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Air India Express B738 crash

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Old 20th Feb 2012, 16:13
  #521 (permalink)  
 
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Worthless peice of ****?.... Christ calm down he died aswell he has a family that would be mourning the loss, a mistake was made i agree but still please dont be disrespectful to the dead
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Old 20th Feb 2012, 16:51
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Livesinafield:

Worthless peice of ****?.... Christ calm down he died aswell he has a family that would be mourning the loss, a mistake was made i agree but still please dont be disrespectful to the dead
If you consider landing in the last 2,500 feet of such a runway in a 737-800 a mistake in nice VFR conditions, then you and I have a vastly different understanding of airline flying.

Those who die on death row have families too. They also have their victim(s).
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Old 20th Feb 2012, 16:57
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Well said livesinafield. Also as stated earlier in this thread he could also have been suffering some sort of incapitance.
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Old 20th Feb 2012, 18:51
  #524 (permalink)  
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Ice Pack:

Well said livesinafield. Also as stated earlier in this thread he could also have been suffering some sort of incapitance.
Indeed the report did mention once such possibility; that is, self inflicted incapacitation:

“In spite of availability of adequate rest period prior to the flight, the Captain was in prolonged sleep during flight, which could have led to sleep inertia. As a result of relatively short period of time between his awakening and the approach, it possibly led to impaired judgment. This aspect might have got accentuated while flying in the Window of Circadian Low (WOCL).”

That long “nap” wasn’t long on professionalism either.
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Old 21st Feb 2012, 08:38
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Aterpster,

Are you even a pilot? Just because you have adequate rest time doesn't mean you get adequate rest. Early in my carrier I could sleep any time, as I got older it has become increasingly hard to sleep during the day. You can't force yourself to sleep. Don't think your above making a bone headed mistake you are human after all. The second you think your above doing something like this is the day you should leave the cockpit. Degrading the guy like he intentionally killed all those people and himself makes me think your not a pilot, very fresh ppl pilot, very immature, or arrogant, any of the above doesn't belong in the air in any capacity other than a passenger.
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Old 21st Feb 2012, 09:16
  #526 (permalink)  
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drive - the point is valid whatever. Yes, we all get dog-tired at some point, but it behoves us to then put in place a controlled rest environment - in this case an agreed appropriate 'wake-up' point which appears to have been missing..
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Old 21st Feb 2012, 10:47
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i am not defending his mistakes or trying to justify them, all i am saying is like what drive said nobody is immune to them

this guy im pretty sure didnt set out that day to do this, sleep inertia is a form of incapacitation and if it did play a role would be significant, i am afraid it can happen to all of us

mistake,useless a murderer call him what you like but he is dead now and cannot defend himself the case can be investigated to the end but we will never know what was happening iside the guys head, and that is the most frightening thing about aviaition accidents
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Old 21st Feb 2012, 12:40
  #528 (permalink)  
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drive73:

Are you even a pilot? Just because you have adequate rest time doesn't mean you get adequate rest. Early in my carrier I could sleep any time, as I got older it has become increasingly hard to sleep during the day. You can't force yourself to sleep. Don't think your above making a bone headed mistake you are human after all. The second you think your above doing something like this is the day you should leave the cockpit. Degrading the guy like he intentionally killed all those people and himself makes me think your not a pilot, very fresh ppl pilot, very immature, or arrogant, any of the above doesn't belong in the air in any capacity other than a passenger.
27 years with TWA and 20,000 hours. I flew my share of multi-leg overnight trips and horribly long duty days. My crews and I declared crew fatigue after excessively long duty days on a few occasions over those years.

I also participated in several air carrier accident investigations. I am well aware of the stress and circumstances that cause honest mistakes to be made, which in some cases result in horrible accidents.

I am also aware of the Comair 5191 crash at KLEX. I did some technical work on that one. It was similar to the crash at issue that the "mistake level" rose to gross negligence.

The late captain at issue was grossly negligent. Had he survived he would have been criminally prosecuted in many countries, as well as he should been. He isn't here to defend himself; by the same token he has been spared a trial at which he would have mostly likely been found guilty of criminal neglegence. It is a shame the F/O didn't take control before it was too late. But, apparently he had been so poorly treated by this egomaniac he just gave up. It is shockingly similar to Islamabad.

If you don't see this after a careful read of the official report, what more can I say?

Are you aware of the various criminal legal levels of taking another life?
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Old 21st Feb 2012, 15:36
  #529 (permalink)  
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aterpster;

Re, "It was similar to the crash at issue that the "mistake level" rose to gross negligence." [referencing Lexington in re Mangalore]

Yes. Continuing an highly unstable approach after forceful, verbal interventions by one's crew member(s) does not belong to the category of "an honest mistake".

And all else being equal, the time for bombastic personalities over-ruling CRM principles is over and the matter, difficult though it may be, begs to be addressed. Fortunately there are extremely few examples of such unprofessional behaviour with which to come to terms in some form (criminal prosecution?) or another.

I don't wish to re-argue views on criminal prosecutions and aircrews involved in accidents because I know you know the arguments. However, while I do acknowledge a long (by centuries) history of English tort law and the more serious criminal jurisprudence, the circumstances in aviation are materially different, with the notion of "the greater good" lurking in the background, and the need to "find out to prevent".

We know that in extremely rare cases, accidents occur to perfectly serviceable airplanes in which crew behaviour and actions are nothing short of gross negligence.

Aviation safety is advanced by knowing and understanding accidents, yet criminal prosecution opposes such knowing by enframing the dialogue such that the law, and not human factors is the arbiter of understanding and final outcomes.

I don't disagree with your views on this captain and it is difficult to keep emotion out of it when such outlying behaviours are involved. The accident brings to mind the Garuda over-run accident in 2007 at Yogyakarta, and a couple of others.

But the backdrop to any such views and emotions is Human Factors. The quote above from your post defines the fork in the road in this ongoing argument: At what point does an accident cross over and move from the need to understand, to the need to merely prosecute? So far as society is concerned, it is not an open-shut question.

I don't know the answer of course and it wouldn't matter if I did anyway, because such judgements are in the end a societal matter and not merely a "DGCA", (or NTSB or...?) matter. It is a credit to the existing system that such seemingly-negligent causes are so rare. But we in Canada have already "gone there" and neither the aviation system nor the courts have answered the question. Despite the law against it, (TSB Act), CVRs have been played in open court.

The point is made more stark by asking, for example, questions about the captain's physical health, and considering just the possibility of, say brain disease, (cancer/stroke/latent epilepsy) which had not manifested itself in previous medicals etc. As well-written as it is, the DGCA Report does not discuss this and, likely correctly, cites sleep inertia etc.

It is very difficult to condemn a fellow airman, but it is equally difficult to accept unprofessional standards when obvious answers (go-around) are at hand and especially when fatalities are involved.

Where do we cast our nets?
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Old 22nd Feb 2012, 06:00
  #530 (permalink)  
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Aterpster/livin'field



OK... in living memory there have been only a few highly public events where an aircraft has been deliberately crashed... it is a fairly large headline, (or was when it ended up with the "Patriot Act"... and a war or two on questionably dubious grounds).

If you assume that the PIC was not either homicidal or suicidal, then he is about the same boat as the Air France FO's or the Polish Airforce Captain... and hundreds of others that given slightly different circumstances would be relating another hangar/war story rather than at best wishing for an opportunity to redo 10 seconds of their life, or at worst have their families and those of their victims wishing for that opportunity.

Being human is a double edged sword, occasionally we see the benefit of humans in the loop, ie QF32, US1549 and many more daily events that culminate in a save that doesn't rate a headline, and other times you don't.

There is a fair chance that the PIC's family in this case feels rather conflicted, with some thoughts aligned with Aterpster's but would also have all the natural grieving processes of any human loss.

A more constructive question may be why does one crew get themselves into such an out of sorts event when others (Aterpster included, naturally) can avoid it for 20,000hrs/25 years. In the cold light of day, it is often staggering to consider how risky a particular event was that a crew has on the day considered as being worth staying with. Cognitive overload, loss of AS, or pure incompetence, whatever, is far more common than is indicated in the funny pages, most stuff ups result in nothing more than embarrassment and dented ego's, and underneath it all, the group risk taking generally proceeds unabated. Every event you "get away with" assists in normalising deviation, and this is universal behaviour, exhibited in the USA, China, Korea, Europe and the Antibodies etc., civil and military.

It is harsh to attack the departed who cannot defend their own name, but then, a lot of other grieving families are invested heavily in the decisions that the PIC took... and their burden is no less severe.
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Old 22nd Feb 2012, 13:00
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At/PJ, is hindsight bias is enhancing emotion?
Those who wish to prosecute ‘deviant’ crews without all of the evidence (because many cognitive aspects are not available), should consider what aspects of safety could be learnt from alternative viewpoints. Try being the defense lawyer.

There is much that we (industry / humans) do not understand about human behavior, particularly in the interactions present in modern, complex operations.
For an alternative view of LEX, see
http://ida.dk/netvaerk/fagtekniskene...l%20040210.pdf
and
Application of Functional Resonance Accident Model (FRAM) to - rossir24-0004

Anyone care to speculate about alternative contributions to this B738 accident and possible interactions:
Pilot selection, personality (prone to deviation – done it before do it again), training, operational procedure, regulatory oversight, data monitoring, cognitive processes; … … monitoring and intervention – do these really work.
The surrounding infrastructure, organization, and operational situation probably had greater influence than any ‘legal’ human behavior.
Consider all of the successful (not necessarily safe) landings in similar circumstances, what contributed to the successful outcome, what contributes to being safe?
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Old 22nd Feb 2012, 14:41
  #532 (permalink)  
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safetypee:

Those who wish to prosecute ‘deviant’ crews without all of the evidence (because many cognitive aspects are not available), should consider what aspects of safety could be learnt from alternative viewpoints. Try being the defense lawyer.
Hindsight is indeed 20/20. The report is quite thorough and provides more than sufficient information to conclude that the captain did not conduct the flight properly.

Had the captain survived no doubt we would have been afforded the opportunity to hear the criminal case as presented by both the prosecution and defense. My experience with defense lawyers is their objective is to get their client off, not present the truth in a court of law.

As to your complex science and its criticism of the NTSB, you need to take that up with them. My simple, flight operations oriented mind agrees completely with their analysis and conclusions with Comair 5191. The papers to which you refer brush over the large amount of non-pertinent conversation between those two crew members.
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Old 22nd Feb 2012, 15:18
  #533 (permalink)  
 
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My experience with defense lawyers is their objective is to get their client off, not present the truth in a court of law.
or that could be re-written:

My experience with prosecuting lawyers is their objective is to get their accused found guilty, not present the truth in a court of law.
Aterpster - I'd like to think that we were having a discussion about how we stop this sort of event from re-occurring. I thought we had moved on from -

The late captain at issue was grossly negligent. Had he survived he would have been criminally prosecuted in many countries, as well as he should been.
You are wrong. Here's why. Let's say the guy emerged from the smoking hole in the ground totally unscathed. And then you get your way and they guy is prosecuted by the judicial system. You just tell me why he would help with his own prosecution? If that were you, I'd suggest you'd say nothing to convict yourself. I certainly wouldn't, even if innocent lest my comments were misinterpreted by some scumbag lawyer. Yet your testimony would be the most valuable thing for the investigation team. Now let's stick him in prison until he rots. We've just punished the guy - well you can say "That's justice!" But have YOU done ANYTHING to prevent this from re-occurring? No, you've just clumsily nailed up a sign that says "Trespassers will be shot!" Now, whenever there's any sort of incident, CVR/FDR's will "malfunction", paperwork will be shredded, crews will bugger off out of the country or hide away and become "sick" etc. Redneck justice deals only with pain, there is no gain.

What the investigators who wrote this report were trying to achieve was to understand the human factors that drove this crew into doing what they did. For this they should be commended.

PM
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Old 22nd Feb 2012, 16:21
  #534 (permalink)  
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PM:

You are wrong. Here's why. Let's say the guy emerged from the smoking hole in the ground totally unscathed. And then you get your way and they guy is prosecuted by the judicial system. You just tell me why he would help with his own prosecution? If that were you, I'd suggest you'd say nothing to convict yourself. I certainly wouldn't, even if innocent lest my comments were misinterpreted by some scumbag lawyer. Yet your testimony would be the most valuable thing for the investigation team. Now let's stick him in prison until he rots. We've just punished the guy - well you can say "That's justice!" But have YOU done ANYTHING to prevent this from re-occurring? No, you've just clumsily nailed up a sign that says "Trespassers will be shot!" Now, whenever there's any sort of incident, CVR/FDR's will "malfunction", paperwork will be shredded, crews will bugger off out of the country or hide away and become "sick" etc. Redneck justice deals only with pain, there is no gain.
I've heard your argument and the contra-arguments since the first accident investigation in which I was involved; 1972.

What the investigators who wrote this report were trying to achieve was to understand the human factors that drove this crew into doing what they did. For this they should be commended.
Yes, because they were trying to set forth a possible explanation for the captain's series of bad decisions. Nonetheless, the report also tells it the way it was.
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Old 22nd Feb 2012, 16:48
  #535 (permalink)  
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safetypee;

Re your observation, "Those who wish to prosecute ‘deviant’ crews without all of the evidence (because many cognitive aspects are not available), should consider what aspects of safety could be learnt from alternative viewpoints. Try being the defense lawyer."

With respect, please re-read my contribution to the discussion. Given my history here you should be well aware that I understand both the phenomenon of hindsight bias, and the broader notions of organizational failure.

While we may not be able to discern the cognitive state of the captain in this accident such that understanding and thus prevention are possibilities, I did clearly state,

"The point is made more stark by asking, for example, questions about the captain's physical health, and considering just the possibility of, say brain disease, (cancer/stroke/latent epilepsy) which had not manifested itself in previous medicals etc. As well-written as it is, the DGCA Report does not discuss this and, likely correctly, cites sleep inertia etc."

There is already much to learn from this accident, including the issues of mandatory go-arounds by the PM even if the cognitive sources of abnormal cockpit behaviours on the part of the PF cannot be discerned in the moment.

In flight data analysis I have seen and see daily trends of long landings, some well beyond the TDZ. I see power-off, high-rate-of-descent, high-speed approaches where go-arounds are absolutely indicated yet crews press on, some on 6000ft runways. Do we investigate the cognitive states and predispositions of each PF involved? Of course not... The tools and processes for prevention are already available.

Cognitive processes are, in the end, (and as you almost certainly know) complex to the point of being serious subjects of the philosophy of mind, and if you are aware of those areas of serious academic work, you will know that strong differences of interpretations of cognitive processes exist even at these levels.

Most certainly, "prosecution" is not the answer, and I should have thought that the "but..." in my post would have made that clear.

PJ2
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Old 22nd Feb 2012, 18:08
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At, I agree that legal debate does little to enhance safety, thus my question - 'what contributes to being safe'.
A Socratic debate (seeking truth) about the contributing factors in this accident, without judgement, would better benefit the industry.
What entails a “properly conducted flight”, where is this defined; - not an individual’s version, but that of the crew’s at the time, and in the circumstances of the accident. All of these aspects require definition – establishing a local ‘truth’ about them at that time, not one of an idealistic operation.

You appear to dismiss the ‘complex science’ (FRAM). I agree that the scientific outcome is not necessarily relevant, but the process or similar, might enable the identification of additional contributions or re-evaluation of the effective magnitude of the existing factors, this could enhance safety.

Re non-pertinent conversation; this appears to be a personal judgement. How can we judge (in hindsight) what was or not relevant to the human behavior in that situation, as seen (perceived and understood) by the crew. We were not there, all that we might do is surmise the human thoughts and behaviour, but even this would have some bias – our experience, culture, personality, etc, etc.

I don’t argue for right or wrong; instead I seek a wide view to identify potential contributors which any organization could consider in their safety programmes – could this happen to us.
Blaming the crew does nothing to help maintain / improve safety.

PJ,
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Old 22nd Feb 2012, 19:24
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aterpstar:
How old are you now? 70+? I strongly recommend that you visit doctor and check for Alzheimer's.
In your mind only Captain exist, you should understand that there was also F/O on that flight. As many colleagues wrote, if F/O took control there would be no tragedy, do you understand that?
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Old 22nd Feb 2012, 20:32
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moon11:

aterpster:
How old are you now? 70+? I strongly recommend that you visit doctor and check for Alzheimer's.
In your mind only Captain exist, you should understand that there was also F/O on that flight. As many colleagues wrote, if F/O took control there would be no tragedy, do you understand that?
Probably a lot sharper than you are:

I quote myself in Post 498 on Feb 19th:

In a sense this accident (crash) is similar to the OPRN Jet Blue crash. A seriously messed up captain and a fairly experienced, but too timed F/O.

At 500 feet the AIE F/O should have shoved the throttles to "radar power" rotated, then exclaimed to the captain, "Would you like the airplane back to fly a proper approach, or should I do it?"
In more civil discourse I would expect an apology from someone of the likes of you who fails to read my previous posts then makes an inappropriate insult. I'll match wits and knowledge of instrument procedures with you any day of the week.
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Old 22nd Feb 2012, 21:48
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Mr Bloggs"swiss cheese"

Conflicting reporting; Bloogs states runway drenched and below's input
mentions dry runway. Keep it factual fellows and galls.



Just talked to a friend at Mangalore with ix. confirmed no MELs.
He quoted eyewitnesses as saying that the aircraft made a pretty steep approach and touched down close to half way down the runway. They heard the thrust reversers and then a loud thud which was caused by the right wing hitting the Localiser at the end of runway. part of the wing fell there and the aircraft then fell over into the valley below. Then burst into flames.
Very sad incident and may God give strength to the bereaved families in this hour of distress.

PS: no precipitation at time of crash. Runway was dry.
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Old 23rd Feb 2012, 00:02
  #540 (permalink)  
 
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In more civil discourse I would expect an apology from someone of the likes of you who fails to read my previous posts then makes an inappropriate insult. I'll match wits and knowledge of instrument procedures with you any day of the week.
Wouldn't be much of a contest, Terp, I doubt he's a pilot.
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