French Concorde crash

[stepwilk]

Nobody seems to have made it through more than half of the AvWeek editorial. It's not so much about the specific accident as it is about the trend toward the criminalization of aircraft accidents.

[ChristiaanJ]

Originally Posted by stepwilk

Nobody seems to have made it through more than half of the AvWeek editorial. It's not so much about the specific accident as it is about the trend toward the criminalization of aircraft accidents.

I rather agree...
Nobody seems to have read down to even this...
"We bring this up not to shift blame from Continental to Air France, Aeroports de Paris or EADS (the successor to the Concorde’s developers) but to point out the futility of trying to assign blame at all."

[kappa]

Warning, thread drift!

In Post 411 Iron Duck correctly traced the development of aircraft building as related to commercial aviation in the aftermath of WW2. But I cannot let the bolded quote below stand unchallenged! The poster strays from aviation into global politics and the prejudices become apparent.

And was there ever going to be a 1000+ market for it in the post-war Marshall Plan world, in which the USA was making quite sure that Britain took its post-imperial "rightful place" in the global power structure? The USA's entry into WW2 was its bid for global domination. The Marshall Plan was the outcome. The USA always plays to win.

I was a teenager and keen student of current events when WW2 broke out in Europe. Being from an extremely anglophile family, we followed the radio broadcasts from London during the Blitz as if it were happening in New York. There is no question that Roosevelt wanted to do more than Lend-Lease to assist Britain, but we were in no way prepared to go to war, either mentally nor materially. The ‘isolationists’ were in the majority and believed the two oceans, and Naval forces to match, was our security. It was only 22 years since we had ‘voluntarily’ joined the “war to end all wars”.

Had the Japanese not attacked Pearl Harbor and Hitler not declared war on us, I honestly believe all Europeans would have been learning Deutsch. Churchill was right in his acknowledged relief that he was then sure Britain would survive.

The statement, “The USA's entry into WW2 was its bid for global domination” is ludicrous. I’m not sure what the poster meant by the word “bid”, which is a voluntary act or an “attempt”. We entered WW2 involuntarily and the fact that we came out of it ‘globally dominant’ was due to the USA not being the scene of the battle. We were a country that had taxed and given of ourselves for what was required to win against two enemies across two oceans. But we were spared the destruction.

Again we asked nothing but the European land to bury our dead. But we stayed in Europe as part of the occupying forces and even to help rebuild the defeated enemy under the Marshall Plan.


Yes, the USA always “plays to win”. So tell me, what country doesn’t?

[PBL]

Thank you, everyone, for returning this thread to interesting discourse. I was despairing of the increasing number of willfully ignorant declamations and am glad it has turned again towards discussing criminalisation.

Concerning wings folded's suggestion about Aviation Week, although it is published in the US it is not clear that its majority readership resides there. It is one of the two major industry publications, and has recently "poached" some senior people from the other. It has excellent journalists based all over the world. Pierre Sparaco has written a number of columns in recent years on the criminalisation of aircraft accidents. It is one of his big themes; he deplores it. Pierre is of course French, and writes from France. He could very well have written, or been involved in writing, that editorial (I could ask him, if anyone really wants to know). His carefully-presented views are always worth considering carefully, even if one doesn't accept all of them. I have kept copies of all his essays on criminalisation from 2006.

I particularly appreciate Iron Duck's essay on the post-WW-II polity and kappa's reply! Interesting thoughts, well put together, and, when one thinks about it, very relevant to the circumstances in which Concorde was conceived. I already noted the contrast to the B-58 Hustler, with the incident in 1961 (that came straight from the 2001 revised edition of Kenneth Owen's book, published by the Science Museum).

Concorde was a very high-performance airplane. I think the previous time that a civil transport was higher-performance than military aircraft was in the times of the Beech Staggerwing. (That may seem ancient, but keep in mind there was less time between Staggerwing and Concorde than between Concorde and A380!). It was a very high-performance airplane with, as M2Dude pointed out, characteristics necessary for its high performance which posed risks different from those being mitigated and solved in the rest of aviation. Most notably, issues with high-speed landing gear. But there were also issues with the rudder.

It was also produced in very limited quantities for what turned out to be a very limited market (but also a very profitable one for BA, which is why mike-wsm's comments are just so off-the-wall). When you have a one-off design point, and relatively low accumulation of operational hours, it is going to be correspondingly difficult to cope with emergent risks (and there are always - always - emergent risks).

And there lies the most astonishing phenomenon with the aircraft, to my mind. That aircraft flew twenty-four years of commercial service without endangering the lives of anyone on board or on the ground.

Compare with the nearly-contemporary Boeing 727, one of the most successful passenger transports of all time, and loved by many pilots. Seven fatal accidents in the first five years of service introduction, killing a total of 368 people (if my arithmetic is correct - from Aviation Safety Network's database at Aviation Safety Network > ASN Aviation Safety Database > Type index > ASN Aviation Safety Database results).

Then compare with the contemporary Boeing 737, which went five years in-service without a fatal accident, but then had three within about a year (Aviation Safety Network > ASN Aviation Safety Database > Type index > ASN Aviation Safety Database results).

The Boeing 747 also went five years in-service before a fatal accident. Then there were four fatal accidents in the next four years, killing a total of 813 people (Aviation Safety Network > ASN Aviation Safety Database > Type index > ASN Aviation Safety Database results).

That was the level of safety achievable and achieved at the time with what was to become the conventional transport design.

And Concorde went 24 years in-service without endangering anyone! Despite being a completely different design point.

(BTW, for those really interested in that design point, there is a superb article on-line, which unfortunately costs nearly $42 to download, A Review of the Technical Development of Concorde, by C.S.Leyman, Progress in Aerospace Sciences 23(3):185-238, 1986. URL for the on-line version is here (and is rather long).)

To my mind, that record set not only a different performance-design point, but set a different point in design and operations for safety.

Compare following aircraft. The Airbus A300 was in service for 16 years with only nine fatalities (in 1988 one from Iran Air was shot down by the USS Vincennes; I am not counting that incident) until PIA in Kathmandu (1992). The A310, five fatal accidents in the first ten years of service. The A320, also five fatal in the first ten years in service.

Yes, one could compare fatalities per seat-mile or fatalities per operational hour or per flight or other measures, but it is always going to be difficult comparing statistically a low-volume-production low-op-hours singular-design-point with high-volume-production high-op-hours conventional-design-point. Let me just return to the point that for a commercial aircraft to go 24 years in service without endangering anyone on board is unparalleled and, to me, nothing short of spectacular.

And the lessons from that experience have, most obviously, been learned and reapplied in the design and operation of subsequent Airbus aircraft, whose benign aerodynamics was conceived by the same people who designed Concorde. The Concorde was at the cusp of a step change in commercial aviation safety.

This makes it particularly ironic that people are being tried, and some convicted, in 2010 for a freak accident that ended the most spectacular safety record in commercial aviation.

PBL

[Safety Concerns]

come on PBL, first of all a very interesting point and a bit of history, totally agree with your views, however......

This makes it particularly ironic that people are being tried, and some convicted, in 2010 for a freak accident that ended the most spectacular safety record in commercial aviation.

the design is one thing, the other is that a properly qualified and approved individual did not follow procedures and the consequence of his shoddy work brought on this discussion.

I have absolutely no problem at all with his sentence and actually consider him lucky.

Too many individuals link just culture and no blame together. Very simply put, a just culture is about analysing an event and learning from it. Many accidents are just that an accident and therefore should not be criminalized. Wanton disregard for approved procedures and repairs, you get what you deserve, aviation or any other industry.

[Mike7777777]

In overview, from the information within the public domain, the underlying issues behind the Concorde crash are familiar to those who design complex systems and investigate catastrophic failures of complex systems.

1) O&M (or equivalent) documentation states "x"
2) Operatives/users (including maintenance staff) do not comply with "x" for various reasons (cost, time, convenience, "we've always done it like this", "don't see why we need to do that" etc)
3) The complex system generally continues to perform without catastrophic failure for a time period, this can be perceived by operatives/users as validation for non-compliance to "x"
4) Catastrophic failure occurs
5) Subsequent investigation identifies that non-compliance to "x" was a primary factor leading to catastrophic failure
6) Responsibility and liability ("blame") is allocated
7) Reduction in risk occurs .. until the next catastrophic failure

Prime examples are Chernobyl, Piper Alpha, Deep Water Horizon (probably ..)

[PBL]

Safety Concerns,

I think there is a subtle point here. It is not just a matter of agreement or disagreement with a verdict.

About fourteen years ago, Jens Rasmussen wrote an article in which he introduced his Accimaps, which are causal graphs in which the factors are described broadly rather than in detail, and the factors are layered according to the "level" at which they operate: direct causal events; operational background; legal background; organisational factors; and so on. The ATSB currently uses Accimaps, for example in the Lockhardt River report. (They are like Why-Because Graphs, which are, though, more detailed and drawn somewhat more rigorously, but without the layering.). Rasmussen also introduced the phenomenon of "migration to the boundary" (MttB). People doing their jobs optimise the way they accomplish things, in order to achieve their immediate goals, until they come up against constraints (this is MttB). However, the optimisation criteria available or preferred by an individual worker (getting the perceived job done while, say, minimising effort and resources) are not necessarily the criteria to which the task was designed (say, overall safety measures designed in the light of external review of accidents and incidents). He suggested that MttB was by far the most common phenomenon involved in the accidents which they had been looking at (primarily for the Danish process industries, as I recall). Reference: Rasmussen, Risk Management in a Dynamic Society: A Modelling Problem, Safety Science 27(2/3):183-213, 1997.

So the phenomenon of a mechanic effecting a repair without quite the right material, using a material which he may well have thought was better, and which apparently his supervisor thought was OK, is a known phenomenon. Stuff like this is pervasive (MttB).

The question is then what should happen when such behavior contributes in a directly causal way, not just to an accident, but to a freak accident to an airplane with unusual TO constraints.

Compare. German laws of the road are written basically in order to apportion compensation when an accident occurs. That is indeed how the laws read: "This is to be done, and if this is not done, and an incident ensues, then the perpetrator carries x% of the responsibility/blame for the event" and that pays out directly in monetary terms. This is an odd system to those of us used to British or US road law. It means, for example, that you can ride the wrong way on a bicycle track, and if the police stop you, you are not guilty of any offence. After all, there has been no damage. However, there is a legal trick: the police are entitled to give you official advice on the traffic law, and this advice comes with a fee. It is called a "fee for warning".

Germany, for example, is well known as a place in which people get annoyed at you for travelling on the autobahn as slow as 130 kph, which is the maximum speed in France and well over the maximum speed in Britain. People really do travel at 180/200/well over 200 kph depending on the car (usually Mercedes, BMWs and Porsches travelling very fast). However, it is little known that if you are travelling over 130 kph and are involved in an accident, you automatically carry a proportion of the responsibility/blame depending on your speed.

I live in a village, on the outskirts of Bielefeld. There is a narrow main road which curves around the church mound. My road comes off it at right angles, and there are a dozen young kids and a dozen older, not very mobile people all living within about a 100m radius of this junction. A kindergarten, and the church hall, is about 200m up the road. Curves. Houses. Kids who play in the village square and around the road. Old people regularly crossing the road on what amounts to a blind curve (there is a mirror for one direction). There is nominally a 30kph speed limit, which is appropriate. And which is ignored. People regularly come by my house at 40-60 kph, despite that they must stop at the junction, where the road ends, in 50m.

There has not been an accident. The police won't set radar traps unless there is a "reason", meaning it has to be designated a hazardous area by the appropriate political group.

Somebody is going to be hurt, sometime, outside my front door.

So what is best to avoid accidents? The system we have at the moment, in which no responsibility/blame is attached unless there is a resulting accident, in which case the consequences come down heftily? Or a system in which everybody is held strictly to the appropriate speed limitation, which is regularly controlled?

I would suggest: the latter. Taylor may have been engaging in sloppy work, but I would guess he was also working to MttB. And the responsibility for setting the constraints against which MttB behavior strains lies with the company and the regulators. Holding Taylor responsible does not serve the longer-term interests of safety, because the accident was freak. Lessons learned should include a review of safety practices and the way in which a safety culture is promulgated in the concerned organisations, here Continental's maintenance procedures.

There are organisations in which individuals take personal responsibility for safety (and therefore for accidents), and which engage in safety-critical operations to a high level of reliability. They have been studied by Berkeley groups centered around the organisational sociologist Todd La Porte. Th results are that in these high-reliability organisations, the personal responsibility of the individual worker is reinforced by having each critical point in the operation observed and checked independently by three different people reporting along different lines of command. Commercial aviation maintenance organisations have one person, the supervisor, (supposedly) checking and then signing off. The limitations of this system are well-known; see for example the Lufthansa incident at Frankfurt in 2001 in which the captain's side stick was reverse-wired in roll and he almost scraped a wing when responding to a gust during TO: AG RVS - Computer-Related Incidents with Commercial Aircraft

Convicting Taylor focuses away from the lessons that accident investigators believe are there to be learned. I would argue that anything that focuses away from those is less than conducive to aviation safety. This is independent of whether one considers the conviction of Taylor to be "just" or not. It is a point about negative interference amongst processes for achieving socially-important goals: on the one hand, pervasive safety; on the other hand, individual responsibility for negligent action.

(BTW, I expressly disagree with Mike7777777's analogy of the Concorde accident with Chernobyl, Piper Alpha, and Deep Water Horizon. Those all involved multiple instances of direct mistakes, and pervasively poor safety practice. Whereas the only action that could remotely be called poor practice in the Concorde incident was Continental's repair, and even that involvement in the causal factors was arguably extremely improbable.)

PBL

[Mike7777777]

(BTW, I expressly disagree with Mike7777777's analogy of the Concorde accident with Chernobyl, Piper Alpha, and Deep Water Horizon. Those all involved multiple instances of direct mistakes, and pervasively poor safety practice. Whereas the only action that could remotely be called poor practice in the Concorde incident was Continental's repair.)

Question of degree, that is all. Simplistically, could the failure have been averted by adherence to documented procedures? I'm very aware that "by the book" has many critics, and where the hazard to others is minimal then let them get on with it, but the ramifications of catastrophic failure for complex systems can be substantial; the UK potentially faces an electricity generating capacity crisis 2015ish onwards, a primary factor being the failure to enlarge the civilian nuclear power programme, partially as a result of the Chernobyl incident (other factors also apply).

In my experience (working alongside TÜV), the Teutonic approach is very prescriptive with insufficient reference to risk analysis, particularly condition based maintenance, although this is changing.

AFAIK, the Deepwater investigation is continuing.

[Iron Duck]

Warning, thread still drifting...

Kappa

I said

The USA's entry into WW2 was its bid for global domination

WW2 was a historical singularity: an opportunity to recast the world's geopolitics. It was a complex situation and judgements of national self-interest were based on complex calculations and projections. Some of the factors in the USA's judgement are self-evident:

• The European countries and their empires were severely damaged and enervated;
• The USSR under Stalin was increasingly powerful and self-proclaimedly expansionist;
• Hitler, having entered a pact with Stalin, could not be trusted as a bulwark against Soviet expansionism;
• that if the USA limited its circle of influence to its own land area, the USSR was quite likely to dominate Europe and large parts of the rest of the world;
• that it was going to be necessary to revitalise the damaged non-Communist world in order to prevent Soviet domination, but in a way that was not likely to result in another warring outbreak between European nations;
• and that a consequence of this should be the transformation of the revitalised non-Communist world into a ready market for US products and services.

Many, many of the consequences of the USA's entry into WW2 were beneficial to the world in general and the US population and its leadership deserves our gratitude for that, not least for the US lives expended in the process.

Yes, the USA always “plays to win”. So tell me, what country doesn’t?

Having been forced into joining WW2 two and a half years after it started, it would have been grossly negligent of the US leadership not to have attempted to maximise the positive outcome for the USA in every conceivable way. Why else abandon isolationism? The USA has always regarded itself as a nation with a mission, a vision repeatedly reiterated in Pesidential utterances. I am quite sure that Roosevelt saw nothing wrong whatsoever with a vision of the world dominated by American political and economic principles; whereas the likely opposite, a world dominated by the USSR, was anathema to the USA.

So the USA played to win. It was not Roosevelt's intention to end up with a Superpower duopoly; Roosevelt had intended that American political and economic ideas and systems should dominate, under US leadership. France and the UK's acquisition of independent nuclear deterrents were, I'm sure, an unwelcome development for the USA.

There is nothing wrong whatsoever with playing to win. However, this single-mindedness seems to me to have been a relatively new political phenomenon, not previously evident before the war, and one that the old-fashioned Europeans appeared not to have had to the same extent. Previously, as with corporations jostling for market share in a mature market, it appears to me that the geopolitical "great games" were played largely with balance-of-power and containment in mind. Japanese domestic corporate behaviour remains characteristic of this (I have personal experience). We can see this new dynamic played out in a multitude of post-war arenas, one of which is civil aviation.

So WW2 represented a singular opportunity to recast the world's geopolitics before the postwar business-as-usual of political and economic balance-of-power and containment resumed. Of course the USA played to win, and winning meant a world dominated by American political and economic ideas.

I'm not a historian and don't wish to bore people further with these ramblings.

[Safety Concerns]

sorry PBL still disagree on this. Freak accident and irresponsible behaviour are two separate entities here.

If we accept what you are saying there is no point in licensing individuals, there is no point in accepting responsibility for what you do. The actual mechanics of the accident may have been freak but the route to it was not.

One is licensed which gives authority, responsibility and accountability. It is one's duty to repair in accordance with approved manuals. It is one's duty to say NO when its being done incorrectly. That is the whole point of responsibility.

If you then turn round and say, well life is hard you poor thing go home and forget it, we will be turning the clock backwards and not forward. The effect of charging the mechanic will wake up a few other individuals and improve safety.

A just culture with accountability is what we need, not a mollycoddle state.

[Shell Management]

Too many individuals link just culture and no blame together.

Very true and a fundamental misrepresentation spread by the unionised flight safety mafia.

Very simply put, a just culture is about analysing an event and learning from it.

AND holding people accountable when their performance is significantly below par.

In this case the concious deviations by Continetal staff are just that. It is crazy to compare their reckless actions in maintaining a small metal strip to the far more complex actions of certificating a unique supersonic transport aircraft.

[T-21]

The whole accident could have been avoided if the French airport authorities had conducted a proper runway check before the Concorde had departed. Why was a FOD check not carried out prior to take off ? rather than shift the blame to Continental Airlines.

[Safety Concerns]

are you serious?

It's like saying well sorry me honor, it snowed after I set off so how can I be responsible for running over the poor old lady. Some people need to get real.

The source of this accident is clearly an individual who chose to do something his way rather than the approved way. Even then he didn't so a particularly good job of it.

Remove that one single factor and we have nothing post about here.

[Mike7777777]

The source of this accident is clearly an individual who chose to do something his way rather than the approved way.

From the info available, I suspect that - under UK law - Continental senior management would have been charged with manslaughter.

[Johnm]

Quote:
The source of this accident is clearly an individual who chose to do something his way rather than the approved way.

From the info available, I suspect that - under UK law - Continental senior management would have been charged with manslaughter.

I suspect not, a charge of corporate manslaughter takes a lot of justification and proof of wilful neglect of duty.

I also suspect that a BA Concorde would have survived the incident as they all had modified tyres with precisely this kind of risk in mind.

[Chu Chu]

Suppose someone has walked up to the Continental mechanic and told him that if he installed the wear strip incorrectly it might fall off. And just maybe it would fall off on a runway. And maybe the next airplane to take off would hit it. And maybe that next airplane would be one of a handful in the world that, as it would turn out, could suffer a fatal crash if a tire hit the metal strip. And if that happened, 10 years later he might be sentenced to a suspended jail term in a country he may never have visited. My guess he would have said "yeah, right" and gone on with the repair. And even if he had changed his ways, I think it would have been for fear of causing a crash, not of getting a suspended jail term.

Of course, it's important to deter unsafe practices, but it seems to me that a punishment that's less likely than winning the lottery isn't much of a deterrent. Supervise the mechanics better. Make the airlines accountable for ensuring that their airplanes arrive with all the bits of metal they left with. Do a forensic examination of every piece of FOD that ends up on a runway. I don't know if any of those are feasible, but they'd all be better deterrents than what happened here.

I'm not saying the French law or French court was right or wrong. Laws can serve as deterrents, but that's not the only reason they are passed. And presumably the French legal system wasn't established as an aviation safety system. But I think it's hard to justify the verdict on the grounds that it will improve aviation safety.

[wings folded]

One last attempt at explaining French judicial process, then I give up and leave ignorance, prejudice and parochialism to get on with it.
I will try to give parallel equivalences purely to aid a misty understanding. The parallels will of course not always coincide in the detail.
French law has three levels of procedure
1) "Tribunal de Police" concerned with mundane matters such as traffic offenses
2) "Tribunal Correctionnel", concerned with "delits" which may be thought of by British readers as "misdemeanours. I do not know if US readers have an equivalent in their multiple systems of law.
3) "Cour d' Assise" to try "crimes". No translation needed. The word is spelt the same in both languages.
We can forget 1) above; it has no relevance here.
Those against whom the process is applied are termed:
- in the case of 2), "prevenus" which translates as "forewarned"
- in the case of 3), "accusés", which of course translates as "accused"
Now, here is where you have to pay attention.
The procedure at Pontoise was "correctionnel", not criminal (or criminelle if you prefer).
So to all posters, using the inflammatory expression "criminalisation" or "criminalization", pleas note that had the intent of the procedure been to criminaliz(se) the interested parties, the forum would have been the Cour d'Assise, not the Tribunal Correctionnel.
French procedure was applied absolutely correctly.
Those who proclaim that we all in this debate regret the absence of an inquest system in French law do not speak for me. French law has perfectly workable systems in place to deal with this kind of tragic event.
The methods may appear different, and perhaps unfamiliar, but they are valid.
Just a footnote on the use of the word "blame".
As I read or hear the word, it has heavy connotations. I think it should not.
If I sneeze and deposit the product on somebody, I am to blame for soiling their jacket.
It was not a voluntary act.
If I do something in defiance of established law, rules, procedures or whatever, we will use the same term. "I am to blame" or "he is to blame"

[Mike7777777]

I suspect not, a charge of corporate manslaughter takes a lot of justification and proof of wilful neglect of duty.

My understanding is that the Continental corporate body has been found guilty of a form of manslaughter under French law, not certain how this would equate to a manslaughter charge of some form under UK law.
Are Continental's H&S management procedures with regards to maintenance and inspection activities in the public domain as a result of the court case? Would these be examined rigorously under French law?

[subsonicsubic]

The act of an individual....

I immediately thought you were referring to the PF in the Concorde.

But no. You are referring to the scapegoat...poor bugger.

Screw maintenance, bugger COG, Screw a tailwind etc etc.

[Safety Concerns]

the problem is subsonic everything you mention had nothing to do with bringing the aircraft down.

He isn't a poor bugger because he knowingly ignored approved procedures. Stupid maybe but poor bugger he ain't.

It is very simple:

bodgit repair
bit falls of
concorde catches it during take off roll
accident investigators prove link and cause

As to the French case and blame. You can use what terms you like but the fact is a sentence has been issued and rightly so for this tragedy.