French Concorde crash

[wings folded]

bearfoil,

The takeaway from this unfortunate accident is that to focus "Blame" is far more important than the progress of safety.

The progress of aviation safety (and I assume that you meant safety in that arena), is a proper matter for that industry, those who work in it, those who regulate it.
I have already posted some remarks regarding "blame".
I imagine that all practioners in the aviation industry want to take heed of every incident, even minor ones, to improve safety. Lessons can be learned daily. Not just in one's professional sphere.
The particular topic we debate here has a high profile, partially at least on account of the charisma of the airframe which was lost.

Back to your quote.

The aviation industry must imperatively take every opportunity to learn something about safety. That is its duty.

National law, and its mechanisms, has a duty to inquire into to what happened on its turf.

Nobody half serious could accuse French process of being hasty, nor pre-judged.

The timetable speaks for itself.

A cursory read of the trial transcripts reveals an attention to detail, and every opportunity given to interested parties to plead.

A detailed read reveals a degree of competence and fairness shown by the the tribunal of which France can be proud.

The case was heard at the Tribunal Correctionnel de Pontoise, the correct forum according to where the event occurred.

This was perhaps, and we hope, the last time, that they had to hear a case of this nature.

The findings and judgement are the result of judicial process. The aviation industry must draw its own conclusions about methods, adherence to protocols and so forth.

[JFZ90]

I got the impression a lot had been done in the problem area on Concorde - in other words the actions of the manufacturer etc. were consistent with trying to ensure the aircraft would not be vulnerable. The facts are that it was bad luck rather than lax certification that led to the crash. Obviously, once the weakness was fully understood after the accident, things were changed, but it appears to be an abuse of hindsight to accuse the manufacturer/authorities of not attempting to address the tyre burst hazard adequately.

Conversely, it is harder to be sympatheic towards an abuse of airworthiness maintenance procedures - which at the end of the day did lead to the end of Concorde and significant loss of life.

The more I think about it the more I find myself agreeing with the french verdict.

[bearfoil]

wings folded

Complete agreement here. Your last sentence is a different way to express the salient thrust of my message.

"the Aviation Industry must draw its own conclusions about methods, adherence to protocols, and so forth."

So here you demonstrate what is wrong. The verdict is what it is. It has no bearing on the larger issue, that of Safety in the Industry. Left to its own devices, the Industry will recover quickly and inexpensively from an event that happened ten years ago.

Permit a reference to another and current thread, anent the "Industry".

The most recent AD re: Rolls Royce engines (from a read) designates authority for compliance and judgments of airworthiness to the manufacturer itself !!! ........ It cannot be read another way.

Inspections are relaxed, the critical inspection of the problem area is deferred for two hundred cycles.........etc. etc.

A marvelous opportunity to turn the Titanic around has been lost once again. The "Hen" in the "Wolfhouse"?

[Lemurian]

Responsibility

A mechanic is certified to standards set by the regulating authority.

It is not for the mechanic to make judgments relative to airworthiness, only to comply with "the book".

Thank you ! Quod erat Demonstrandum.
(i.e. the mechanic didn't comply with the books and then made an unauthorized repair with an unauthorized material... whether or not the consequences were foreseeable is just a matter of semantics on your side of the Atlantic ocean and which in this matter we don't give a hoot to ).
Of course, the responsibility of the supervisor who presumably signed the chit off and the airline procedures are heavily engaged, and that's what tyhe verdict reflects, too.
Tha's how the Freench law saw it and that's how the verdict stays until the decision of the appellate court.
And it's tough that you don't like it. You've got to live with the fact that your law system doesn't get an application everywhere.
Tough indeed.

[bearfoil]

Lemurian

With utmost respect, I do not disagree with the verdict, and (dis)approval of same is irrelevant.

[wings folded]

bearfoil,

I am afraid that I am not at all sure about what you are saying in many of your posts, because, I think, you use a jargon or shorthand with which I am not familiar.

I think I can grasp the following:

So here you demonstrate what is wrong. The verdict is what it is. It has no bearing on the larger issue, that of Safety in the Industry. Left to its own devices, the Industry will recover quickly and inexpensively from an event that happened ten years ago.

The point of my posts is that safety in the industry is a matter for the industry. National laws have a responsability to determine how people lost their lives, if that is the outcome of a failure of safety in the industry.

I am not at all sure I understand your emboldened "inexpensively".

Cost should not be a factor in this kind of incident.

[Safety Concerns]

The point of my posts is that safety in the industry is a matter for the industry.

Now I don't follow you. Safety is a matter for industry in as much as they must meet the level set by the regulator.

There is only one successful way because the UK has proven it over many years. That may also explain why they come across as arrogant at times.

Government tasks the regulator
regulator tasks industry (by producing regulations)
industry has responsibilities and is accountable
key individuals are licensed (pilots and engineers) they are responsible and accountable for their actions

The airworthiness of Concorde was sound as highlighted in post 446 by PBL.
If you want safe flying people must be accountable for their actions.
There is no escaping the downright shoddy, inappropriate, unapproved repair carried out by the mechanic. It is that simple.

Repair done properly, NO ACCIDENT.

[wings folded]

Lemurian

Of course, the responsibility of the supervisor who presumably signed the chit off and the airline procedures are heavily engaged, and that's what tyhe verdict reflects, too.

I am not sure you are correct in affirming that the supervisor's liability was "engagé. "

As I read the verdict, the supervisor was "relaché".

Continental was not, nor was the mechanic.


(Forgive my smugness, but notwithstanding your impeccable English in your posts, you are slightly guilty of a small dose of franglais there. "Engagé" does not easily translate, and "engaged" is not really English at all in this context).

But I appreciate the qualty of your contributions.

[wings folded]

Safety Concerns,

I sometimes wright briefly so as not to bore readers unduly.

Quote:
The point of my posts is that safety in the industry is a matter for the industry.

Now I don't follow you. Safety is a matter for industry in as much as they must meet the level set by the regulator.

By that I meant the industry in its fullest sense:
-practioners, involving flying crew, maintenance personnel etc.
-regulators

I meant that courts, civil or criminal, are not the best equipped to dictate how to aviate safely. They are necessarily called upon after a failure of the industry to aviate safely, especially where loss of life occurred.

I think that we can all agree that where the law is called upon to investigate and judge an event, with loss of life in particular, there has been a failure to aviate safely. For which somebody carries the responsibilty.

[Safety Concerns]

ok sorry, you had me worried for a moment.

b) A certificated mechanic may not exercise the privileges of his certificate and rating unless he understands the current instructions of the manufacturer, and the maintenance manuals, for the specific operation concerned.

If american law genuinely excuses the mechanic and holds the the company responsible despite this FAR 65.81 statement, then there is something seriously lacking in american law.

Unless of course in american society the most important aspect of an accident is the legal scrum for damages. Because if we were not at all interested in the safety aspect from a legal perspective, then naturally a mechanic has less money in the bank than the company.

It then follows that if you screw the company regardless its more bucks all round.

Sad, very, very sad.

[wings folded]

Unless of course in american society the most important aspect of an accident is the legal scrum for damages. Because if we were not at all interested in the safety aspect from a legal perspective, then naturally a mechanic has less money in the bank than the company.

Now, I do not want to be accused of American bashing, but it is an unavoidable part of that culture that searching for what in my industry is known as the "deep pocket" is inate.

That means you go after corporations. That means that even if your own actions may have been less than prudent, you sue anyway, and either you win, or you might be bought off.

I do not aver that this approach is wrong per se, it is simply different from the way things are dealt with in Europe.

Finding a Continental mechanic to be wanting in his professional competence is a matter of judgement. Again, I repeat that the "criminal" sanction (for those still unable to differentiate delit and crime) demanded by the prosecution, and handed down by the court, was a suspended prison term, with obviously no practical impact on this individual.

[Safety Concerns]

Finding a Continental mechanic to be wanting in his professional competence is a matter of judgement.

where's the judgement? You need to explain that one to me. I do not follow instructions, I am licensed and required to follow instructions by law. I am required to follow approved instructions and not just any instruction by law. I choose not to.

Please explain where is judgement required here other than your nicked.

[wings folded]

Safety Concerns

where's the judgement?

Pontoise

I confess to being baffled by your post:

I do not follow instructions, I am licensed and required to follow instructions by law. I am required to follow approved instructions and not just any instruction by law. I choose not to.

Do you follow instructions or not? Are you under a legal obligation/constraint?

Sorry if I appear obtuse, but it is not clear to me.

[Lemurian]

wings folded

I am not sure you are correct in affirming that the supervisor's liability was "engagé. "

Sorry, I should have known one can't marry one responsibility, unless that's another name for a wife.
I bow to your expertise 1

[Safety Concerns]

@wings

you said:

Finding a Continental mechanic to be wanting in his professional competence is a matter of judgement.

The certified mechanic is licensed and required to follow instructions by law. He is also required to follow approved instructions and not just any instructions by law. He chose not to.

Where is the judgement?

[mercurydancer]

legal concepts

Whilst being neither an expert in law French or English, there does seem to be two legal principles which do apply to the mechanic who applied the titanium strip

1. A frolic of his own. This archaic language means largely that the mechanic decided to do something outside of the known limits of what his actions should be. No company/authority can be blamed for someone doing something against instruction, unless the company knew and agreed or permitted the act.

2. If not for.... This is very plain. If not for the titanium strip being on the ground would Concorde have flown normally? It doesnt seem so.

[Lemurian]

Whilst being neither an expert in law French or English

...
and apparently you're not even an expert at reading all the previous posts .

the mechanic decided to do something outside of the known limits of what his actions should be. No company/authority can be blamed for someone doing something against instruction, unless the company knew and agreed or permitted the act.

Yes it is,.., and that's the finding of the court. A company is responsible for its employee's actions, too.
But in fact, Continental wasn't only found guilty for the mechanic's actions, it was as well - and more - because the mounting and rigging of that thrust reverser were totally out of the manufacturer's tolerances. for a very long time. The mis-alignment of the reverser door caused a friction on the wear strip that *wore* it a lot faster than it should, hence the need for replacement of the strip on repeated occasions and very probably the reason why the mechanic chose a titanium strip (probably in the hope that it would stand the wear a lot more than it did.). I let the engineers amongst you draw their conclusion on that sort of thinking.
Proof of the numerous instances of that strip replacement is that the investigators found 256 rivets or rivet heads inside the cowling (I could just about set up a rivet shop with that number ! )
So please, spare us the whining about Continental's responsibility and the poor mechanic being made a scapegoat, because to me that's exactly what you mean.
I might add that during the trial, Continental and their lawyers never questioned the above findings, concentrating on some half-cooked theory that the aircraft was on fire way before the wear strip entered the plot.
That's also why among their recommendation the BEA asked for an audit of Continental maintenance. Whether it has been done , I don't know...but I've never heard of it.

[overthewing]

As a humble passenger, but someone who has often had to delegate technical work to others, I confess I'm surprised that all blame landed on the mechanic.

Surely he wasn't just handed the task, and the aircraft passed fit to fly because he said he'd done it? Doesn't anyone check repairs? Would no-one have seen that the finished job didn't match what the manufacturer specified, or the airline's practices stipulated? Perhaps they wouldn't have been able to identify that it was titanium rather than stainless steel, but surely they would have seen the problem with the holes? And if they saw it, and passed it on the basis that it was 'good enough', doesn't that propagate responsibility to line management? Was the supervisor cleared because it would not have been possible for him to check the repair, once done? Is this kind of maintenance autonomy common within the industry?

I also can't judge how rare it is for such bits to fall off planes. I presume that wear strips, by definition, get worn. Is it common for them to fall off? Or do they tend to stay attached if they're made of the right material, and correctly fitted with the right number of bolts through the right number of holes in the right position?

[JFZ90]

^^
You are right to suggest the mechanic is not the only guilty party in continental - his line management should also bear some responsibility and his work should be checked. But it is also clear that a licenced technician should never have been doing what he did.

From an airworthiness point of view bits should never fall off planes - as there us a direct hazard they will drop on someone and kill them. From a probability point of view you can never say never, so the probability of it happening should be consistent with a fatal outcome - I.e. 10x9 or similar - some expert may have the exact number.

On this basis, the continental aircraft was almost certainly rendered unairworthy as a result of the mechanics actions. Makes you wonder if it was a typical practice!

[bearfoil]

Perhaps like using a Forklift to install engines with Pylons attached at AA.