Jet goes down on its way to Medellin, Colombia
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Consider that the dispatcher pushing for acceptance of the flight plan boarded the flight! That must have been somewhat persuasive that he knew what he was doing when he filed the flight plan.
Sure, the numbers were wrong, but those are just numbers. Who really flight plans 4:22 with 4:22 fuel on board? What, they were planning on being towed off the runway? So the woman accepted the flight plan with this tell-tale mistake on it, when she should have made that fool dispatcher come back with one reading 3:52 and 4:22 instead, as I suppose he would have done.
The Swiss cheese model does not work when there's criminal negligence involved. If there's one guy not playing by the rules, then the system breaks down very easily.
Sure, the numbers were wrong, but those are just numbers. Who really flight plans 4:22 with 4:22 fuel on board? What, they were planning on being towed off the runway? So the woman accepted the flight plan with this tell-tale mistake on it, when she should have made that fool dispatcher come back with one reading 3:52 and 4:22 instead, as I suppose he would have done.
The Swiss cheese model does not work when there's criminal negligence involved. If there's one guy not playing by the rules, then the system breaks down very easily.
Roberto Curilovic, head of International programming at Corporación America, an Argentine conglomerate that operates 53 airports around the world, said “there’s no way that flight plan should have been approved.”
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Given what we've heard of the local authority gradient I find it impressive that a mere AIS clerk would take her objections as far as she did. We should be very very careful before blaming her for anything. If blame must be attached blame the authority for accepting the plan, not the poor clerk for merely filing it after being repeatedly belittled by the despatcher.
I can well believe that stringing up some minor player in the matter is important to protect those above from too much criticism but its a pretty shoddy way to treat the only person who seemed to object to it.
I can well believe that stringing up some minor player in the matter is important to protect those above from too much criticism but its a pretty shoddy way to treat the only person who seemed to object to it.
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Regarding Celia, this is disgusting but not surprising behaviour by Bolivia.
Ultimately it's the Captain (and Owner), who is responsible, the buck stops with him, and in such a Latin American country, dominated by "macho" culture, and fairly poor CRM, it's pretty obvious that she stood no chance in stopping this flight.
Who knows what was said, end of the day en-route the flight crew should have had enough SA to see that they was going below Final Reserve, gone to alternate refuelled or / and made a Mayday call prior to going into their final reserve.
Then again no surprise, easier to blame Celia who is on $300 a month, kind of makes you wonder with the article about the Captains bodies hero return in Bolivian news, ironic.
No doubt the Captain did not set out that day to end up dead, and nobody is saying his a bad person, but what he did on this day was criminal, it was a completely avoidable.
Ultimately it's the Captain (and Owner), who is responsible, the buck stops with him, and in such a Latin American country, dominated by "macho" culture, and fairly poor CRM, it's pretty obvious that she stood no chance in stopping this flight.
Who knows what was said, end of the day en-route the flight crew should have had enough SA to see that they was going below Final Reserve, gone to alternate refuelled or / and made a Mayday call prior to going into their final reserve.
Then again no surprise, easier to blame Celia who is on $300 a month, kind of makes you wonder with the article about the Captains bodies hero return in Bolivian news, ironic.
No doubt the Captain did not set out that day to end up dead, and nobody is saying his a bad person, but what he did on this day was criminal, it was a completely avoidable.
from AndyJS - You obviously haven't paid any attention to, for example, Geert Hofstede's work on Power Distance. South American countries have some of the highest ratings on this scale, just as high as many Asian countries. A high Power Distance rating basically means it's extremely difficult for subordinates to challenge the person in charge in any given situation.
Hofstede's data was prominently used by Malcolm Gladwell in his 2008 book "Outliers" to promote his "ethnic theory of plane crashes" which he summarises as "The single most important variable in determining whether a plane crashes is not the plane, it is the [national] culture the pilot comes from". He used 2 particular accidents to demonstrate this - Avianca B707 fuel exhaustion New York which has already been mentioned in some media as being like this accident, and Korean Air CFIT at Guam.
There are often generalisations on PPrune about accidents in particular parts of the world quoting specific pilot groups as susceptible to high Power-Distance index etc. and Hofstede is sometimes used to justify them, in order to show that some cultures are inherently less safe than others.
For example the useful reference AndyJS provides goes on to say "Subsequent studies validating the earlier results include such respondent groups as commercial airline pilots and students in 23 countries, civil service managers in 14 counties, 'up-market' consumers in 15 countries and 'elites' in 19 countries."
This implies you can take Hofstede's statements about a national culture as being applicable to all pilots from that country. The actual study of pilots PDI was by Ashleigh Merritt, a colleague of well known CRM expert Bob Helmreich. Gladwell specifically refers to it as justifying his "theory" but he seriously misreports it.
The study actually noted that many factors make commercial pilots DIFFERENT to the general populations studied by Hofstede. Merritt's paper validated that Hofstede's research methods could be applicable to pilots, but went on to show that the actual results for pilots could then be very different to the general populations.
So while many people think Hofstede says for example that all Korean pilots have high PDI and American pilots very low PDI, the research showed are actually very similar.
The four elements of Merritt's study are shown below. Ashleigh confirmed a few months ago that these graphs of her data are valid, and went on to say "Why Gladwell made that huge leap from a couple of accidents to his "theory" is beyond me."
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I feel for Celia but unfortunately it's a third world country that only knows how to dispense third world (rate) justice.
The authorities here will look for anyone still alive who could have broken the chain of events - irrespective of whether it was within the realms of their area of competence or authority.
The authorities here will look for anyone still alive who could have broken the chain of events - irrespective of whether it was within the realms of their area of competence or authority.
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Actually, that Avianca crash in New York was an example of something other than a steep authority gradient, if I remember the report correctly.
From Wikipedia:
The report references the 360° turn that the flight was ordered to make at 20:54 as evidence that the crew should have known that they were being treated routinely and not given any emergency priority. Instead, the CVR revealed that the flight crew was convinced that they were being given priority. Additionally, the NTSB criticized the first officer for failing to use the word "emergency" as the captain had insisted he do. Compounded with the apparent inability of the captain to hear or understand the radio communications, the NTSB called the situation a "total breakdown in communications by the flightcrew." Summarizing, the investigators cited "the flightcrew's failure to notify ATC of their fuel situation while holding at CAMRN in order to ensure arrival at the approach fix with an adequate approach minimum fuel level and a breakdown in communications between the flightcrew and ATC, and among the flight crewmembers" as the two main factors that led to the crash.
For some unknown reason the FO did not make a "Mayday" call as he had been ordered to by the Captain, so that this accident was not due to a steep authority gradient but something more the opposite.
From Wikipedia:
The report references the 360° turn that the flight was ordered to make at 20:54 as evidence that the crew should have known that they were being treated routinely and not given any emergency priority. Instead, the CVR revealed that the flight crew was convinced that they were being given priority. Additionally, the NTSB criticized the first officer for failing to use the word "emergency" as the captain had insisted he do. Compounded with the apparent inability of the captain to hear or understand the radio communications, the NTSB called the situation a "total breakdown in communications by the flightcrew." Summarizing, the investigators cited "the flightcrew's failure to notify ATC of their fuel situation while holding at CAMRN in order to ensure arrival at the approach fix with an adequate approach minimum fuel level and a breakdown in communications between the flightcrew and ATC, and among the flight crewmembers" as the two main factors that led to the crash.
For some unknown reason the FO did not make a "Mayday" call as he had been ordered to by the Captain, so that this accident was not due to a steep authority gradient but something more the opposite.
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I feel for Celia but unfortunately it's a third world country that only knows how to dispense third world (rate) justice.
The authorities here will look for anyone still alive who could have broken the chain of events - irrespective of whether it was within the realms of their area of competence or authority.
The authorities here will look for anyone still alive who could have broken the chain of events - irrespective of whether it was within the realms of their area of competence or authority.
If I understand the information currently available, a person related by family to the owner of the company worked in a government aviation regulatory agency (the same one Celia worked for?) which means that this company had "pull" and could (and possibly had in the past) try to intimidate a lower level functionary with that connection if (as she noted before) she had previously raised questions and they did not (in her terms) take her objections seriously. She doesn't want to lose her job. Putting a human face on how one deals with corruption or undue influence in any nation (not just in Bolivia) is what I am trying to do here.
I am also unclear on the following point: did she have the authority to disapprove / reject the flight plan submitted? I don't understand clearly what her position is.
I am also unclear on the following point: did she have the authority to disapprove / reject the flight plan submitted? I don't understand clearly what her position is.
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- Is that a commendation?
- A criticism?
- Supplementary information; allowing readers to make an informed and balanced judgement as to the reliability of the information provided by the person in question ?
Just curious ... so far.
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Why did she just buckle and allow the flight to take off. Hopefully we will find out in the fullness of time
Are you suggesting she should have buckled herself to the nose wheel? She could have informed the tower not to give clearance, and then what? This muppet could have still rolled and flown off. It's the cry for blood that is fuelling this process, and blood is only taken from the living. I hope her lawyers are beyond reproach and will do a diligent and worthy job of booting this out of the park.
As for cockpit gradient? It seems RHS was ex-military, mid-hi ranking officer and must have known the basic civil rules and those of airmanship. He was not a fighter jock who sat on an escape route if it all went quiet. I suspect some of them are almost on fumes at TOD when returning under radar PAR. The CVR will prove very enlightening.
Roasting the most junior lady in a male macho world would be beneath even them, surely. Let the local priest call down the raining fires of damnation if they try.
Are you suggesting she should have buckled herself to the nose wheel? She could have informed the tower not to give clearance, and then what? This muppet could have still rolled and flown off. It's the cry for blood that is fuelling this process, and blood is only taken from the living. I hope her lawyers are beyond reproach and will do a diligent and worthy job of booting this out of the park.
As for cockpit gradient? It seems RHS was ex-military, mid-hi ranking officer and must have known the basic civil rules and those of airmanship. He was not a fighter jock who sat on an escape route if it all went quiet. I suspect some of them are almost on fumes at TOD when returning under radar PAR. The CVR will prove very enlightening.
Roasting the most junior lady in a male macho world would be beneath even them, surely. Let the local priest call down the raining fires of damnation if they try.
Chuks, the Avianca example was Gladwell's to make his point about cultural inadequacy, not mine. I referred to it to put his use of Hofstede's data in context.
The F/O doing the comms was literally translating the Captain's requests (from Spanish to English and vice versa) and urgency got lost both in language translation and mitigation between the parties (Capt-F/O-ATC-F/O-Capt). The Captain didn't ever specifically order a Mayday call as far as I can see, the CVR translation reads "tell them we are in emergency". It appears to me that there were other authority and workload management issues but the comms problem was certainly primary. I have the full report, PM me if you want it.
The F/O doing the comms was literally translating the Captain's requests (from Spanish to English and vice versa) and urgency got lost both in language translation and mitigation between the parties (Capt-F/O-ATC-F/O-Capt). The Captain didn't ever specifically order a Mayday call as far as I can see, the CVR translation reads "tell them we are in emergency". It appears to me that there were other authority and workload management issues but the comms problem was certainly primary. I have the full report, PM me if you want it.
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Lonewolf:
I am also unclear on the following point: did she have the authority to disapprove / reject the flight plan submitted? I don't understand clearly what her position is.
I am also unclear on the following point: did she have the authority to disapprove / reject the flight plan submitted? I don't understand clearly what her position is.
ARO is -usually- part of ATC which enforces ICAO and country rules and regs.
So ARO has executive authority.
Often though to avoid arguing with 'pussy' pilots or dispatchers, they just call
the GND/TWR controller, very difficult to be reached, and when clearance is requested, the involved are informed of the ATS rejection of that flight plan.
If the individual still persist, police follows...
Mere FPL submission, does not make it a 'guarantee' the flight will operate.
IFPS in Europe rejects dozen 'wrong' FPLs every day.
HTH
BTW, Celia's report was after the accident, on the 29th, apparently forced to make. Also unknown if GND/TWR controller(s) were informed of the FPL issue, in that case they share responsibility.
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Slast, I'm not picking on you, nor on anyone else here commenting, aside from saying that assuming that Culture X is always going to have a steep authority gradient on the flight deck is not a valid assumption.
It's just an observed tendency, not necessarily a given, that a culture of "machismo" will show that authority gradient, and it's noticeable that it was absent in that Avianca accident near JFK. The FO, for whatever reason, went his own way when speaking to ATC. One would assume that the Captain said something in Spanish about an "emergencia" and that's pretty clearly going to translate as "emergency," a word the FO never used.
Of course, one might counter-argue that the Avianca FO saw ATC as over the flight crew, as of higher authority, so that he was unduly submissive to ATC, not speaking up about their low-fuel emergency but meekly accepting those vectors away from the airport.
Another thing is that aviation is oriented towards proper behavior, towards people following the rules. When you have people exhibiting transgressive behavior, rule-breaking behavior such as deliberately ignoring fuel requirements, it's so that the system may not be geared to preventing that behavior. ATC is not primarily there to prevent us from attempting suicide-murder. It's not so, however, that such behavior always goes unpunished; this latest rule-breaker, or pair of rule-breakers, on the flight deck of that RJ85 got the death penalty!
It's just an observed tendency, not necessarily a given, that a culture of "machismo" will show that authority gradient, and it's noticeable that it was absent in that Avianca accident near JFK. The FO, for whatever reason, went his own way when speaking to ATC. One would assume that the Captain said something in Spanish about an "emergencia" and that's pretty clearly going to translate as "emergency," a word the FO never used.
Of course, one might counter-argue that the Avianca FO saw ATC as over the flight crew, as of higher authority, so that he was unduly submissive to ATC, not speaking up about their low-fuel emergency but meekly accepting those vectors away from the airport.
Another thing is that aviation is oriented towards proper behavior, towards people following the rules. When you have people exhibiting transgressive behavior, rule-breaking behavior such as deliberately ignoring fuel requirements, it's so that the system may not be geared to preventing that behavior. ATC is not primarily there to prevent us from attempting suicide-murder. It's not so, however, that such behavior always goes unpunished; this latest rule-breaker, or pair of rule-breakers, on the flight deck of that RJ85 got the death penalty!
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I am for leniency and compassion.
However 71 dead and those living affected by this accident, as with every other accident, demand justice.
In any judicial system - maybe with the exception of Islamic Sariah - justice cannot be served without 'apportioning blame' first.
Then we discuss the leniency.
If heads must roll, so be it.
If jobs or businesses must be lost, so be it.
If ranks, privileges etc must be surrendered, so be it.
If cultural behaviors must be condemned, so be it.
Justice must be served !
However 71 dead and those living affected by this accident, as with every other accident, demand justice.
In any judicial system - maybe with the exception of Islamic Sariah - justice cannot be served without 'apportioning blame' first.
Then we discuss the leniency.
If heads must roll, so be it.
If jobs or businesses must be lost, so be it.
If ranks, privileges etc must be surrendered, so be it.
If cultural behaviors must be condemned, so be it.
Justice must be served !
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I think it's pretty disgraceful that Celia Castedo is being blamed by the Bolivian authorities while the people flying the plane are being viewed as heroes. Maybe it's a cultural thing, where it's okay to blame someone who's still alive but the deceased have to be accorded respect no matter what they might have done.
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Few things are as keenly perceived, yet so incredibly subjective, as justice.
Traces of something Godly in us, strive for perfection though.
Whilst I accept that the shocking fuel plan appears not to comply with the extant regulations, surely these 71 people died because the crew (captain) made a complete hash of putting his engine-less aircraft down in a considerable more controlled fashion.
I know it's not part of one's LPC, but surely aircrew do occasionally 'play' in the sim and have a go at completing an all-engine-out forced landing. Of course it's a situation you should never get yourself into, but having a very basic idea of how you'd do it is surely not rocket science.
A big difference between day/night, weather and terrain etc, but this crew appear to have had no idea what they were doing.
Forget that this crew ran themselves out of fuel. Put a competent crew in their type, established at 20,000ft in the hold at RNG and fail all the engines. Who wouldn't manage to save at least half of those on board?
I know it's not part of one's LPC, but surely aircrew do occasionally 'play' in the sim and have a go at completing an all-engine-out forced landing. Of course it's a situation you should never get yourself into, but having a very basic idea of how you'd do it is surely not rocket science.
A big difference between day/night, weather and terrain etc, but this crew appear to have had no idea what they were doing.
Forget that this crew ran themselves out of fuel. Put a competent crew in their type, established at 20,000ft in the hold at RNG and fail all the engines. Who wouldn't manage to save at least half of those on board?