Canadian Court Requires CVR Disclosure
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From people I know who have served on juries (I confess I never have, and having heard from some I consider myself fortunate) I think that Joe Q Public takes his duties as a juror rather seriously.
Its the job of the judge to direct and assist the jury with regard toi how evidence is considered, and the jobs of both sets of lawyers to present appropriate experts.
Its the job of the judge to direct and assist the jury with regard toi how evidence is considered, and the jobs of both sets of lawyers to present appropriate experts.
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I think (and this is off the top of my head) that there was a fraud case about Guinness which took a long time to resolve. The jury were dismissed because they didn't have the ability to judge the case on it's technical merits, as it involved very tricky accounting.
I may well be wrong, I'd welcome some other legal experts to clarify this.
I may well be wrong, I'd welcome some other legal experts to clarify this.
PBL, PJ2, enjoyed the discussion.
Reality remains that where evidence exists that is not subject to privilege, then it is fair game in discovery. The NZL Dash-8 accident use of the CVR by the police was justified on this basis, and later the law amended to limit the problem.
Since mandating of CVR's in air transportation in 1965, it is notable that almost all, if not all other close coupled professions do not use operational recording systems, yet the fatalities in say, the medical profession, is orders of magnitude greater than the losses in aviation, in fact, the losses in the USA annually exceed by orders of magnitude the total losses in global jet transportation. From negligence, or other causation excluding natural cause.
One can imagine the reticence of any O.R. staff to the implementation of any recording system in the "interests of safety" that are subsequently available for the purpose of litigation.
Aviation losses are newsworthy. Aviation is high profile. Aviation is also historically proactive in the field of safety, yet the society that benefits from this openness, wants to additionally be able to use the same information for determination of liability; have your cake and eat it too...
As PBL notes, the solution is not clear in the question of access to the information. As is also noted variously, the interpretation of an audio tape by a jury or by the opposing counsels in the adversarial arena of a civil case is hardly optimal, or even likely to be valid or fair to any parties. Further, even competent analysts of CVR and spectra often have difficulty determining a particular meaning or event from the data, a case that becomes more difficult where the question of liability intrudes. Observer bias...
In this particular instance, it is unusual that the plaintiff is the one with the data, and the party requesting the access is the defendant, particularly in light of the known facts of the flight. While there are issues related to RESA and WADD etc that may be of interest to systemic risk reduction, it pales in comparison to the reported operation.
Aviations safety programs will survive this issue, and crews will be put at higher levels of personal liability than previously accepted in the interest of safety. Pilots will continue to fly and grumble about the inequity of the issue, and at the same time their professional standing will continue to be eroded beyond where it has decayed to, to date, that of a burger flipper. The public will continue to be complicit in this erosion, by demanding cheaper commodities in air travel, while being surprised when they get dead as a consequence. At least if the professional erosion continues long enough the health of the pilots will improve, the Colgan pilots won't be able to afford french fries, and the Russians won't be able to buy Vodka!
Arbitrage of safety doesn't work.
L.B. Pearson has some issues, but it just one of a long line of airports where safety is hardly the major driver. Perhaps we will have some indication of a serious interest in safety by the public when noise abatement stops having a greater operational priority than operational safety of flight which results in reduced safety margins and qualitative risk management decisions by crews on issues of quantitative outcomes.
cheers
FDR
Reality remains that where evidence exists that is not subject to privilege, then it is fair game in discovery. The NZL Dash-8 accident use of the CVR by the police was justified on this basis, and later the law amended to limit the problem.
Since mandating of CVR's in air transportation in 1965, it is notable that almost all, if not all other close coupled professions do not use operational recording systems, yet the fatalities in say, the medical profession, is orders of magnitude greater than the losses in aviation, in fact, the losses in the USA annually exceed by orders of magnitude the total losses in global jet transportation. From negligence, or other causation excluding natural cause.
One can imagine the reticence of any O.R. staff to the implementation of any recording system in the "interests of safety" that are subsequently available for the purpose of litigation.
Aviation losses are newsworthy. Aviation is high profile. Aviation is also historically proactive in the field of safety, yet the society that benefits from this openness, wants to additionally be able to use the same information for determination of liability; have your cake and eat it too...
As PBL notes, the solution is not clear in the question of access to the information. As is also noted variously, the interpretation of an audio tape by a jury or by the opposing counsels in the adversarial arena of a civil case is hardly optimal, or even likely to be valid or fair to any parties. Further, even competent analysts of CVR and spectra often have difficulty determining a particular meaning or event from the data, a case that becomes more difficult where the question of liability intrudes. Observer bias...
In this particular instance, it is unusual that the plaintiff is the one with the data, and the party requesting the access is the defendant, particularly in light of the known facts of the flight. While there are issues related to RESA and WADD etc that may be of interest to systemic risk reduction, it pales in comparison to the reported operation.
Aviations safety programs will survive this issue, and crews will be put at higher levels of personal liability than previously accepted in the interest of safety. Pilots will continue to fly and grumble about the inequity of the issue, and at the same time their professional standing will continue to be eroded beyond where it has decayed to, to date, that of a burger flipper. The public will continue to be complicit in this erosion, by demanding cheaper commodities in air travel, while being surprised when they get dead as a consequence. At least if the professional erosion continues long enough the health of the pilots will improve, the Colgan pilots won't be able to afford french fries, and the Russians won't be able to buy Vodka!
Arbitrage of safety doesn't work.
L.B. Pearson has some issues, but it just one of a long line of airports where safety is hardly the major driver. Perhaps we will have some indication of a serious interest in safety by the public when noise abatement stops having a greater operational priority than operational safety of flight which results in reduced safety margins and qualitative risk management decisions by crews on issues of quantitative outcomes.
cheers
FDR
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I think the NTSB are on the right lines when they encouraged the use of routine CVR replays by airlines for sterile cockpit complaince monitoring after the Q400 accident in NY state. Its only the industry's militant union tradition and the lax appoach to safety improvement by airline management that is blocking this important risk reducing advance.
I think the NTSB are on the right lines when they encouraged the use of routine CVR replays by airlines for sterile cockpit complaince monitoring after the Q400 accident in NY state. Its only the industry's militant union tradition and the lax appoach to safety improvement by airline management that is blocking this important risk reducing advance.
Compliance monitoring implies publicity of private conversations for the purpose of punishement and/or warnings.
Seeing as how multiple trained professionals are having a conversation they are best to sense the interruption in duties at the time and suggest to themselves to mind the store. This timeliness of identification and correction is far preferred versus after the fact revelation.
Out of the cockpit it is well and fine to reinforce the importance in routine training.
And just because not everybody agrees with your wishes does not imply a lax approach to safety
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Below FL100 there should be no private conversations!
Routine CVR Monitoring (CVRM) is just a natural extension to both LOSA and Flight Data Monitoring and a natural form of FOQA, no different than having a trusted observer on the flight deck.
Any non-compliance should be dealt with in a just and accountable way.
Why would anyone want to be in the postion of flying with a rogue pilot?
Routine CVR Monitoring (CVRM) is just a natural extension to both LOSA and Flight Data Monitoring and a natural form of FOQA, no different than having a trusted observer on the flight deck.
Any non-compliance should be dealt with in a just and accountable way.
Why would anyone want to be in the postion of flying with a rogue pilot?
CVR sampling
R.O.F.L.! 
The NTSB is one institution which knows full well what the overhead of conducting such a program would be; they get swamped with 2 guys having to look at one CVR in detail for a period of 16.5 seconds. That analysis takes weeks to months to complete, for one case. A mid size airline is operating say 100 AC, conducting 3 4 sectors a day.... so, not too sure how that would look to the creditors, investors etc when they find the airline has more CVR analysts than customers.
A brief perusal of a CVR is nearly meaningless. Without contextual understanding any crew can appear distracted, preoccupied, or nearly incoherent. Tape yourself for 30 minutes conducting a menial task and then get someone to work out if you complied with your expected protocols. Even video is limiting. Recall how much of communication is non verbal, even in the flight deck environment, and pointed away from the video camera... remember your last videotaped LOFT exercise? The two clowns with cotton wool in their mouths? Half competed statements etc? (from being a clown (clownee?) and watching clowns...
(clowner?) ).
Data capture is easy, but meaningful information retrieval from behavioral observations by means of textural utterances takes skills that most flight operations and few safety departments have. For years, NTSB had 2 guys, for CVR... M. Cash and co. NSA's task is simplified by using key words to identify communication of interest, which is not a method that would work in the flight deck, we know what words are likely to be used, what is unknown is the level of understanding and compliance that occurs at the individual or group level. At present, this becomes obvious when the crew report a self identified error (in an ideal world - parallel universe...) or when the slip between the operation and the procedure becomes evident as an incident or accident, ie an exception occurs.
Look forward to some system other than management by exception, but won't be holding my breath for that. On the off chance it does occur in the foreseeable future, will be surprised if it adds meaningful understanding to the existing knowledge base of human frailties and operational error. Hope it does...
PS; a fair data recovery rate in FOQA is 80%, and not too many departments achieve much higher than that level, due to the problems of sensors, data capture, recording, transport (and mishandling :|). CVR data integrity is even more fragile IMHO, due to environmental issues.
PPS; regular CVR screening will sort out in short order how many flight operations departments have a pathological punitive culture.
FDR
The NTSB is one institution which knows full well what the overhead of conducting such a program would be; they get swamped with 2 guys having to look at one CVR in detail for a period of 16.5 seconds. That analysis takes weeks to months to complete, for one case. A mid size airline is operating say 100 AC, conducting 3 4 sectors a day.... so, not too sure how that would look to the creditors, investors etc when they find the airline has more CVR analysts than customers.
A brief perusal of a CVR is nearly meaningless. Without contextual understanding any crew can appear distracted, preoccupied, or nearly incoherent. Tape yourself for 30 minutes conducting a menial task and then get someone to work out if you complied with your expected protocols. Even video is limiting. Recall how much of communication is non verbal, even in the flight deck environment, and pointed away from the video camera... remember your last videotaped LOFT exercise? The two clowns with cotton wool in their mouths? Half competed statements etc? (from being a clown (clownee?) and watching clowns...
(clowner?) ).Data capture is easy, but meaningful information retrieval from behavioral observations by means of textural utterances takes skills that most flight operations and few safety departments have. For years, NTSB had 2 guys, for CVR... M. Cash and co. NSA's task is simplified by using key words to identify communication of interest, which is not a method that would work in the flight deck, we know what words are likely to be used, what is unknown is the level of understanding and compliance that occurs at the individual or group level. At present, this becomes obvious when the crew report a self identified error (in an ideal world - parallel universe...) or when the slip between the operation and the procedure becomes evident as an incident or accident, ie an exception occurs.
Look forward to some system other than management by exception, but won't be holding my breath for that. On the off chance it does occur in the foreseeable future, will be surprised if it adds meaningful understanding to the existing knowledge base of human frailties and operational error. Hope it does...
PS; a fair data recovery rate in FOQA is 80%, and not too many departments achieve much higher than that level, due to the problems of sensors, data capture, recording, transport (and mishandling :|). CVR data integrity is even more fragile IMHO, due to environmental issues.
PPS; regular CVR screening will sort out in short order how many flight operations departments have a pathological punitive culture.
FDR
Last edited by fdr; 15th Oct 2010 at 20:38.
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There are many ways to do this practically (if you have the will and the right culture):
Random sampling - they key word is random, the very fact that a flight might be sampled will drive the right behaviour on everey flight
Also only sample when a sterile cockpit is manadated or when FOQA highlights exceedances.
Use speech recognition technology to filter in the same way that FOQA data is filtered before an analyst examines the data.
Luddite excuses are not acceptable from anyone committed to air safety.
Random sampling - they key word is random, the very fact that a flight might be sampled will drive the right behaviour on everey flight
Also only sample when a sterile cockpit is manadated or when FOQA highlights exceedances.
Use speech recognition technology to filter in the same way that FOQA data is filtered before an analyst examines the data.
Luddite excuses are not acceptable from anyone committed to air safety.
Calling someone a luddite for expressing legitimate concerns is unlikely to sway much opinion on this forum. Try lightening up a bit.
That's like saying that FOQA programs will stop pilots from making operational errors. Pilots soon forget that they're being watched and human nature has a habit of taking over.
Random sampling - they key word is random, the very fact that a flight might be sampled will drive the right behaviour on everey flight.
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try telling cops that too
many, many cases where cops are busted, recorded by their own car cameras.
It is nonsensical to imagine another layer of technology, thrown own like another band aid can solve anything
It is nonsensical to imagine another layer of technology, thrown own like another band aid can solve anything
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Luddites want to dismiss the benefits of technology through fear or ignorance.
The more you monitor the more that risk is reduced.
Non compliance is different from errors. Errors are not a choice, non-compliance is a choice, a non-professional one. The NTSB have certainly realised that they are often investigating accidents where pilots (or controllers) have been blatantly unprofessional (eg Colgan, Hudson collision, teh A320 overfly, the CRJ wrong runway take off etc etc) and that those people wre probablu habitually un-professional but assumed that their slackness was OK because they had never had an accident.
Major Tony Kern, USAF Ret., was a U.S. Air Force pilot with operational experience in the Rockwell B-1B supersonic bomber, Boeing KC-135 Tanker, and the Slingsby T-3 Firefly. During his 15-year Air Force career, he served in various operational and training capacities including the Chief of Cockpit Resource Management (CRM) Plans and Programs at the USAF Air Education and Training Command (AETC). He wrote a case study of the B-52 crash titled "Darker Shades of Blue". It is an intriguing, in depth report of failed leadership and cultural issues that directly contibuted to the incident. It's the story of a "hot dog" pilot and how he lived outside the regs.
http://mysite.verizon.net/res7zx3v/s...arker_blue.doc
That is an accident that would have been prevented by CVRM.
The more you monitor the more that risk is reduced.
Non compliance is different from errors. Errors are not a choice, non-compliance is a choice, a non-professional one. The NTSB have certainly realised that they are often investigating accidents where pilots (or controllers) have been blatantly unprofessional (eg Colgan, Hudson collision, teh A320 overfly, the CRJ wrong runway take off etc etc) and that those people wre probablu habitually un-professional but assumed that their slackness was OK because they had never had an accident.
Major Tony Kern, USAF Ret., was a U.S. Air Force pilot with operational experience in the Rockwell B-1B supersonic bomber, Boeing KC-135 Tanker, and the Slingsby T-3 Firefly. During his 15-year Air Force career, he served in various operational and training capacities including the Chief of Cockpit Resource Management (CRM) Plans and Programs at the USAF Air Education and Training Command (AETC). He wrote a case study of the B-52 crash titled "Darker Shades of Blue". It is an intriguing, in depth report of failed leadership and cultural issues that directly contibuted to the incident. It's the story of a "hot dog" pilot and how he lived outside the regs.
http://mysite.verizon.net/res7zx3v/s...arker_blue.doc
That is an accident that would have been prevented by CVRM.
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Ok, I'll say it...this is why they don't want CVRs in court.....
FO: 'Uh Capt, I think we are below the Glideslipe and inside the outter marker, and the airport is behind us'
Capt: 'Shut up and do what your told'
- Crash -
Capt: 'Shut up and do what your told'
- Crash -
Thread Starter
J.O.
Yes you are quite right; - its a human factors issue, and monitoring recidivism is one aspect of an active FOQA Program. It works well when all the information is provided to the pilots, de-identified of course.
Another aspect of an enlightened program is managing those extremely rare circumstances in which a non-standard event appears to be intentional. This is recognized, twice in fact, in the FAA's SAFO's, which caution those running FOQA Programs to carefully examine all flight data from non-revenue flights, (SAFO 08024). The process, including the crew contact, works.
PJ2
Pilots soon forget that they're being watched and human nature has a habit of taking over.
Another aspect of an enlightened program is managing those extremely rare circumstances in which a non-standard event appears to be intentional. This is recognized, twice in fact, in the FAA's SAFO's, which caution those running FOQA Programs to carefully examine all flight data from non-revenue flights, (SAFO 08024). The process, including the crew contact, works.
PJ2
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Certainly the number of NTSB/AAIB/ATSB reports that highlight that pilots are not reporting significant safety issues is growing (though many turn a blind ear to that ringing alarm bell).
On cockpit non compliances - from the NTSB:
CVRM is one such innovative action that can be incorporated within an airline SMS (if and when airlines start to get their act together on SMS).
It is rteally time that someone had tehe courage to trial CVRM.
More from Tony Kern on why complaceny in the airline industry kills
http://www.ntsb.gov/events/symp-prof...lism-Forum.pdf
On cockpit non compliances - from the NTSB:
Both pilots of Flight 3407 engaged in non-pertinent conversation during the flight, and neither pilot addressed the other pilot’s deviation from sterile cockpit procedures. Their ease in engaging in non-pertinent conversation suggested that the practice is not unusual among company pilots during critical phases of flight.
The sterile cockpit rule (14 CFR 121.542) is intended to ensure that a pilot’s attention is directed to operational concerns during critical phases of flight rather than nonessential activities or conversation. In 2006, the NTSB recommended that the FAA direct POIs of all Part 121 and 135 operators to reemphasize the importance of strict compliance with the sterile cockpit rule (A-06-7). In response to this recommendation, the FAA issued SAFO 06004 on April 28, 2006, to emphasize the importance of sterile cockpit discipline. Four months after the SAFO was issued, the crew of Comair Flight 5191 attempted to take off on the wrong runway in Lexington, Kentucky. There were 49 fatalities in that accident, and the NTSB determined that the crew missed important cues during their taxi because they were engaged in non-essential conversation. Since the SAFO was issued, the NTSB has continued to investigate other accidents where the sterile cockpit rule was violated.
Even though the responsibility for sterile cockpit adherence is ultimately a matter of a pilot’s own professional integrity, pilots work within the context of professionalism created through the mutual efforts of the FAA, operators, and pilot groups. The continuing number of accidents involving a breakdown in sterile cockpit discipline warrants innovative action by the FAA and the aviation industry to promptly address this issue.
The sterile cockpit rule (14 CFR 121.542) is intended to ensure that a pilot’s attention is directed to operational concerns during critical phases of flight rather than nonessential activities or conversation. In 2006, the NTSB recommended that the FAA direct POIs of all Part 121 and 135 operators to reemphasize the importance of strict compliance with the sterile cockpit rule (A-06-7). In response to this recommendation, the FAA issued SAFO 06004 on April 28, 2006, to emphasize the importance of sterile cockpit discipline. Four months after the SAFO was issued, the crew of Comair Flight 5191 attempted to take off on the wrong runway in Lexington, Kentucky. There were 49 fatalities in that accident, and the NTSB determined that the crew missed important cues during their taxi because they were engaged in non-essential conversation. Since the SAFO was issued, the NTSB has continued to investigate other accidents where the sterile cockpit rule was violated.
Even though the responsibility for sterile cockpit adherence is ultimately a matter of a pilot’s own professional integrity, pilots work within the context of professionalism created through the mutual efforts of the FAA, operators, and pilot groups. The continuing number of accidents involving a breakdown in sterile cockpit discipline warrants innovative action by the FAA and the aviation industry to promptly address this issue.
It is rteally time that someone had tehe courage to trial CVRM.
More from Tony Kern on why complaceny in the airline industry kills
http://www.ntsb.gov/events/symp-prof...lism-Forum.pdf
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Regarding the Q400 accident, weren’t they discussing icing whilst in icing conditions? I’ve not understood how the sterile concept was breached in that particular case. Discussing about icing seems rather relevant when in icing conditions.
If you’re advocating that sterile cockpit should mean only expressing SOP related items you’ve never sat on the flight deck. Communication of operational related items can be very subtle and sometimes roundabout. Equally, listening to a CVR tape or reading a transcript doesn’t tell you what the speaker is looking at. I was taught from day one to talk to the instrument panel.
Reading the CVR transcript of the Q400 accident my first thoughts were that the FO was relaying to the Captain that she was inexperienced regarding icing conditions. That seems a relevant point to communicate. I also feel that they reacted to the situation thinking it was the stabilizer that was stalling.
If you’re advocating that sterile cockpit should mean only expressing SOP related items you’ve never sat on the flight deck. Communication of operational related items can be very subtle and sometimes roundabout. Equally, listening to a CVR tape or reading a transcript doesn’t tell you what the speaker is looking at. I was taught from day one to talk to the instrument panel.
Reading the CVR transcript of the Q400 accident my first thoughts were that the FO was relaying to the Captain that she was inexperienced regarding icing conditions. That seems a relevant point to communicate. I also feel that they reacted to the situation thinking it was the stabilizer that was stalling.