of you is completely immune to making any sort of human error? The point is, that when they ended up flying a glider, they did their best under the circumstances, with the information they had.
I think the sentence they received could influence a flight crew's decision making in similar situations in the future, in that part of the world. Would you be motivated to try your utmost in a similar scenario, knowing that if you do survive you can expect a long prison sentence if any blame can be attributed to you or your colleagues?
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Shades of Monty Python Life of Brian if I'm not mistaken " so then , tell me, what did the Romans do for us then "?
Don't think the list included ATC, or fair and uncorrupted / politically interfered with accident investigation however.
Don't think the list included ATC, or fair and uncorrupted / politically interfered with accident investigation however.
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I have just watched the National Geographic programme about this accident. It gives a fair (if incomplete) summary of the events and the investigation, and correctly (in my view) credits the crew for their judgement in handling the ditching.
Reflecting on my recollection of the investigation report, about which I posted earlier in this thread, I have realised there is a spectacular fallacy in one of the key recommendations - namely that the FQIs for the ATR42 and ATR72 types should be redesigned with different connectors, so they cannot be mistakenly interchanged. The entire premise of the recommendation is that different connectors would ensure that the error of installing the 'wrong' FQI cannot be repeated. That is false. The FQIs rely on internal logic to provided a fuel quantity indication that is based on data provided by a number of sensors in the tanks. To prove this is false, simply ask this question - suppose that type 42 and type 72 FQIs did have different connectors but that a 'type 72' FQI had been mistakenly programmed at manufacture with 'type 42' logic and this was fitted to the accident flight. All of the subsequent errors and the resulting accident would have occurred in exactly the same way!
A post-installation cross-check (e.g. drip-stick measurement) to validate the accuracy of the new FQI WOULD have trapped such an error (and makes the argument for different connectors redundant).
Such a fault would also have been trapped by the diligent application of the simple cross-check against refuelling records. This procedure is based on the simple equation:
Reading 1 + fuel loaded - fuel used = reading 2.
Fuel used is measured independently of fuel reading and this procedure, if applied, is virtually infallible. For it to fail in a way that allows a fuel quantity indication to be materially erroneous (and go un-noticed) requires that two independent fuel measuring systems fail not only simultaneouly but in a way that gives equal and opposite measures of error. The maths for calculating the probability of that happening are beyond me, but I would imagine it would meet the 10^-9 test.
A better recommendation would have been to emphasise the critical importance of the cross-check prcedure in assuring sufficient fuel quantity for any planned flight.
Reflecting on my recollection of the investigation report, about which I posted earlier in this thread, I have realised there is a spectacular fallacy in one of the key recommendations - namely that the FQIs for the ATR42 and ATR72 types should be redesigned with different connectors, so they cannot be mistakenly interchanged. The entire premise of the recommendation is that different connectors would ensure that the error of installing the 'wrong' FQI cannot be repeated. That is false. The FQIs rely on internal logic to provided a fuel quantity indication that is based on data provided by a number of sensors in the tanks. To prove this is false, simply ask this question - suppose that type 42 and type 72 FQIs did have different connectors but that a 'type 72' FQI had been mistakenly programmed at manufacture with 'type 42' logic and this was fitted to the accident flight. All of the subsequent errors and the resulting accident would have occurred in exactly the same way!
A post-installation cross-check (e.g. drip-stick measurement) to validate the accuracy of the new FQI WOULD have trapped such an error (and makes the argument for different connectors redundant).
Such a fault would also have been trapped by the diligent application of the simple cross-check against refuelling records. This procedure is based on the simple equation:
Reading 1 + fuel loaded - fuel used = reading 2.
Fuel used is measured independently of fuel reading and this procedure, if applied, is virtually infallible. For it to fail in a way that allows a fuel quantity indication to be materially erroneous (and go un-noticed) requires that two independent fuel measuring systems fail not only simultaneouly but in a way that gives equal and opposite measures of error. The maths for calculating the probability of that happening are beyond me, but I would imagine it would meet the 10^-9 test.
A better recommendation would have been to emphasise the critical importance of the cross-check prcedure in assuring sufficient fuel quantity for any planned flight.