SQ006 final report out 26/4/02
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I agree 100% with Hawkeye's last posting except that I would delete the parentheses. Making the wrong turn AND taking off from an obstructed runway are inextricably linked and confirm the old adage that accidents are rarely attributable to a single cause but result from a chain of events, as others have pointed out in this very same discussion.
With respect, Capt Stable, I don't agree with your flat declaration that turning on to the wrong runway was not the cause of the accident. Sure, if, say, one of the engines had quit during the turn, they would have aborted the takeoff, taxied back to the terminal, and no one would have been any the wiser. But an accident would have been avoided only by pure chance. On the other hand, had they executed the proper turn on to 05L, they would, in all probability, have taken off safely. I can't see how one can deny the close causal relationship between turning on to the wrong runway and taking off from that runway.
I also agree with Hawkeye and others that the format of the ASC report, which is otherwise so thorough and comprehensive, is unfortunate, in that it overzealously separates factors related to "cause" and to "risk". Murrelet's posting in which he summarized the main findings didn't make that distinction (rightly, in my opnion) but unfortunately the ASC did.
With respect, Capt Stable, I don't agree with your flat declaration that turning on to the wrong runway was not the cause of the accident. Sure, if, say, one of the engines had quit during the turn, they would have aborted the takeoff, taxied back to the terminal, and no one would have been any the wiser. But an accident would have been avoided only by pure chance. On the other hand, had they executed the proper turn on to 05L, they would, in all probability, have taken off safely. I can't see how one can deny the close causal relationship between turning on to the wrong runway and taking off from that runway.
I also agree with Hawkeye and others that the format of the ASC report, which is otherwise so thorough and comprehensive, is unfortunate, in that it overzealously separates factors related to "cause" and to "risk". Murrelet's posting in which he summarized the main findings didn't make that distinction (rightly, in my opnion) but unfortunately the ASC did.
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From the the event logs of the accident, no mention was make whether the duty air traffic controller had SQ 006 in sight when he/she issued the takeoff clearance.
Taking into consideration a distance of close to 1 nm from the Air Traffic Tower to the threshold of 05R ,with prevaling visibilty of 400-450 meters (my assumption , actual vis believe was lesser at the time). It was doubtful that the duty air traffic controller had visual contact with SQ 006 as it approched 05R.
Isn't it a requirement for ATC to ascertain aircraft requesting for takeoff clearance is on the correct platformm prior to issue of takeoff clearance??
Especially so on a non- ASD airport under inclement weather , It should have been mandatory for ATC to visually confirmed aircraft is lineup on the correct runway prior to issuing takeoff clearance under such circumstances.
This could be the reason for the Singaporean MOT raising the issue under Safety Recommendation to ASC :
"4.CKS Airport should ensure that its Air Traffic Controllers adhere to their Standard Operating Procedures. In particular, when aircraft cannot be seen from the control tower, controllers should advise pilots of this situation, and that they should taxi with caution. "
Infering that the tower controller violated its standing SOPs in takeoff clearance under adverse weather.... not having visual contact with SQ006.
If that is so then it leads to another question , is the airport takeoff minimum comensurate with its controllers' ability in visually acquiring aircraft on the operating platform of the non-ASD airport??? eek:
Are all takeoff clearances in CKS " blind " clearances from the Tower under adverse weather when visibility falls below 600 meters !!!??
Your comments will be most appreciated.
Cheers!
Hawkeye:
Taking into consideration a distance of close to 1 nm from the Air Traffic Tower to the threshold of 05R ,with prevaling visibilty of 400-450 meters (my assumption , actual vis believe was lesser at the time). It was doubtful that the duty air traffic controller had visual contact with SQ 006 as it approched 05R.
Isn't it a requirement for ATC to ascertain aircraft requesting for takeoff clearance is on the correct platformm prior to issue of takeoff clearance??
Especially so on a non- ASD airport under inclement weather , It should have been mandatory for ATC to visually confirmed aircraft is lineup on the correct runway prior to issuing takeoff clearance under such circumstances.
This could be the reason for the Singaporean MOT raising the issue under Safety Recommendation to ASC :
"4.CKS Airport should ensure that its Air Traffic Controllers adhere to their Standard Operating Procedures. In particular, when aircraft cannot be seen from the control tower, controllers should advise pilots of this situation, and that they should taxi with caution. "
Infering that the tower controller violated its standing SOPs in takeoff clearance under adverse weather.... not having visual contact with SQ006.
If that is so then it leads to another question , is the airport takeoff minimum comensurate with its controllers' ability in visually acquiring aircraft on the operating platform of the non-ASD airport??? eek:
Are all takeoff clearances in CKS " blind " clearances from the Tower under adverse weather when visibility falls below 600 meters !!!??
Your comments will be most appreciated.
Cheers!
Hawkeye:
Last edited by hawkeye18; 5th May 2002 at 18:04.
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Both first officers of SQ006 had their ATPL, correct (by luck). Other first officers of other SQ B747-400 flights did not.
The word 'crew configuration' (in the beautiful color) in your post is exactly what the CAAS notice to SIA was all about, and SQ006 had that very crew configuration.
You are having trouble putting 2 and 2 together (are you a pilot?). If this was a court of law (not a court in Singapore), this memo would be a very important exhibit.
Mind you sir, it is now a part of PPRuNe archives. There is going to be litigation up the yeng yang over SQ006. Sharp lawyers read carefully, including PPRuNe.
Have a nice day.
The word 'crew configuration' (in the beautiful color) in your post is exactly what the CAAS notice to SIA was all about, and SQ006 had that very crew configuration.
You are having trouble putting 2 and 2 together (are you a pilot?). If this was a court of law (not a court in Singapore), this memo would be a very important exhibit.
Mind you sir, it is now a part of PPRuNe archives. There is going to be litigation up the yeng yang over SQ006. Sharp lawyers read carefully, including PPRuNe.
Have a nice day.
The purpose of accident investigation is prevention (of future accidents) and not blame.
So what is need here is the statements and analysis of recommendations stemming from this investigation.
I have seen neither as yet.
All I have seen so far in the various discussion forums is discussions of the wording of the accident reports.
So what is need here is the statements and analysis of recommendations stemming from this investigation.
I have seen neither as yet.
All I have seen so far in the various discussion forums is discussions of the wording of the accident reports.
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Does anybody have any idea when the last time 05R was actually used for takeoffs and/or landings? How long have the Taiwanese maintained this hazard to operations, a taxiway marked as an active runway? I started operating into there in '92; never saw it used as a runway, but it was marked & lighted as such, though always used as a taxiway. Might as well put vasi's on Mt. Fuji.
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GLADIATOR - what you quoted is an instruction to the pilots on the B744 fleet from their fleet boss, it is definitely NOT the memo from the CAAS to SIA advising that the 3 crew concept as previously practiced by SIA was no longer approved.
You ask us to take special note of the date, (07 Nov) but for this to have any relevance at all can you please quote the actual memo from the CAAS to SIA and, most importantly, give the date of that memo?
You ask us to take special note of the date, (07 Nov) but for this to have any relevance at all can you please quote the actual memo from the CAAS to SIA and, most importantly, give the date of that memo?
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lomapaseo
The detailed analysis are voluminous, u can access them at the following links:
http://www.asc.gov.tw/asc/_file/2217...e/3844_en.html
http://www.sq006.gov.sg/final_draft/fr_final_draft.htm
Cheers!
Hawkeye
The detailed analysis are voluminous, u can access them at the following links:
http://www.asc.gov.tw/asc/_file/2217...e/3844_en.html
http://www.sq006.gov.sg/final_draft/fr_final_draft.htm
Cheers!
Hawkeye
Last edited by hawkeye18; 6th May 2002 at 04:42.
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Semaphore Sam, not sure how long 05R had been inactive as a runway. Heard rumours it was as much as 12 years! Not sure though!
Hawkeye 18, your statement on some responsibility of the tower being able to see the aircraft it clears for take-off has some merit, though not sure if this is a regulation. However, your statement that the pilots should have been extra careful if they could not be seen by the tower does not quite coincide with my own operating point of view. To me, whether or not I can be seen for a takeoff or taxi, if I am cleared onto a runway or taxiway, I should always exercise maximum caution wherever I am. The tower may not have been able to help them. In Anchorage, the tower could see China Airlines, yet they too made a gross error and departed on a taxi way.
GLADIOLI, you seem to have much to say to others, but STILL waiting to hear about your misunderstanding of a 3 crew operation and your obvious malpractice of it in your days at SQ. You are obviously one of the confused who could not easily differentiate the subtleties between a 3 man (2 f/o's, 1 capt) and an augmented (2 capts, 1 f/o) crew operation. This explains your reaction, along with others, to the CAAS ruling. To me, and those in the know, it made LITTLE DIFFERENCE OPERATIONALLY.
Hawkeye 18, your statement on some responsibility of the tower being able to see the aircraft it clears for take-off has some merit, though not sure if this is a regulation. However, your statement that the pilots should have been extra careful if they could not be seen by the tower does not quite coincide with my own operating point of view. To me, whether or not I can be seen for a takeoff or taxi, if I am cleared onto a runway or taxiway, I should always exercise maximum caution wherever I am. The tower may not have been able to help them. In Anchorage, the tower could see China Airlines, yet they too made a gross error and departed on a taxi way.
GLADIOLI, you seem to have much to say to others, but STILL waiting to hear about your misunderstanding of a 3 crew operation and your obvious malpractice of it in your days at SQ. You are obviously one of the confused who could not easily differentiate the subtleties between a 3 man (2 f/o's, 1 capt) and an augmented (2 capts, 1 f/o) crew operation. This explains your reaction, along with others, to the CAAS ruling. To me, and those in the know, it made LITTLE DIFFERENCE OPERATIONALLY.
hawkeye18
Thanks for the link.
What I was trying to say was that I have yet to see any discussions on the forums of what recommendations are identified by the authorities that stem from the investigation. Lacking this, the forums (not just PPrune) in general seem to be caught up in the blame game led by the press.
Thanks for the link.
What I was trying to say was that I have yet to see any discussions on the forums of what recommendations are identified by the authorities that stem from the investigation. Lacking this, the forums (not just PPrune) in general seem to be caught up in the blame game led by the press.
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Lets not hijack the one decent thread and turn it into a slanging match between all and sundry.The important thing here is what happened and why?Gladiator is entitled to mention what he perceives as flaws in the operating environment at SIA.I dont know whether he´s correct or not.I do know he wouldnt be the first to cast a shadow on the operating psyche in SIA.
The report avoids unveiling the "golden nugget" and instead opts for a mish-mash of comments and diatribe on several elements that make up the whole.Yes,an accident is usually the result of a chain of events but the "probable cause" theory is still the best way to go,in my opinion.What was the last chain in the link that made the accident inevitable?Turning on to the wrong runway is about as clear an error as you can get.This was the last chain in the link,and if the NTSB had been at the helm,you can bet your bottom dollar that this would have been their conclusion.I see their recommendations centre almost entirely on developing cockpit moving-map nav displays for ground operations.
The report avoids unveiling the "golden nugget" and instead opts for a mish-mash of comments and diatribe on several elements that make up the whole.Yes,an accident is usually the result of a chain of events but the "probable cause" theory is still the best way to go,in my opinion.What was the last chain in the link that made the accident inevitable?Turning on to the wrong runway is about as clear an error as you can get.This was the last chain in the link,and if the NTSB had been at the helm,you can bet your bottom dollar that this would have been their conclusion.I see their recommendations centre almost entirely on developing cockpit moving-map nav displays for ground operations.
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lomapaseo,
All the recommendations and actioned items by the various parties are all within the 2 links I've mentioned:
For your benefits, and those that are too lazy to search for them , I attached the shorter of the appendix from the Singapore side (ASC report is 508 pages!):
Appendix to Part 1
Singapore Ministry of Transport Investigation Team’s Submission Relating to Safety Actions and Safety Recommendations
SAFETY ACTIONS
1 CKS Airport
CKS Airport has advised that since the accident, the following actions have been taken:
a) Efforts have been initiated to set up safety inspection teams and self audit programmes.
b) Runway 05R was decommissioned with effect from 1 February 2001 and has since been reopened as a taxiway.
c) The take-off minima for Runway 05L has been changed to 350m Runway Visual Range (RVR).
d) The Airport Emergency Handling Procedures, Civil Aircraft Accident Handling procedures, and the Emergency Airport Rescue Procedures have been revised.
e) CKS Airport is expediting the installation of Surface Movement Radar (SMR) at the airport.
2 CAA Taiwan
CAA Taiwan has advised that the following actions have been taken since the accident:
a) A review of ICAO Annexes and documents has been carried out, and a mechanism has been set up for follow-up action.
b) Expatriate advisors on airport standards have recently been appointed.
3 Singapore Airlines
SIA has advised that the following actions have been taken since the accident to SQ006:
a) A new CRM training programme for pilots has been developed and implemented, which includes situational awareness and error management training as separate modules.
b) Human factors and accident prevention training for inclusion in the pilot command training programme is being planned by SIA Flight Crew Training Centre.
c) A risk assessment tool to enable crew to manage risk in their operations has been developed and is being evaluated.
d) Redesign of the female cabin crew’s footwear had been initiated in December 1999. New footwear has been introduced.
e) Checklists have been amended to require all crew in the cockpit to visually confirm the correct runway designation before commencing the take-off run.
f) The Flight Crew Operating Manual has been amended to formally require the pilot taxiing the aircraft to refer to signage and markings. It also requires the other pilot to confirm the correct taxi route is being used with reference to airport charts.
g) The Flight Crew Training Manual has been amended to formally document procedures, instructions and the training curriculum for ground operations in poor visibility conditions.
h) The Cross Wind Limitation Policy has been revised and the Flight Crew Operating Manual has been amended accordingly. The revision has a more conservative limit for ‘wet’ runway conditions.
i) An airport specific operational information gathering process has been implemented to provide additional information with regard to operational procedures and facilities specific to the airport not routinely included in Jeppesen route manuals.
j) Boeing’s GPS based “Take-off Runway Disagree Alerting Function” has been accepted by the company for installation on B777 and B747-400 aircraft.
k) An Electronic Moving Map system which provides a pictorial depiction of airport movement areas is being evaluated for installation in SIA aircraft.
l) The FAA Advisory Circular on Runway Safety (FAA AC 120-74) has been reviewed with the objective of identifying useful points for incorporation in the SIA low visibility operations, training and procedures.
4 CAAS
CAAS has advised that the following actions have been taken since the accident:
a) Singapore operators have been required to review their ‘before take-off’ checklists.
b) Singapore operators have been required to update their CRM training programmes in keeping with current industry best practice.
c) Singapore operators have been required to review the FAA Advisory Circular (AC120-74) to assess its suitability to enhance their low visibility operations, training programmes and procedures.
d) A proposal to amend the current regulations to require earlier CVR power-on and later power-off times has been submitted to the Ministry of Transport.
SAFETY RECOMMENDATIONS
1. CKS Airport should ensure that, whenever runways or taxiways are closed to aircraft operations, be it partially or fully, suitable barriers are provided at locations that would physically prevent aircraft from entering such closed movement areas. The relevant ICAO standards and recommended practices (SARPs) concerning runway/taxiway closure markings should be adhered to.
2. A formal mechanism among international airlines needs to be developed by means of which operators can actively seek out and exchange local ‘intelligence’ on potential safety hazards, and ensure that such information is made available to crews. SIA should initiate coordination with other major airlines to better utilise the present “informal” and “ad hoc” exchange of local knowledge regarding operational safety hazards at airports.
3. SIA should review its emergency safety training programme to determine whether it is possible, and practical, to incorporate more realism, and to inculcate more awareness of the potential difficulties flight and cabin crew may encounter in catastrophic aircraft emergencies.
4. CKS Airport should ensure that its Air Traffic Controllers adhere to their Standard Operating Procedures. In particular, when aircraft cannot be seen from the control tower, controllers should advise pilots of this situation, and that they should taxi with caution.
5. CKS Airport should set up an integrated safety management system, so that systematic safety reviews, hazard analyses, and risk assessments are undertaken before implementing any airside work or changes that could affect aircraft operations.
6. CAA Taiwan and CKS Airport management should establish a joint task force to review the US FAA National Blueprint for Runway Safety (details at: www.faa.gov/runwaysafety), and wherever appropriate, adopt the safety philosophy and operational recommendations of that programme, so as to improve operational safety.
7. CKS Airport should ensure that the contents of all NOTAMs and AIP Supplements pertaining to airfield work contain clear and current information on the actual status of the taxiways/runways, and the configuration of the markings, signage and lighting. This will also facilitate the issuance of supplementary information by airport chart providers.
8. CKS Airport should utilise frangible barriers to demarcate work areas on the airfield.
9. The aviation industry should establish a working group, involving the airport authorities, airlines, regulators, ICAO, Flight Safety Foundation, IFALPA, Airports Council International and the IATA Safety Committee to develop a system to objectively determine whether a runway is “wet” or “contaminated” due to the presence of water. At present, there is no objective method by means of which this can be determined.
10. CKS Airport should formulate a written Surface Movement Guidance and Control System (SMGCS) plan to ensure the safety of aircraft movements on the ground.
11. CKS Airport should clearly define the operational responsibilities and safety accountabilities of the departments involved in the airside operations of the airport, so as to ensure that timely implementation of safety measures and improvements are not delayed due to ambiguities in areas of responsibility.
12. CAA Taiwan, in cooperation with the ASC, should establish and promote a more effective air safety incident reporting programme as part of an overall integrated safety management system. Such an incident reporting programme would provide a wide range of safety information, including data on airport safety issues.
13. CKS Airport should review its ARFF procedures to ensure that its personnel are able to carry out rescue operations inside aircraft using breathing apparatus.
14. ASC should coordinate with the relevant authorities to ensure that autopsies of all aircraft accident fatalities are performed to determine the survivability aspects of the accident.
15. ASC should ensure that blood toxicology tests are carried out on all relevant personnel such as pilots, air traffic controllers and apron controllers immediately after an accident.
16. ICAO should establish a study group to investigate the parameters affecting the functionality of aircraft escape slides in high wind conditions, with a view to determining a revised basis for the certification of these slides.
17. Aircraft manufacturers should review the design of public address systems so that these systems can continue to function largely independently of airframe or engine system condition in the event of an accident.
All the recommendations and actioned items by the various parties are all within the 2 links I've mentioned:
For your benefits, and those that are too lazy to search for them , I attached the shorter of the appendix from the Singapore side (ASC report is 508 pages!):
Appendix to Part 1
Singapore Ministry of Transport Investigation Team’s Submission Relating to Safety Actions and Safety Recommendations
SAFETY ACTIONS
1 CKS Airport
CKS Airport has advised that since the accident, the following actions have been taken:
a) Efforts have been initiated to set up safety inspection teams and self audit programmes.
b) Runway 05R was decommissioned with effect from 1 February 2001 and has since been reopened as a taxiway.
c) The take-off minima for Runway 05L has been changed to 350m Runway Visual Range (RVR).
d) The Airport Emergency Handling Procedures, Civil Aircraft Accident Handling procedures, and the Emergency Airport Rescue Procedures have been revised.
e) CKS Airport is expediting the installation of Surface Movement Radar (SMR) at the airport.
2 CAA Taiwan
CAA Taiwan has advised that the following actions have been taken since the accident:
a) A review of ICAO Annexes and documents has been carried out, and a mechanism has been set up for follow-up action.
b) Expatriate advisors on airport standards have recently been appointed.
3 Singapore Airlines
SIA has advised that the following actions have been taken since the accident to SQ006:
a) A new CRM training programme for pilots has been developed and implemented, which includes situational awareness and error management training as separate modules.
b) Human factors and accident prevention training for inclusion in the pilot command training programme is being planned by SIA Flight Crew Training Centre.
c) A risk assessment tool to enable crew to manage risk in their operations has been developed and is being evaluated.
d) Redesign of the female cabin crew’s footwear had been initiated in December 1999. New footwear has been introduced.
e) Checklists have been amended to require all crew in the cockpit to visually confirm the correct runway designation before commencing the take-off run.
f) The Flight Crew Operating Manual has been amended to formally require the pilot taxiing the aircraft to refer to signage and markings. It also requires the other pilot to confirm the correct taxi route is being used with reference to airport charts.
g) The Flight Crew Training Manual has been amended to formally document procedures, instructions and the training curriculum for ground operations in poor visibility conditions.
h) The Cross Wind Limitation Policy has been revised and the Flight Crew Operating Manual has been amended accordingly. The revision has a more conservative limit for ‘wet’ runway conditions.
i) An airport specific operational information gathering process has been implemented to provide additional information with regard to operational procedures and facilities specific to the airport not routinely included in Jeppesen route manuals.
j) Boeing’s GPS based “Take-off Runway Disagree Alerting Function” has been accepted by the company for installation on B777 and B747-400 aircraft.
k) An Electronic Moving Map system which provides a pictorial depiction of airport movement areas is being evaluated for installation in SIA aircraft.
l) The FAA Advisory Circular on Runway Safety (FAA AC 120-74) has been reviewed with the objective of identifying useful points for incorporation in the SIA low visibility operations, training and procedures.
4 CAAS
CAAS has advised that the following actions have been taken since the accident:
a) Singapore operators have been required to review their ‘before take-off’ checklists.
b) Singapore operators have been required to update their CRM training programmes in keeping with current industry best practice.
c) Singapore operators have been required to review the FAA Advisory Circular (AC120-74) to assess its suitability to enhance their low visibility operations, training programmes and procedures.
d) A proposal to amend the current regulations to require earlier CVR power-on and later power-off times has been submitted to the Ministry of Transport.
SAFETY RECOMMENDATIONS
1. CKS Airport should ensure that, whenever runways or taxiways are closed to aircraft operations, be it partially or fully, suitable barriers are provided at locations that would physically prevent aircraft from entering such closed movement areas. The relevant ICAO standards and recommended practices (SARPs) concerning runway/taxiway closure markings should be adhered to.
2. A formal mechanism among international airlines needs to be developed by means of which operators can actively seek out and exchange local ‘intelligence’ on potential safety hazards, and ensure that such information is made available to crews. SIA should initiate coordination with other major airlines to better utilise the present “informal” and “ad hoc” exchange of local knowledge regarding operational safety hazards at airports.
3. SIA should review its emergency safety training programme to determine whether it is possible, and practical, to incorporate more realism, and to inculcate more awareness of the potential difficulties flight and cabin crew may encounter in catastrophic aircraft emergencies.
4. CKS Airport should ensure that its Air Traffic Controllers adhere to their Standard Operating Procedures. In particular, when aircraft cannot be seen from the control tower, controllers should advise pilots of this situation, and that they should taxi with caution.
5. CKS Airport should set up an integrated safety management system, so that systematic safety reviews, hazard analyses, and risk assessments are undertaken before implementing any airside work or changes that could affect aircraft operations.
6. CAA Taiwan and CKS Airport management should establish a joint task force to review the US FAA National Blueprint for Runway Safety (details at: www.faa.gov/runwaysafety), and wherever appropriate, adopt the safety philosophy and operational recommendations of that programme, so as to improve operational safety.
7. CKS Airport should ensure that the contents of all NOTAMs and AIP Supplements pertaining to airfield work contain clear and current information on the actual status of the taxiways/runways, and the configuration of the markings, signage and lighting. This will also facilitate the issuance of supplementary information by airport chart providers.
8. CKS Airport should utilise frangible barriers to demarcate work areas on the airfield.
9. The aviation industry should establish a working group, involving the airport authorities, airlines, regulators, ICAO, Flight Safety Foundation, IFALPA, Airports Council International and the IATA Safety Committee to develop a system to objectively determine whether a runway is “wet” or “contaminated” due to the presence of water. At present, there is no objective method by means of which this can be determined.
10. CKS Airport should formulate a written Surface Movement Guidance and Control System (SMGCS) plan to ensure the safety of aircraft movements on the ground.
11. CKS Airport should clearly define the operational responsibilities and safety accountabilities of the departments involved in the airside operations of the airport, so as to ensure that timely implementation of safety measures and improvements are not delayed due to ambiguities in areas of responsibility.
12. CAA Taiwan, in cooperation with the ASC, should establish and promote a more effective air safety incident reporting programme as part of an overall integrated safety management system. Such an incident reporting programme would provide a wide range of safety information, including data on airport safety issues.
13. CKS Airport should review its ARFF procedures to ensure that its personnel are able to carry out rescue operations inside aircraft using breathing apparatus.
14. ASC should coordinate with the relevant authorities to ensure that autopsies of all aircraft accident fatalities are performed to determine the survivability aspects of the accident.
15. ASC should ensure that blood toxicology tests are carried out on all relevant personnel such as pilots, air traffic controllers and apron controllers immediately after an accident.
16. ICAO should establish a study group to investigate the parameters affecting the functionality of aircraft escape slides in high wind conditions, with a view to determining a revised basis for the certification of these slides.
17. Aircraft manufacturers should review the design of public address systems so that these systems can continue to function largely independently of airframe or engine system condition in the event of an accident.
Last edited by hawkeye18; 6th May 2002 at 13:32.
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Hi In The Slot,
I totally agree with you on the point that at all times we must be extra cautious, especially on wet and rainy nites!
I am quite certain that ATC procedures require the Tower controller to positively indetified a departing aircraft either visually or electronically (Surface Movement Radar - SMR ) prior to issuing of takeoff clearance.
The reason I mentioned takeoff mimima with reference to a non SMR equipped airfield is to highlight the difficult position the Tower controller will face,... when visibilty deteriorated below his maximum visual range but it is still within takeoff minima for departing aircraft.
When this occurs, like on the nite of SQ006, it effectively took the Tower controller out of the safety loop as he could not possibily see beyound the prevailing airfield visibility ., and in effect he was giving takeoff clearance "blind" ...... the only information/ feedback will be from the aircraft( pilot) which he is supposed to direct/control!!.
The same predicament will be face by the ground controller using good old "MK I eyeballs" in providing surface movement control.
So my point is :
Takeoff minima established for a non-SMR equipped Airports must be in touch with reality....... the limit of the human eyes , both pilots and controllers.
Dun expect the controller to have better eyesight then aircrew and be able to see thru rain and clouds!
Cheers!
Hawkeye
I totally agree with you on the point that at all times we must be extra cautious, especially on wet and rainy nites!
I am quite certain that ATC procedures require the Tower controller to positively indetified a departing aircraft either visually or electronically (Surface Movement Radar - SMR ) prior to issuing of takeoff clearance.
The reason I mentioned takeoff mimima with reference to a non SMR equipped airfield is to highlight the difficult position the Tower controller will face,... when visibilty deteriorated below his maximum visual range but it is still within takeoff minima for departing aircraft.
When this occurs, like on the nite of SQ006, it effectively took the Tower controller out of the safety loop as he could not possibily see beyound the prevailing airfield visibility ., and in effect he was giving takeoff clearance "blind" ...... the only information/ feedback will be from the aircraft( pilot) which he is supposed to direct/control!!.
The same predicament will be face by the ground controller using good old "MK I eyeballs" in providing surface movement control.
So my point is :
Takeoff minima established for a non-SMR equipped Airports must be in touch with reality....... the limit of the human eyes , both pilots and controllers.
Dun expect the controller to have better eyesight then aircrew and be able to see thru rain and clouds!
Cheers!
Hawkeye
Last edited by hawkeye18; 6th May 2002 at 15:51.
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You can twist the story back and forth, say the dates are not relevant, etc.
The 3-pilot crew operation of SIA was flawed from day one. Make no mistake that I have a very comprehensive understanding of how it was conducted. In this regard I also have very good understanding of the ICAO safety requirements and how SIA goofed in reflecting them in their FAM (even though my spelling and grammer sucks).
The Captain going to the toilet is not an issue at all. Now you are giving yourself selective memory when it comes into the dark silent don't tell operations of SIA leaked by a whistleblower.
If you are real, and I presume you are, you know very well how the 3-pilot crew operations were conducted. At every fleet meeting the issue came up over and over again with the same result. One big grey area (intended to be so).
On line 99% of the time the captain of the 3-pilot operation ended in the bunkroom sleeping (without proper oxygen equipment), leaving two improperly licensed and trained first officers at the controls.
I suppose the next thing you want to say is that this never happened (then you will sound like SIA's lawyers).
Proper 3-pilot operations as intended by the design of the B747-400 (the crew bunk oxygen system) would assume that the relief first officer occupying the left hand seat is, a) properly licensed (regulatory requirement), and b) left seat trained (safety requirement).
Outside these parameters the left hand seat can be unattended for a period of time necessary for physiological needs (toilet) only.
SIA and your understanding is/was that if the Captain can go to the toilet and leave his duty station unoccupied, why can't he be gone for 3.5 hrs sleep in the bunkroom. Ken T of CAAS in front of an FAA representative tried to defend CAAS and SIA by saying that the Captain can be gone for 3.5 hrs (sleep in the bunkroom), since sleep is a physiological need. That would be OK if you leave a qualified crewmember in the left hand seat duty station (a first officer without left hand seat training and certainly without an ATPL does not qualify).
We can argue about this all day. One thing remains fact, CAAS did cover their backside and informed SIA that this practice is no longer allowed as well as finally taking the ATPL issue seriously (in a different notice).
Of course none of this would have happened, if this matter was not brought to the attention of ICAO, FAA and NTSB. SQ006 doesn't help as it had/has the potential to become a legal mine field.
May I suggest you read SIA's FAM (Flight operations Manual) previous to SQ006 with full attention in regards to 3-pilot crew operations and realize the flaws and inadequate attention to the ultimate goal, safety.
If you need the page numbers, let me know.
As for SQ006 cause of the accident discussion, etc, yes the swiss cheese is real and TPE airport markings may be one of the slices. However many flight crews that day looked out of the window of their hotel room and decided not to go.
The 3-pilot crew operation of SIA was flawed from day one. Make no mistake that I have a very comprehensive understanding of how it was conducted. In this regard I also have very good understanding of the ICAO safety requirements and how SIA goofed in reflecting them in their FAM (even though my spelling and grammer sucks).
The Captain going to the toilet is not an issue at all. Now you are giving yourself selective memory when it comes into the dark silent don't tell operations of SIA leaked by a whistleblower.
If you are real, and I presume you are, you know very well how the 3-pilot crew operations were conducted. At every fleet meeting the issue came up over and over again with the same result. One big grey area (intended to be so).
On line 99% of the time the captain of the 3-pilot operation ended in the bunkroom sleeping (without proper oxygen equipment), leaving two improperly licensed and trained first officers at the controls.
I suppose the next thing you want to say is that this never happened (then you will sound like SIA's lawyers).
Proper 3-pilot operations as intended by the design of the B747-400 (the crew bunk oxygen system) would assume that the relief first officer occupying the left hand seat is, a) properly licensed (regulatory requirement), and b) left seat trained (safety requirement).
Outside these parameters the left hand seat can be unattended for a period of time necessary for physiological needs (toilet) only.
SIA and your understanding is/was that if the Captain can go to the toilet and leave his duty station unoccupied, why can't he be gone for 3.5 hrs sleep in the bunkroom. Ken T of CAAS in front of an FAA representative tried to defend CAAS and SIA by saying that the Captain can be gone for 3.5 hrs (sleep in the bunkroom), since sleep is a physiological need. That would be OK if you leave a qualified crewmember in the left hand seat duty station (a first officer without left hand seat training and certainly without an ATPL does not qualify).
We can argue about this all day. One thing remains fact, CAAS did cover their backside and informed SIA that this practice is no longer allowed as well as finally taking the ATPL issue seriously (in a different notice).
Of course none of this would have happened, if this matter was not brought to the attention of ICAO, FAA and NTSB. SQ006 doesn't help as it had/has the potential to become a legal mine field.
May I suggest you read SIA's FAM (Flight operations Manual) previous to SQ006 with full attention in regards to 3-pilot crew operations and realize the flaws and inadequate attention to the ultimate goal, safety.
If you need the page numbers, let me know.
As for SQ006 cause of the accident discussion, etc, yes the swiss cheese is real and TPE airport markings may be one of the slices. However many flight crews that day looked out of the window of their hotel room and decided not to go.
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Straits Times latest
Taiwan will let SQ 006 pilots go after interview
Taiwanese prosecutors say trio will not be indicted immediately after May 8 session; pilots to consult lawyer first
By GOH SUI NOI IN TAIPEI
AND DOMINIC NATHAN IN SINGAPORE
THE pilots involved in the Singapore Airlines SQ 006 crash will be free to leave Taiwan after their interview next week, Taiwanese prosecutors said yesterday.
Representatives for the pilots welcomed this but said that the trio - Captain Foong Chee Kong, and first officers Latiff Cyrano and Ng Kheng Leng - will meet their lawyer from Taiwan, who is flying down this weekend, before deciding if they will return for the interview.
Air Line Pilots Association Singapore vice-president (industrial affairs) Francis John said: 'The pilots would certainly be more favourable about returning with such an assurance, but they cannot decide based on media reports and will want to hear from their lawyer first.'
The next move of both the Taiwanese prosecutors and the pilots has become the focus of attention since the release of two conflicting investigation reports last week into the crash that killed 83 people on Oct 31, 2000.
Taiwan's Aviation Safety Council pinned the blame for the crash mainly on the pilots.
In its own investigation, a Singapore Transport Ministry team found that the crash was the result of a combination of many contributory factors, including deficiencies at Chiang Kai-shek airport.
After the reports were released, Taiwan's prosecutors summoned the three pilots to appear at a hearing in Taipei next Wednesday, fuelling speculation that the pilots may be detained right after their testimony.
The pilots, as well as airport personnel, are under investigation for possible professional negligence, which carries a jail sentence of not more than five years.
Yesterday, Mr Chiang Kuei-chang, spokesman for the Taoyuan prosecutors' office that is handling the case, said: 'The pilots will not be indicted immediately after the questioning and will be free to leave Taiwan after the session.'
Any decision to indict would be made about a fortnight after the May 8 interview, once prosecutors have completed their investigation and ascertained that their information was reliable, he added.
This would include interviews with airport personnel as well as contractors responsible for repairs on the partially closed runway that the pilots had tried to take off from.
The prosecutors will also refer to the factual portion of the recently released investigation report, which was the result of an 18-month probe by aviation experts.
Mr Chiang explained that the interview was to supplement information that had been gathered so far.
The pilots had attended a similar session in 2000, when they had been banned from leaving the island for about seven weeks after the crash.
'Since then, new questions have cropped up and new findings made,' he said.
'The session will also give the pilots a chance to make a full reply to queries and to state their views, which is their right,' he added.
This formal interview is part of the investigation process and no judge will be present. It is conducted by prosecutors and the pilots' lawyer will be present and will be allowed to speak for them.
The pilots' lawyer in Taipei, Mr Daniel Song, who has represented them since the crash, confirmed that he was preparing the logistics for the interview, including arranging for an interpreter for the pilots.
Taiwan will let SQ 006 pilots go after interview
Taiwanese prosecutors say trio will not be indicted immediately after May 8 session; pilots to consult lawyer first
By GOH SUI NOI IN TAIPEI
AND DOMINIC NATHAN IN SINGAPORE
THE pilots involved in the Singapore Airlines SQ 006 crash will be free to leave Taiwan after their interview next week, Taiwanese prosecutors said yesterday.
Representatives for the pilots welcomed this but said that the trio - Captain Foong Chee Kong, and first officers Latiff Cyrano and Ng Kheng Leng - will meet their lawyer from Taiwan, who is flying down this weekend, before deciding if they will return for the interview.
Air Line Pilots Association Singapore vice-president (industrial affairs) Francis John said: 'The pilots would certainly be more favourable about returning with such an assurance, but they cannot decide based on media reports and will want to hear from their lawyer first.'
The next move of both the Taiwanese prosecutors and the pilots has become the focus of attention since the release of two conflicting investigation reports last week into the crash that killed 83 people on Oct 31, 2000.
Taiwan's Aviation Safety Council pinned the blame for the crash mainly on the pilots.
In its own investigation, a Singapore Transport Ministry team found that the crash was the result of a combination of many contributory factors, including deficiencies at Chiang Kai-shek airport.
After the reports were released, Taiwan's prosecutors summoned the three pilots to appear at a hearing in Taipei next Wednesday, fuelling speculation that the pilots may be detained right after their testimony.
The pilots, as well as airport personnel, are under investigation for possible professional negligence, which carries a jail sentence of not more than five years.
Yesterday, Mr Chiang Kuei-chang, spokesman for the Taoyuan prosecutors' office that is handling the case, said: 'The pilots will not be indicted immediately after the questioning and will be free to leave Taiwan after the session.'
Any decision to indict would be made about a fortnight after the May 8 interview, once prosecutors have completed their investigation and ascertained that their information was reliable, he added.
This would include interviews with airport personnel as well as contractors responsible for repairs on the partially closed runway that the pilots had tried to take off from.
The prosecutors will also refer to the factual portion of the recently released investigation report, which was the result of an 18-month probe by aviation experts.
Mr Chiang explained that the interview was to supplement information that had been gathered so far.
The pilots had attended a similar session in 2000, when they had been banned from leaving the island for about seven weeks after the crash.
'Since then, new questions have cropped up and new findings made,' he said.
'The session will also give the pilots a chance to make a full reply to queries and to state their views, which is their right,' he added.
This formal interview is part of the investigation process and no judge will be present. It is conducted by prosecutors and the pilots' lawyer will be present and will be allowed to speak for them.
The pilots' lawyer in Taipei, Mr Daniel Song, who has represented them since the crash, confirmed that he was preparing the logistics for the interview, including arranging for an interpreter for the pilots.
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Gladdy
Well I think I'm real. Saw a reflection in front of the mirror today, so I must be!!!! Won't insult the other readers by going off the subject again.
I wonder how much more the courts expect to glean from the pilots' testomonies next week, considering it is 18 months after the event, and in the 7 weeks right after the crash, there seemed to be confusion about certain facts. Are they expecting that this uncertainty will suggest incompetence and therefore negligence. I hope not.
Well I think I'm real. Saw a reflection in front of the mirror today, so I must be!!!! Won't insult the other readers by going off the subject again.
I wonder how much more the courts expect to glean from the pilots' testomonies next week, considering it is 18 months after the event, and in the 7 weeks right after the crash, there seemed to be confusion about certain facts. Are they expecting that this uncertainty will suggest incompetence and therefore negligence. I hope not.
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Incompetence or negligence. My opinion only.
Crew incompetence, NO (even though SIA's operations did not meet ICAO minimum safety standards, inadequate CRM).
Negligence, possible but not the pilots. The negligence lies with the SIA management and the culture they cultivated through the years (money first, safety last), therefore the Captain's decision was the direct result of operational culture.
Where I work, for the purpose of safety, the Captain and or the first officer can simply say, NO GO. There will be no fear of getting fired, promotions destroyed for life, contracts not renewed, called to see the boss for an A55 chewing, or even ask why no go.
I started my original post by being fair and did particularly mention that SIA is making an honest effort to better themselves. This comes from the inside. So there is hope, however it is important to face reality.
Drop the 'LOSS OF FACE' and 'SAKKA' factor and get on with the business of airline pilotting. You cannot apply Lee Kuan Yew's economic secret of 'anxiety increases productivity'(quote) and apply it to the business of airline pilots.
To come back to the original discussion of SIA B747-400 operations not having met the ICAO minimum safety standards at least up to the date of SQ006 accident, I managed to dig through PPRuNe archives.
Posted December 7, 2000, Far East forum
The problem with SIA 3-pilot crew operation.
On long haul flights, B747-400, A-340, etc, it is normal and accepted practice for a carrier to use a pilot other than the Captain (pilot-in-command) as relief for the Captain during cruise only. However, common sense dictates that the relief pilot MUST meet pilot-in-command qualifications. The qualifications are not limited to the number of stipes or the rank of Captain; it is based on two criteria.
First, the relief pilot must meet the license requirement as pilot-in-command. This is a non-ambiguous clear-cut area; the relief pilot must hold an ATPL (frozen ATPL does not qualify).
Second, the relief pilot MUST receive training from the pilot-in-command duty station, the LHS. The training must include unusual attitude training as well as non-normal and emergency procedures.
In regards to long haul flights, the design of the Boeing B747-400 cockpit crew bunkroom was not intended for operation with only one qualified pilot-in-command. The reason is that the oxygen system in the crew bunkroom is the same as the passenger oxygen system. Therefore in the event of depressurization the crewmember in the bunkroom will be incapacitated and not considered fit to perform crewmember duties.
In regards to the B747-400 systems, the primary duty station is the LHS. Therefore, in certain non-normal situations (standby bus) both A/Ps as well as the RHS duty station instruments will be unusable. This situation would require the crewmember in the LHS duty station to manually fly the aircraft.
I would like to make reference to SIA’s own 1993 incident of the A-310 (yes, the famous Bay of Bengal acrobat) that lost control of the aircraft. If this were to happen with the pilot-in-command in the bunkroom, would the pilot-in-command be able to come out and exchange seats with the unqualified pilot in the LHS?The answer is a big NO.
In regards to relief pilot operations (3-pilot crew), SIA operated the largest B747-400 fleet in the world opposite the design philosophy of the aircraft thus seriously breaching passenger and cabin crew safety.
Passenger and cabin crew safety was breached when:1) SIA replaced the Captain (pilot-in-command) during Captain relief period, with a pilot only holding a CPL (commercial pilot license) as opposed to the required ATPL (Airline Transport Pilot License).
2) The pilots occupying the Captain (pilot-in-command) duty station, the LHS, received no training whatsoever in the LHS.
There is no possible explanation SIA, CAAS and ALPA-Singapore can give to explain why the above was allowed to continue for over 10 years.
The only explanation is that it was cheaper to replace a Captain during Captain relief period with a co-pilot. It was further cheaper to not train the co-pilot in the LHS.To make the argument stick SIA, CAAS and ALPA-Singapore came up with some unclear and muddy explanation of co-pilots trained to (Part1) the same standard as the Captain. The 3-pilot crew operation policy from day one was a conspiracy.
There was never a written policy in this regard. The only policy was a verbal policy that went something like this, “First, this time period is not ‘rest’ period, it is ‘relief’ period. Second, during this relief period the Captain will stay in the cockpit and seated in the observer’s seat".
In reality during this period the Captain would rest in the bunkroom (97% of the Captain would do this). This would be considered true rest/relief and the intended purpose of the cockpit crew bunkroom.
Please note below SIA’s only written policy in regards to 3-pilot crew operation,
FLIGHT ADMINISTRATION MANUAL, LINE OPERATIONS
Cockpit seats/A340 Crew Rest Facility Seats
Operating Crew
For take-off and landing, the required operating crew members of the minimum crew complement shall be in their assigned seats. In all other phases of flight, both pilot’s seats and, if applicable, the flight engineer’s seat must be manned by the operating crew except when:-
1. a crew member’s absence is necessary for the performance of duties in connection with the operation of the flight; or
2. a crew member’s absence is in connection with physiological needs.
In a 3-pilot crew operation, the third pilot may, at the Commander’s discretion, occupy either the left hand seat or the first observer’s seat during cruise, when the Commander is taking inflight relief. When the third pilot is in the left hand seat, the designated first officer must be in the right hand seat. In the event of an emergency, the third pilot, if he is in the left hand seat, shall be the pilot not flying. End.
Now please note the ALPA-Singapore policy,
Page 90.
Inflight relief and rest facilities on board –
(2) In the case of the “3-pilot” crew, the additional pilot allows in-flight relief from duty for each of the pilots. Rest facilities need not be provided for such a crew complement. End.
How do you like the last paragraph where it says, “need not be provided?”
In reality, the crew bunkroom is there, SIA replenishes the bed sheets, pillow covers, and blankets at every station, but hey, MUMS the word. Who is going to tell? No co-pilot in the right mind would tell, otherwise no promotion ever.
In the legal case Singapore Airlines vs. Gladiator (refer to PPRuNe search Singapore Airlines vs. Gladiator Parts 1, 2, and 3), SIA faced a big black hole.
SIA’s Flight Administration Manual not only was at best ambiguous in the 3-pilot crew policy, but the section; ‘Line Operations’ contradicted ‘Administration’,creating a legal mine field that left several SIA lawyers without legs.
Please note the following,
FLIGHT ADMINISTRATION MANUAL, LINE OPERATIONS
First Officer Route Flying
After taking all factors (such as airplane technical status, airport and environmental conditions, pilot experience, etc.) into consideration, a commander may at his absolute discretion permit First Officers to carry out route flying under his supervision, provided that the commander:-
1. occupies the left-hand seat during all phases of flight;
2. complies with the operations manual policy on the delegation of pilot-flying duties to the First Officer.
The Commander and First officer must ensure that the route flying is properly recorded in the Voyage Record, utilizing the appropriate codes, and in the flying log book. End.
Point number 1 contradicts the 3-pilot crew policy above when the First Officer is P1(U/S). It gets even worst on the last paragraph above where it states, “utilizing the appropriate codes” (logging of hours/Sectors).
Please note the following,
FLIGHT ADMINISTRATION MANUAL, ADMINISTRATION
Logging of Hours/Sectors
1. Commanders
P1 - when flying in command, under line check or when part of a 5-man crew.
P1(U/S) – when under training.
P2 – when flying as co-pilot2.
First Officers
P1(U/S) – when operating a sector under supervision.
P2 – when operating as a co-pilot in right hand seat or when operating as a Supervisory First Officer or when assisting the Training Captain who is in the right-hand seat checking or training a Captain in the left-hand seat.
P3 – when under training and occupying the jump seat with a Training Captain or Supervisory First Officer in the right-hand seat. End.
There are no codes or provisions to explain the capacity of a First Officer (co-pilot) occupying the Captain (pilot-in-command) duty station, the LHS.
In the case Singapore Airlines vs. Gladiator, the deficiencies in the SIA 3-pilot crew operation was presented as a counterclaim as follows:
“deny that the CPL license issued to XXX qualified him to: (a) act as a flight crewmember on the B747-400 aircraft in any capacity; (b) act as inflight relief for the pilot-in-command in the left pilot seat; and (c) be delegated responsibility for the operation and safety of the aircraft by performing the duties of Pilot-in-Command without supervision."
SIA repeatedly denied the defendants counterclaim as, “non-factual”.
These facts were brought to the attention of ICAO and FAA. Behind the curtain both organizations were outraged. In February 2000, at the request of Gladiator, FAA summoned CAAS to explain SIA’s operation in this regard. ICAO conducted an audit of CAAS in July/September 2000.
The bottom line is that in November 2000, CAAS, SIA and ALPA-Singapore finally stopped this 3-ring circus.
Crew incompetence, NO (even though SIA's operations did not meet ICAO minimum safety standards, inadequate CRM).
Negligence, possible but not the pilots. The negligence lies with the SIA management and the culture they cultivated through the years (money first, safety last), therefore the Captain's decision was the direct result of operational culture.
Where I work, for the purpose of safety, the Captain and or the first officer can simply say, NO GO. There will be no fear of getting fired, promotions destroyed for life, contracts not renewed, called to see the boss for an A55 chewing, or even ask why no go.
I started my original post by being fair and did particularly mention that SIA is making an honest effort to better themselves. This comes from the inside. So there is hope, however it is important to face reality.
Drop the 'LOSS OF FACE' and 'SAKKA' factor and get on with the business of airline pilotting. You cannot apply Lee Kuan Yew's economic secret of 'anxiety increases productivity'(quote) and apply it to the business of airline pilots.
To come back to the original discussion of SIA B747-400 operations not having met the ICAO minimum safety standards at least up to the date of SQ006 accident, I managed to dig through PPRuNe archives.
Posted December 7, 2000, Far East forum
The problem with SIA 3-pilot crew operation.
On long haul flights, B747-400, A-340, etc, it is normal and accepted practice for a carrier to use a pilot other than the Captain (pilot-in-command) as relief for the Captain during cruise only. However, common sense dictates that the relief pilot MUST meet pilot-in-command qualifications. The qualifications are not limited to the number of stipes or the rank of Captain; it is based on two criteria.
First, the relief pilot must meet the license requirement as pilot-in-command. This is a non-ambiguous clear-cut area; the relief pilot must hold an ATPL (frozen ATPL does not qualify).
Second, the relief pilot MUST receive training from the pilot-in-command duty station, the LHS. The training must include unusual attitude training as well as non-normal and emergency procedures.
In regards to long haul flights, the design of the Boeing B747-400 cockpit crew bunkroom was not intended for operation with only one qualified pilot-in-command. The reason is that the oxygen system in the crew bunkroom is the same as the passenger oxygen system. Therefore in the event of depressurization the crewmember in the bunkroom will be incapacitated and not considered fit to perform crewmember duties.
In regards to the B747-400 systems, the primary duty station is the LHS. Therefore, in certain non-normal situations (standby bus) both A/Ps as well as the RHS duty station instruments will be unusable. This situation would require the crewmember in the LHS duty station to manually fly the aircraft.
I would like to make reference to SIA’s own 1993 incident of the A-310 (yes, the famous Bay of Bengal acrobat) that lost control of the aircraft. If this were to happen with the pilot-in-command in the bunkroom, would the pilot-in-command be able to come out and exchange seats with the unqualified pilot in the LHS?The answer is a big NO.
In regards to relief pilot operations (3-pilot crew), SIA operated the largest B747-400 fleet in the world opposite the design philosophy of the aircraft thus seriously breaching passenger and cabin crew safety.
Passenger and cabin crew safety was breached when:1) SIA replaced the Captain (pilot-in-command) during Captain relief period, with a pilot only holding a CPL (commercial pilot license) as opposed to the required ATPL (Airline Transport Pilot License).
2) The pilots occupying the Captain (pilot-in-command) duty station, the LHS, received no training whatsoever in the LHS.
There is no possible explanation SIA, CAAS and ALPA-Singapore can give to explain why the above was allowed to continue for over 10 years.
The only explanation is that it was cheaper to replace a Captain during Captain relief period with a co-pilot. It was further cheaper to not train the co-pilot in the LHS.To make the argument stick SIA, CAAS and ALPA-Singapore came up with some unclear and muddy explanation of co-pilots trained to (Part1) the same standard as the Captain. The 3-pilot crew operation policy from day one was a conspiracy.
There was never a written policy in this regard. The only policy was a verbal policy that went something like this, “First, this time period is not ‘rest’ period, it is ‘relief’ period. Second, during this relief period the Captain will stay in the cockpit and seated in the observer’s seat".
In reality during this period the Captain would rest in the bunkroom (97% of the Captain would do this). This would be considered true rest/relief and the intended purpose of the cockpit crew bunkroom.
Please note below SIA’s only written policy in regards to 3-pilot crew operation,
FLIGHT ADMINISTRATION MANUAL, LINE OPERATIONS
Cockpit seats/A340 Crew Rest Facility Seats
Operating Crew
For take-off and landing, the required operating crew members of the minimum crew complement shall be in their assigned seats. In all other phases of flight, both pilot’s seats and, if applicable, the flight engineer’s seat must be manned by the operating crew except when:-
1. a crew member’s absence is necessary for the performance of duties in connection with the operation of the flight; or
2. a crew member’s absence is in connection with physiological needs.
In a 3-pilot crew operation, the third pilot may, at the Commander’s discretion, occupy either the left hand seat or the first observer’s seat during cruise, when the Commander is taking inflight relief. When the third pilot is in the left hand seat, the designated first officer must be in the right hand seat. In the event of an emergency, the third pilot, if he is in the left hand seat, shall be the pilot not flying. End.
Now please note the ALPA-Singapore policy,
Page 90.
Inflight relief and rest facilities on board –
(2) In the case of the “3-pilot” crew, the additional pilot allows in-flight relief from duty for each of the pilots. Rest facilities need not be provided for such a crew complement. End.
How do you like the last paragraph where it says, “need not be provided?”
In reality, the crew bunkroom is there, SIA replenishes the bed sheets, pillow covers, and blankets at every station, but hey, MUMS the word. Who is going to tell? No co-pilot in the right mind would tell, otherwise no promotion ever.
In the legal case Singapore Airlines vs. Gladiator (refer to PPRuNe search Singapore Airlines vs. Gladiator Parts 1, 2, and 3), SIA faced a big black hole.
SIA’s Flight Administration Manual not only was at best ambiguous in the 3-pilot crew policy, but the section; ‘Line Operations’ contradicted ‘Administration’,creating a legal mine field that left several SIA lawyers without legs.
Please note the following,
FLIGHT ADMINISTRATION MANUAL, LINE OPERATIONS
First Officer Route Flying
After taking all factors (such as airplane technical status, airport and environmental conditions, pilot experience, etc.) into consideration, a commander may at his absolute discretion permit First Officers to carry out route flying under his supervision, provided that the commander:-
1. occupies the left-hand seat during all phases of flight;
2. complies with the operations manual policy on the delegation of pilot-flying duties to the First Officer.
The Commander and First officer must ensure that the route flying is properly recorded in the Voyage Record, utilizing the appropriate codes, and in the flying log book. End.
Point number 1 contradicts the 3-pilot crew policy above when the First Officer is P1(U/S). It gets even worst on the last paragraph above where it states, “utilizing the appropriate codes” (logging of hours/Sectors).
Please note the following,
FLIGHT ADMINISTRATION MANUAL, ADMINISTRATION
Logging of Hours/Sectors
1. Commanders
P1 - when flying in command, under line check or when part of a 5-man crew.
P1(U/S) – when under training.
P2 – when flying as co-pilot2.
First Officers
P1(U/S) – when operating a sector under supervision.
P2 – when operating as a co-pilot in right hand seat or when operating as a Supervisory First Officer or when assisting the Training Captain who is in the right-hand seat checking or training a Captain in the left-hand seat.
P3 – when under training and occupying the jump seat with a Training Captain or Supervisory First Officer in the right-hand seat. End.
There are no codes or provisions to explain the capacity of a First Officer (co-pilot) occupying the Captain (pilot-in-command) duty station, the LHS.
In the case Singapore Airlines vs. Gladiator, the deficiencies in the SIA 3-pilot crew operation was presented as a counterclaim as follows:
“deny that the CPL license issued to XXX qualified him to: (a) act as a flight crewmember on the B747-400 aircraft in any capacity; (b) act as inflight relief for the pilot-in-command in the left pilot seat; and (c) be delegated responsibility for the operation and safety of the aircraft by performing the duties of Pilot-in-Command without supervision."
SIA repeatedly denied the defendants counterclaim as, “non-factual”.
These facts were brought to the attention of ICAO and FAA. Behind the curtain both organizations were outraged. In February 2000, at the request of Gladiator, FAA summoned CAAS to explain SIA’s operation in this regard. ICAO conducted an audit of CAAS in July/September 2000.
The bottom line is that in November 2000, CAAS, SIA and ALPA-Singapore finally stopped this 3-ring circus.
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A couple of years ago Insider 107 produced "SQ006 revisited", one of the finest threads ever on PPrune, at least from a flight safety standpoint.
His position was that SIA culture was a major contributing factor in the way events unfolded that evening. Some of us were unconvinced at first but must admit that Insider 107 proved his point in a very thoughtful and brilliant way.
It would be interesting to know other SIA insiders opinion and whether SQ culture has changed in any direction as a result of that accident.
His position was that SIA culture was a major contributing factor in the way events unfolded that evening. Some of us were unconvinced at first but must admit that Insider 107 proved his point in a very thoughtful and brilliant way.
It would be interesting to know other SIA insiders opinion and whether SQ culture has changed in any direction as a result of that accident.
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Having been there and done it I don't think culture had very much at all to do with the demise of SQ6.
I can think of a number of possibilities that might have been seen to incur the wrath of the fourth floor and thus produce pressure on the crew but none of those possibilities pertain to the crash of SQ6.
The locals have a very healthy respect for typhoons and since some other operators had already cancelled this captain, who had reached his zenith as a B744 commander and was not destined to go much further, had little to fear, so no culture issue there either. An error of judgement and an error of skill, or so it would seem, could have happened to anyone of any nationality and any airline, but how easy it all is with 20/20 hindsight.
I can think of a number of possibilities that might have been seen to incur the wrath of the fourth floor and thus produce pressure on the crew but none of those possibilities pertain to the crash of SQ6.
The locals have a very healthy respect for typhoons and since some other operators had already cancelled this captain, who had reached his zenith as a B744 commander and was not destined to go much further, had little to fear, so no culture issue there either. An error of judgement and an error of skill, or so it would seem, could have happened to anyone of any nationality and any airline, but how easy it all is with 20/20 hindsight.
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G.Khan You really are an apologist for SIA are you not. Would you by chance be related to the Ostrich with your head firmly in the sand and therefore blind to all things around you.
I cannot agree with your suggestion that all the bad facts about SIA are coming from disgruntled ex F/O who skipped bail.
As we inSIA all know these guys were all totally deceived by SIA who hid behind pages of small print in their contracts which any lawyer would say was totally one sided and they {SIA} took advantage of their predicament. When these young people arrived in SIA some spent a whole year in office work before which did not count for their bonds and when those on the B747-300 when it was phased out found that their bonds on that aircraft continued to run and new bonds on their next aicraft did not start until the end of the other one even though the aircraft was no longer in service. No wonder some of them decided enough was enough and did a runner after 5/6 years.
All F/O's in SIA National and expat {not that many of these are left} are treated absolutely apallingly by this company SIA, They have their leave cancelled at the last moment ,they get sent on leave without any warning when SIA don't require them, if they are on a type conversion I have seen some have been forced to take 2 days leave because SIA did not have a Sim slot for a few days.
I cannot agree with your suggestion that all the bad facts about SIA are coming from disgruntled ex F/O who skipped bail.
As we inSIA all know these guys were all totally deceived by SIA who hid behind pages of small print in their contracts which any lawyer would say was totally one sided and they {SIA} took advantage of their predicament. When these young people arrived in SIA some spent a whole year in office work before which did not count for their bonds and when those on the B747-300 when it was phased out found that their bonds on that aircraft continued to run and new bonds on their next aicraft did not start until the end of the other one even though the aircraft was no longer in service. No wonder some of them decided enough was enough and did a runner after 5/6 years.
All F/O's in SIA National and expat {not that many of these are left} are treated absolutely apallingly by this company SIA, They have their leave cancelled at the last moment ,they get sent on leave without any warning when SIA don't require them, if they are on a type conversion I have seen some have been forced to take 2 days leave because SIA did not have a Sim slot for a few days.
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I regret my recent absence from cyberspace during the period covering publication of the Taiwanese ASC Draft Final Report on the SQ006 disaster and the subsequent comment generated on this thread.
Further, I’ve spent a couple of days looking over its 508 pages which include the entirely predictable criticism by Singapore of the report and I agree with a number of other contributors that the ASC’s efforts have been most thorough and correctly apportion responsibility for the accident to the relevant involved parties.
In particular I would commend Murrelet for his posting of 3 May 2002 in which he summarises the ASC report and comments on the even-handedness of the ASC. It would serve us all well to carefully re-read his post.
I would similarly commend Gladiator for his dogged determination in consistently reaffirming the malign corporate mindset of Singapore Airlines and that of a wider Republic that views profit as the sole determinant of organizational worth, unexplained “merit” the trigger for individual pilot promotional “reward” and punishment for all involved when things go wrong. It is a mindset that I know remains largely in place, despite SQ006 and the subsequent panicky “house cleaning” measures implemented, and which I am convinced was a potent causal factor leading to the accident.
I applaud his recent tour de force, posted 7 May 2002, which irrefutably serves to demonstrate SQ’s breathtaking arrogance in its historic and opportunistic disdain of ICAO recommendations, the relevance of which to this thread, lies in its revelation of a culture of duplicity, coercion and fear. SQ’s come-uppance in the particular matter, at the hands of truthful, honorable and determined individual is cause for both satisfaction and relief that at least one risky area of operation had been eliminated. It is a corollary matter of contempt that SQ cynically cites other ICAO recommendations to castigate a fair report that, unbesmirched, would leave it poorly placed in subsequent ferocious civil litigation.
In passing, perhaps I may be permitted to hope that years of SQ Airbus 310 over-water operation, similarly spurning ICAO’s recommendations in respect of ETOPS and exacerbated by its refusal to observe the Organization’s mandatory requirement to inform both it and SQ’s code-share partners of such non-observation will not be mirrored by the ethos currently crystallizing in the B777 ETOPS fleet and to which I have drawn early-warning attention in past postings. I feel certain that ICAO and FAA will be carefully scrutinizing the proposed operation plus IFSD’s to date and taking the keenest interest in any surprise award of 180 minutes clearance by CAAS, just prior to start of B777 LAS and SFO flights.
Moving on, I’d like to mention a couple of points that seem to have slipped by the ASC.
1. The captain of SQ006 was a day short of statutory rest prior to operating the flight on the fateful day. The rostering girl responsible was subsequently dismissed from her post but what the heck, that’s how we fix problems round here!
2. The ASC seems to have found no evidence that a call had been made to the crew by SQ Ops, prior to leaving the hotel, suggesting an expeditious departure ex CKS might have been in order, before the typhoon struck. However, the rumour persists. Have the hotel telephone records been scrupulously checked and subpoenaed?
Back to the ASC findings which indicate causes as “pilot error” and adverse weather. I’m intrigued by Belgique’s posting of 1 May 2002, for the crucial question is “why did the crew turn onto the incorrect runway for take-off but thought they were on the correct one despite numerous visual clues to the contrary?” Does his hypothesis of syllogism partially explain the phenomenon?
To quote Belgique: <the dismissive mindset of:
”We are lined up for departure on the runway and cleared for take-off. What we are seeing out the front must be the runway. Therefore there is no safety problem nor cause for alarm or query.”
Ie. a simple failure to mentally register any inconsistency…. no alerting mechanisms present at all. Because the predominant concern is about darkness and weather and visibility, a perverse mechanism of reassurance is always tending to suppress any disquiet (the PVD….). That’s the sentient side of human nature. >
Could this, coupled with the desire to move quickly beyond the looming prospect of a highly risky, on time take-off in the middle of a typhoon, so as not to incur the wrath of a punitive organization, be the reason for the accident? I have alluded to this cause in the “SQ006 Revisited” thread and rather than repeat megabytes of stuff here, perhaps I could direct interested readers there.
To conclude. We all know that error is part of the human condition and that current CRM teaching correctly points to a need for its management rather than its punishment. So if I may take that as a “given”, may I ask one question?
How can we possibly hope for the much needed enhancement to SQ’s flight safety environment, when, despite all that has happened, all that has been investigated internally by outside consultants, all that has subsequently been recommended and after the time, trouble and expense expended in the formulation of a new “state of the art” CRM regime, the core feature of which is non-punitive error management, do we still have handed down from the very highest level, the ideology of punishment being the required solution to perceived transgression?
Comments please.
Further, I’ve spent a couple of days looking over its 508 pages which include the entirely predictable criticism by Singapore of the report and I agree with a number of other contributors that the ASC’s efforts have been most thorough and correctly apportion responsibility for the accident to the relevant involved parties.
In particular I would commend Murrelet for his posting of 3 May 2002 in which he summarises the ASC report and comments on the even-handedness of the ASC. It would serve us all well to carefully re-read his post.
I would similarly commend Gladiator for his dogged determination in consistently reaffirming the malign corporate mindset of Singapore Airlines and that of a wider Republic that views profit as the sole determinant of organizational worth, unexplained “merit” the trigger for individual pilot promotional “reward” and punishment for all involved when things go wrong. It is a mindset that I know remains largely in place, despite SQ006 and the subsequent panicky “house cleaning” measures implemented, and which I am convinced was a potent causal factor leading to the accident.
I applaud his recent tour de force, posted 7 May 2002, which irrefutably serves to demonstrate SQ’s breathtaking arrogance in its historic and opportunistic disdain of ICAO recommendations, the relevance of which to this thread, lies in its revelation of a culture of duplicity, coercion and fear. SQ’s come-uppance in the particular matter, at the hands of truthful, honorable and determined individual is cause for both satisfaction and relief that at least one risky area of operation had been eliminated. It is a corollary matter of contempt that SQ cynically cites other ICAO recommendations to castigate a fair report that, unbesmirched, would leave it poorly placed in subsequent ferocious civil litigation.
In passing, perhaps I may be permitted to hope that years of SQ Airbus 310 over-water operation, similarly spurning ICAO’s recommendations in respect of ETOPS and exacerbated by its refusal to observe the Organization’s mandatory requirement to inform both it and SQ’s code-share partners of such non-observation will not be mirrored by the ethos currently crystallizing in the B777 ETOPS fleet and to which I have drawn early-warning attention in past postings. I feel certain that ICAO and FAA will be carefully scrutinizing the proposed operation plus IFSD’s to date and taking the keenest interest in any surprise award of 180 minutes clearance by CAAS, just prior to start of B777 LAS and SFO flights.
Moving on, I’d like to mention a couple of points that seem to have slipped by the ASC.
1. The captain of SQ006 was a day short of statutory rest prior to operating the flight on the fateful day. The rostering girl responsible was subsequently dismissed from her post but what the heck, that’s how we fix problems round here!
2. The ASC seems to have found no evidence that a call had been made to the crew by SQ Ops, prior to leaving the hotel, suggesting an expeditious departure ex CKS might have been in order, before the typhoon struck. However, the rumour persists. Have the hotel telephone records been scrupulously checked and subpoenaed?
Back to the ASC findings which indicate causes as “pilot error” and adverse weather. I’m intrigued by Belgique’s posting of 1 May 2002, for the crucial question is “why did the crew turn onto the incorrect runway for take-off but thought they were on the correct one despite numerous visual clues to the contrary?” Does his hypothesis of syllogism partially explain the phenomenon?
To quote Belgique: <the dismissive mindset of:
”We are lined up for departure on the runway and cleared for take-off. What we are seeing out the front must be the runway. Therefore there is no safety problem nor cause for alarm or query.”
Ie. a simple failure to mentally register any inconsistency…. no alerting mechanisms present at all. Because the predominant concern is about darkness and weather and visibility, a perverse mechanism of reassurance is always tending to suppress any disquiet (the PVD….). That’s the sentient side of human nature. >
Could this, coupled with the desire to move quickly beyond the looming prospect of a highly risky, on time take-off in the middle of a typhoon, so as not to incur the wrath of a punitive organization, be the reason for the accident? I have alluded to this cause in the “SQ006 Revisited” thread and rather than repeat megabytes of stuff here, perhaps I could direct interested readers there.
To conclude. We all know that error is part of the human condition and that current CRM teaching correctly points to a need for its management rather than its punishment. So if I may take that as a “given”, may I ask one question?
How can we possibly hope for the much needed enhancement to SQ’s flight safety environment, when, despite all that has happened, all that has been investigated internally by outside consultants, all that has subsequently been recommended and after the time, trouble and expense expended in the formulation of a new “state of the art” CRM regime, the core feature of which is non-punitive error management, do we still have handed down from the very highest level, the ideology of punishment being the required solution to perceived transgression?
Comments please.