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Canadian Court Requires CVR Disclosure

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Canadian Court Requires CVR Disclosure

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Old 16th Oct 2010, 16:20
  #121 (permalink)  
 
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Icing was not a factor in the accident but chatting about it was.

NTSB scrutinizes pilots in Colgan Q400 crash probe: AINonline

NTSB hearing officer Lorenda Ward reported that the crew engaged in non-essential conversation while flying below 10,000 feet in violation of FAA rules, including, for example, a three-minute discussion on the first officer’s experience in icing conditions and training. “This conversation occurred just a few minutes before the stick shaker activated and while the crew was executing the approach checklist,” said Ward.

Although the pilots reported ice accretion on the airplane’s windshield and wings, airplane performance modeling and simulation conducted by the NTSB show that icing had “minimal effect” on the stall speed of the airplane. Information from the airplane’s FDR indicates that the stick shaker activated at 130 knots, a speed consistent with an engaged de-icing system. FDR data further indicates that when the stick shaker activated, the control column experienced a 25-pound pull force, followed by an up elevator deflection and an increase in pitch, angle of attack and g forces.

During the flight’s climb to 16,000 feet, the crew activated the de-icing systems and left them on throughout the flight. About 40 minutes into the flight, the crew began their descent and at 10:10 p.m. they discussed the build-up of ice on the windshield. At 10:12, the flight received clearance to descend to 2,300 feet and reached that altitude at 10:14. At 10:16 the crew lowered the landing gear, and about 20 seconds later the first officer moved the flaps from 5 to 10 degrees. The stick shaker activated and the autopilot disengaged shortly thereafter. The crew added power to about 75-percent torque and the control column moved aft. That accompanied a pitch-up motion, a left roll, followed by a right roll, during which time the stick pusher activated and the flaps retracted. The airspeed then decreased and after further pitch and roll excursions the airplane pitched down and entered a steep descent from which it did not recover.
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Old 17th Oct 2010, 17:10
  #122 (permalink)  
 
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PJ2 everyone exposed to the Shell management approach will know that this is exactly how the operate - except they will also take credit for the hard work of others after the event. Believe it or not this character, SM, is actually far more polite than some of the Shelldroids focused on their fat bonus payments and prepared to steamroller things through to get them!
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Old 17th Oct 2010, 18:11
  #123 (permalink)  
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squibb66;

For the moment I'm suspending judgement in favour of curiosity.

While it doesn't form a pattern or even provide an example of clear exception, I've worked with Shell Oil flight safety people in safety audits. The experience was a good one, they knew what they were doing and their comments were appropriate and helpful. They focussed on the issues and had the professional integrity to stick to the business at hand.

They would never have thought of employing the term "luddites" when referring to colleagues' input, or characterize flight crews as "being in the business for the gold braid". Perhaps being far from headquarters is a benefit...

That said, I thought the offer of opening the discussion might get it off top-dead-center. We'll see.

PJ2

Last edited by PJ2; 17th Oct 2010 at 18:39.
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Old 17th Oct 2010, 20:32
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Now this is becoming a touch surreal.

They focussed on the issues and had the professional integrity to stick to the business at hand.
There is no need to be sarcastic but on the off chance you are actually serious, as you mention Shell Oil means you are talking about the US operation, where excessive self-righteousness is actually very well known.

I've never heard of anyone at Shell calling themselves a flight safety person as they are 'advisors' (in the same way that 'nice' Alistair Campbell was Tony Blair's commiunication advisor).

I have heard a Shell Advisor rant about the FSO of one major operator but that is another story.
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Old 17th Oct 2010, 20:51
  #125 (permalink)  
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squib66, check your PMs.

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Old 18th Oct 2010, 02:13
  #126 (permalink)  
 
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Ex Cargo Clown wrote:

"I've just had a look elsewhere about this case, and I'm wondering exactly where the tort has come from, as far as the ATC are concerned.

Surely by definition the Captain is in complete legal charge of the aircraft, why are they attempting to sue the ATC. Seems very odd indeed.

I know there are instance whereby criminal charges have been put upon an ATCer, but civil claims?"

I wonder too? A crew fail to do a proper landing and then fail to do a Go-Around. And they sue ATC?
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Old 18th Oct 2010, 02:58
  #127 (permalink)  
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Angry CVRM???

Shell shock: Whatever is being smoked there in Amsterdam, don't take it to Singapore...

I am trying to envisage what the algorithm for screening would look like that would not result in massive manual intervention in the data reduction. Even on completion of that task, assuming we are talking about RPT carriers where the bulk of public risk exists... regional ops, where the largest number of movements exist... etc.

If the intent is just to invade the cockpit and have a pretense of management involvement (interference) in the day to day operation, I think it would be seen as such. Yes, non adherence of sterile cockpit is on occasion coincident with an event, but it is not often the cause of the event directly, merely (arguably..) a symptom of cockpit discipline at the relevant time. There are other simpler methods of identifying operational discipline, that exist and do work already. FOQA. etc.

Frankly, I would think there as much to be gained by placing a CVR in the office of the Accountable Manager and Co, (accountant, safety manager, training manager, scheduler, dispatcher, airport manager, etc) those people who make decisions that affect the balance of commercial imperatives v safety standards, which as often as not results in the crew being placed in invidious circumstances, and making operational compromises which they are then responsible for, all for the grand renumeration of, what, minimum wage for Colgan? F/O's on welfare? Heck, I would be happy if those people had initial and recurrent training on the impact of their actions on operational and public risk.

Now, Shell game, in your case, feel free to pull the CVR for your fleet and charter ops. Should keep you amused for hours. Certainly will endear you to the crews that you show so little faith in.

Safety Cases? worked for the oil & gas programs.... Piper Alpha, Exxon Valdez,Amoco Cadiz, Torrey Canyon, Ixtoc I, lexander L. Kielland, Seacrest, Ocean Ranger... Texas City, Alon USA etc... your (Shell Manglement's) industry is a high risk industry, but as often as not the errors are systemic, with the poor sod on the firing (literally) line being merely the last point of failure, and often as not, the first to die. To that extent there is a commonality to aviation's inherent risk.

At some point management needs to get their foot off the throat of the people they have placed in untenable positions, and look closely in the mirror, and honestly review their culpability in outcomes. Recently, the ambivalent attitude of the oil industry to safety was evident to the public, with the CEO of a major taking time off to go sailing in the midst of a record setting environmental disaster, the result of the corporations desires for returns to investors, and bonuses to bosses... Tape your own offices, and let the professional aircrew got on with their duties. IMHO.



The people who are regarded as moral luminaries are those who forego ordinary pleasures themselves and find compensation in interfering with the pleasures of others. Bertrand Russell (1872-1970)

Last edited by fdr; 18th Oct 2010 at 03:24.
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Old 18th Oct 2010, 18:33
  #128 (permalink)  
 
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PJ2 - I've already highlighted some steps to achieve CVRM in practice.

Remember too that voice analysis software is routinely used for security purposes and the steadily expanding speed of computers also help. If you work in a Shell refinery communications is recorded and available for training and quality purposes using technology used in call centres. Aviation is not that special.

Courage is needed to overcome the resistance to change that is holding back an advance in safety that certainly concerns the NTSB.
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Old 21st Oct 2010, 16:45
  #129 (permalink)  
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Federal Judge Rules Flight 3407 CVR Can Be Used As Evidence

Sorry, the above link provided to the ruling leads to the Second Circuit Court of Appeals but not to the actual ruling. The site is very confusing to search for the uninitiated, and there is no Docket number provided in the story. However, the story has made the usual media outlets.



Federal Judge Rules Flight 3407 CVR Can Be Used As Evidence

Judge Said Written Transcript Does Not Accurately Reflect Actual Conditions

In a decision that could have far-reaching implications for aviation, a federal judge has ruled that the actual recording from the cockpit voice recorder (CVR) made when Continental Connection Flight 3407 went down can be introduced as evidence in the wrongful death suits filed in connection with the accident.

A transcript of the CVR recording was released last year, but judge William M Skretny said the written transcript was not complete and contains inaccuracies. The Buffalo News reports that Skretny listened to the recordings in private before making his ruling.

"Production of the recording [as evidence] is necessary because the written transcript does not and cannot reflect tone of voice, pitch, volume or inflection, nor does it necessarily accurately reflect ambient and other noises pertinent to the aircraft's operation," Skretny wrote in his opinion. "The Second Circuit [Appeals] Court has recognized the evidentiary importance of the audio recording from a cockpit voice recorder, which is often the only piece of neutral evidence in an air crash case," the ruling continued.

Attorneys for the families of some of those fatally injured in the accident said that the written transcript does not convey the "pre-impact terror" aboard the aircraft.

39 lawsuits have been filed in connection with the accident. The paper reports that five have been settled out of court.

Aero-News Analysis: There are few in aviation that will argue with the opinion that this sets an overtly dangerous precedent. Pilots have fought the disclosure of such recordings for years by virtue of the fact that the real factual evidence is contained in the transcripts that ARE released and that the actual recordings will do nothing but harm those involved (emotionally) and enrich grand-standing attorneys. This decision needs to be fought at all costs... as the release of this information has no evidentiary value whatsoever... and is nothing but a ghoulish attempt to profit off tragedy.

-- Jim Campbell, ANN Editor-In-Chief

Last edited by PJ2; 21st Oct 2010 at 16:58. Reason: Further information on link provided
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Old 21st Oct 2010, 18:57
  #130 (permalink)  
 
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Even when a CVR is used in a court case it should be obvious that the families would not be suing the pilots or their estates but would go after the corporations involved because they have the deepest pockets and are more likely to settle out of court when they fail the red face test.

As the judge explains:

"Production of the recording [as discovery material] is necessary because the written transcript does not and cannot reflect tone of voice, pitch, volume or inflection, nor does it necessarily accurately reflect ambient and other noises pertinent to the aircraft's operation,"*
Obviously the unions have to object as pilots collectively can't command a 'Right Stuff' wage at a premium to bus drivers if individual pilots are shown to underperform dramatically with mass fatalities.

Officials of the National Transportation Safety Board have said the transcript shows that the two pilots violated flight safety regulations by engaging in extraneous conversations.

The transcript contains 26 notations indicating the "sound of laughter" by one or both of the pilots, according to court papers.*

CVRM is a real opprtunity to raise standards and reduce non-compliances as pilots would be more focused and attentive to the rules if they knew that their CVR tape may be reviewed at random, its just like random drug and alcohol screeing.

* see here:
Attorneys will hear Flight 3407 cockpit tape - Courts - The Buffalo News
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Old 21st Oct 2010, 19:03
  #131 (permalink)  
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SM;
Obviously the unions have to object as pilots collectively can't command a 'Right Stuff' wage at a premium to bus drivers if individual pilots are shown to underperform dramatically with mass fatalities.
I don't know what you do, but if you believe what you said, you have no comprehension whatsoever of flight safety work and even less of industrial issues and dealing with flight crews. You have no idea what you're talking about in terms of envisioning, designing and implementing anything to do with "CVRM".

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Old 21st Oct 2010, 19:21
  #132 (permalink)  
 
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High pay should not be confused with flight safety.

Also if ALPA claim low pay was a factor in this accident (as it probably was for fatigue reasons) then they have to accept that their infatuation with seniority lists and major carriers is not helping the vulnerable younger pilots in the commuter industry. The US unions management of change has failed to cope with the change in the airline industry since 1979.

Wages are not a factor in the value of CVRM so please do knock safety initiatives for irrelavent reasons.

CVRM, coupled with a Safety Management System, would be an excellent way to counter some of the pressures seen in the Colgan accident and this CNN report:
Secrets pilots won't tell you - CNN.com
That is because the airline management could not claim they didn't know what was really going on or hide under the facarde that they have never had an accident.

This thread gives another justification for CVRM http://www.pprune.org/rumours-news/4...00-meters.html

Last edited by Shell Management; 21st Oct 2010 at 22:14. Reason: Adding extra emphasis
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Old 25th Oct 2010, 11:39
  #133 (permalink)  
 
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I simply do not see how the aviation industry can afford to implement CVRM.

The logistics of being able to capture these "rogue" pilots using analysis of the last two hours of any given flight would require massess of data being processed. Then, as someone has rightly pointed out, the correct contextual meaning of even small samples of voice data could take weeks to determine by well trained specialists. Even then the result can be disputed.

With pilots coming from all over the world, you had also better make sure that the speciallists are multi lingual for the occasions that they break the sterile cockpit in their (non English) mother tongue.
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Old 25th Oct 2010, 18:45
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Firstly there is no such thing as a private conversation when sterile cockpit rules apply. Compliance monitoring during safety critical tasks should be universal. Look what can be done in engineering to prevent maintenance error: http://www.raes-hfg.com/reports/08de...e/comp-mon.ppt or capture terrible medical errors via video: BBC News - Tetraplegic man's life support 'turned off by mistake'

I propose sampling, so perhaps one in 50 flights so that reduces the data to review but the nature of radom sampling means that the unprofessional behaviour NTSB have identified will be reduced as well as some pilots being identified for counceling.

I also propose analysing only those portions of a flight on a CVR recording where sterile cockpit rules apply. In other words a relatively small amount of data but at the most critical time.

Look at Google Earth & Steetmap. 10 years ago we would never have imagined we would have access to so much data.

Some responders may opine negatively here but the airline industry must strive to improve. Per Ardua ad Astra!

Last edited by Shell Management; 25th Oct 2010 at 19:10. Reason: To add extra resources
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Old 26th Oct 2010, 00:03
  #135 (permalink)  
 
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Random sampling will be no better at improving safety than the police who post radar traps once every 6 months on a given stretch of road. The other 363 days a year, people will break the speed limit in that area with impunity. Want to stop it, put up a speed camera that gets everyone. Same would apply to analysis of CVRs, but as has been already pointed out correctly, to do so would be prohibitively complex and expensive with virtually no provable benefit to be had. Unlike flight data, it requires human interpretation, and not just some of the time, but all of the time. Ask a CVR team from your favourite accident investigation authority how long it takes to perform analysis of just one accident CVR, and they already have some idea of what it is they are looking for.

The other thing about random sampling is that while you may only look at a portion of your data, you're responsible for 100% of it. While you're not likely to ever get to 100% of your data, even if you wanted to, it's going to look very bad if one of the ones you "missed" in your 1 in 50 program ends up being later shown to have been a precursor to something serious.

If cockpit discipline is a serious issue for the industry, there are much better ways to assure compliance through reinforcement in training and checking; with frequent published reminders; and by having professionals "self checking" each other. The way forward is to build a culture of compliance, not by using a stick and a carrot.

Last edited by J.O.; 26th Oct 2010 at 11:21.
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Old 26th Oct 2010, 07:24
  #136 (permalink)  
 
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Aircrew must be able to report without fear or favour anything at all that may in the future prevent an accident. The Air India thread provides insight into a culture that seems to actively discourage this.

What we don't need are lawyers using CVRs to shock juries into lucrative verdicts. That was NEVER the objective.
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Old 27th Oct 2010, 18:36
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J.O. what you suggest has been shown by NTSB to be failing - hence the need new techniques to be justly used

Mary - the best way to stop lawyers getting the tapes is not to crash PERIOD. Truth should be an absolute and any expectation that the airline industry can hide data is childish wishfullfilling fantasy.
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Old 27th Oct 2010, 20:12
  #138 (permalink)  
 
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SM

...what you suggest has been shown by NTSB to be failing - hence the need new techniques to be justly used
Provide facts and figures. Whan has Smell ever had a just culture

Smell Accountability Rating
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Old 27th Oct 2010, 20:21
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Of course your link is to one of those crackpot eco group propaganda sites. Though one that clearly hasn't bothered with any muck-racking for 5 years.

Shell have been leaders in the application of just culture for years and is well known for funding much of the prior groundbreaking theory at universities in the UK & Netherlands. Shell has made much of this freely available to the world: Hearts and Minds - Home

TB. via PMs has also reminded me that CVR's of course already would be used as evidence in court in the event of suspected suicides such as Silkair, Egyptair or attempted suicides by crew. A rare, but sadly not unheard of event.
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Old 28th Oct 2010, 19:56
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Shell Management, is that really your title? Are you responsible for the entire company, and that is why it is used as your alias? I don't somehow think that the Shell Company would appreciate your insinuation that the airline industry is attempting to hide data. Truth, actually is far from being an absolute - think of Rashamon -

Air accident investigators do their careful and NON JUDGEMENTAL analysis of accidents using every bit of evidence, at least in the UK, I suspect the same is true of the US and Canada. The point of the analysis thus arrived at is to prevent another accident. Not to apportion blame. The motive of the lawyer is rather different.
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