Accident investigation and PPRuNe (Discussion)
 

I was just wondering.....suddenly it went very quiet regarding the MD 83 accident. No more comments ...no results from any investigation... :bored:
Has the investigation already ended and have any results been published about this accident regarding cause etc?... or is there a reason for this information stop...:confused:

apart from that HAPPY NEWYEAR FOR EVERYONE and keep posting!

vunzke,

there is no activity because the available public data has been exhausted.

ICAO conventions require a preliminary report in 30 days and the final report whenever it is ready. This rarely takes less than a year and rarely more than six years.

PBL

PBL,

Thanks for the info, its just that preliminaries either and was wondering what the status was... was just wondering since usual these threads dont suddenly go quiet... on the other side...better to post confirmed info than the (often) "amateur specialist" opinions :E

Happy new year again

vunkze,

actually, in contrast to many of my colleagues, many professional pilots and at least one moderator, I think that some "amateurs" did some pretty impressive work in this thread with this accident. Like trying to figure out where it was when no one else was saying. (People who poo-poo such things have likely not been involved in an investigation. There is often a helluva task getting even the most basic details straight.)

I also anticipate that what we have concluded so far on this thread will turn out to be the truth. Other opinions may differ.

PBL

PBL,

although not really the subject of this thread... I do (partly) agree with you. "help" is always OK, i just beleive we should refrain := from drawing "conclusions" before the people who are trained and appointed to do so do. No problem with suggestions and opinions :D.

its a bit like in the cockpit.... I ALWAYS support passengers giving me input about observations from the cabin... however i hold it my prerogative (in the cockpit) to draw the "conclusions" as to what action to take.

having sais that... its a different discussion i guess....

with respect:ok:

Vunzke

No, friend. People "trained and appointed" have political constraints and opinions just like anyone else. Most of them do a first rate, sometimes outstanding, job *within those constraints*. But satisfying those constraints often distorts what is proposed in their published report.

Many of us feel that the best objective results are obtained by publishing the data as early as possible, letting everyone who so wants have a go at analysis, and critique of others, and then focusing on those explanations that prevail. It's not perfect, and it is not efficient, but then many of those people are likely working pro bono with a view to other ends (such as tenure, or future private contracts) so nominal efficiency doesn't matter.

This point of view, by the way, extends much further than accident reports, into the assessment of any safety-critical system, and is held by many senior safety-critical system specialists besides myself.

The reason we hold it is what we know of actual accident investigations, as well as what we know of safety cases and such. You may be surprised by the number of senior accident investigators at major agencies who would welcome it too.

PBL

So why is aviation a special case?
 

Perhaps it's just that persecution complex kicking in, but why is it air crashes, incidents and non-events that attract the armchair experts?

You never see this amount of speculation about auto accidents, for instance, do you? Some bus crashes, taking 50 grannies to their screaming doom and no one seems to want to try and guess if the driver was reading "The Beano" at the wheel or was subtly incapacitated or whatever. But it really does seem that many of you are absolutely fascinated by playing "Guess the Cause" within hours of each crash report so that some of the wildest theories get floated.

And now you are claiming that is wished-for and productive. Well, I never.....

I am sorry, but I really do believe the reason that crummy little bag of peanuts is so fiendishly hard to open is to give the SLF something to occupy their minds, rather than looking out the window to try and guess the reason for this or that motion, real or apparent, of their aerial conveyance.

If it were so useful to invite amateur speculation about the cause and circumstance of an air accident, why is there not a mechanism for that? Perhaps someone should get in touch with ICAO and offer to set up a panel of amateur experts to help in this way. Do not forget to involve the psychics, who can help in the searches.

chuks,

the obvious answer to your question is that road crashes are usually easy to explain, and commercial aviation accidents very much harder.

And if you have something against people discussing them in public, I suggest you avoid the discussions and go do something you find more entertaining.

PBL

Chuks

Study the composition of the NTSB - that is the BOARD MEMBERS - and you'll find that ultimately, although they rely on specialists to make the investigation, the actual board members who have the final say are, in fact, "amateurs" - and often bring an outside perspective to the final report.

edit: took some finding...
Current Members of the Board are:
* Mark V. Rosenker, Chairman
* Robert L. Sumwalt , Vice Chairman
* Deborah A. P. Hersman, Member
* Kathryn O'Leary Higgins, Member
* Steven R. Chealander, Member

Links to their bios are here
None are "trained accident investigators" by any stretch of the imagination (two were pilots, but that's not the same thing, obviously)

As to "why is aviation picked on" - it isn't. Ask any, say, nuclear industry employee if he thinks they are immune to "armchair experts". Or the military in general. Or the police forces. Or ....

M(F)S,

it looks like a good argument but I am not at all sure.

At most times in the past, some NTSB board members had accident investigation experience of some sort. The latest composition could well be a political anomaly. Indeed I know people who are very unhappy with the current board composition as well as with some previous compositions.

The U.S. nuclear industry has a history of intervention by very senior scientists, such as the Lewis Report, which is one of the fundamental documents of system safety, even thirty years later. Also NASA space, with the Challenger report including exemplary contributions by a certain R. Feynman, who I understand wrote a set of intro physics textbooks which people like :)

It turns out that Professor Lewis is also very interested in aviation. Given his hard-won achievements with the nuclear industry, I wonder why he was not invited to convene a committee for Lewis Report II on aviation safety?

One possible answer, and I should like to emphasise I am engaging in political speculation here: because major public pronoucements on aviation safety in the U.S. is traditionally the domain of amateurs? Discuss.

PBL

I tried to hold my breath but damn...i cant resist to reply... risking contradicting my previous statement that this thread was not intended for "this" discussion....
Yet "most" of us feel that it is just unnecessary delaying the outcome and (sorry but i disagree strongly with you here PBL) the "efficiency" IS important because the sooner we know the outcome the sooner we can learn from it.
This is very strange for a pilot... in the cockpit we work with constarints aswell.... SOP's, OM's and QRH's... we operate the aircraft within these "constraints" because it is proven to be the safest way. yes we do consult our fellow crewmember in case of an emergency but i defenately wont make a PA announcement asking for "idea's" from my passengers before following the MFDU procedure. i will take observations from passengers serious yes... but within the "constraints" of my SOP's and OM's and the funny thing is.... if we wouldnt...and something would go wrong.... oh my:ugh:.... "pilot error":=, "..didnt follow SOP's":=, ..... insurance company happy...newspaper extatic... NEWS NEWS!!... and if my procedures change for whatever reason I sure feel a lot better if the reason behind this amendment is made based on the knowledge and findings of "professionals" rather than the general public.

vunkze,

understand your reticence, but if you're asking for evidence to persuade you of what I said, then I can provide it. First step is probably to visit our WWW site and look at some of the WBA examples. Next step is probably to meet and discuss at some convenient moment. And if after all of that you are still not convinced, well, then that is your privilege.

PBL

Always ready for a beer ... i mean discussion :ok:and certainly willing to visit your WWW (which one?) to see what you have to say Im in Riga at the moment.... your gladly invited...

Other than that... still curious about the MD outcome:O

BTW...do you ever sleep?... :-)

Is that your polite way of saying you don't agree with what I said?

So, what points can you make against the published evidence?

PBL

PBL;

His, "What Do You Care What Other People Think?" is very readable as is his "The Character of Physical Law".

In support of the "interested amateur" and to elaborate on a point being made, let us unpack the notions of "amateur" and "professional", notions of the expertocracy, which, though not the spawning ground, the Internet has certainly fed and created new cults of "plastic language". Ivan Illich espoused the domain of the amateur and is worth reading.

Such terms are of recent origin and come from the preceding notion of guilds where the need for specialist knowledge gave rise to "specialist education" which gave rise to exclusionary groups which "had" the royal jelly, so to speak, the intention of which was to leave out others despite what increasingly came to be known as "amateur" contributions. The two notions have more to do with social control and power than they do with describing how various people who are so described may (or may not) contribute. Conferring the title of "professional" infers, but does not confer knowledge while the notion of "amateur" provides a way for professionals (those of the guild), to marginalize "untrained" commentary as intrusive or otherwise plain wrong and thus illegitimate.

Regarding the "trained specialists pronouncing" argument, there is of course merit to the point but it is not, as is assumed by so many here and elsewhere, not, by virtue of titles and letters-after-names, an exclusionary process from which one pronounces, it is partly from education and training but it is also from the ability to think and see critically and to be keenly aware of the reversal of that popular phrase, which goes, "I'll see it when I believe it".

After all, intelligent inquiry can do some very good work as has been observed on the Turkish MD82 accident thread, to which this entire contribution addresses itself albeit in a round-about way.

I am in full support of releasing as much information as possible and this is from a flight safety specialist's point of view. There is a natural winnowing process in such an open discussion which is, after all, seeking truth not blame. Such a view is idealistic because, as has been correctly stated, appointments to positions of authority do have political aspects to them.

Notwithstanding Feynman's example of "amateur sleuthing", the best example of a non-specialist doing superb investigative aviation work is the Moshansky Commission and it's Report in the accident at Dryden, the recommendations of which were largely though not wholly adopted by Transport Canada, (which was heavily criticized in the Report, and to which strong criticisms have since been directed regarding SMS (which I have called "the de-regulation of flight safety"), by the same man). Here was a man who knew nothing about aviation yet had tremendous access to wide-ranging information, all with good results.

I wouldn't begin to compare the work done on PPRuNe with the Moshansky Report of course because the means, the goals and discussion levels are vastly different as one expects on a public forum with contributors of varying backgrounds but informed speculation along with the ecology of ideas can bring about interesting and correct conclusions even though they may be "unofficial".

Re amateur and formal investigation; there is both opportunity and need for two forms (or levels) of ‘investigation’.
Formal investigations are often constrained by considerations beyond the ICAO guidelines e.g politics, practicality, experience. Many of these reports fail to explain why an accident occurred, or insufficiently to provide specific safety solutions. This might be due to the lack of data or inability to understand the human activity from the available recordings. Any resultant safety activity in the latter case would be speculative. I believe that these limitations also apply to why-because (W-B) analysis.

An alternative (amateur) analysis is valuable when conducted by operators and individuals who ask ‘could this happen to me’. The process of thinking about an accident has safety value; it can be equated to a safety audit on a specialist subject. This is also somewhat speculative, but can occur more quickly while the event is fresh in peoples minds (greater training effectiveness), and can be more proactive in looking ahead to avoid a similar accident, as opposed to a formal report of how to avoid the accident we have just had.
The value of the audit can be greater where specific details of the situation and activities leading to the accident are known, hence the need to publish ‘public’ data (not all data) quickly and without comment. This process can be aided with use of web forums and appropriate ‘eye-witness’ reporters; and even with some erroneous data the safety activity of thinking about the situation would not be significantly compromised.

The difference between the two; – a formal report has accountability to a higher authority (usually government).
A safety audit, thinking about safety has accountability, but this is within the operation or directly to the individual providing professional development; perhaps of far greater value than formal reports.

News of an accident gets attention and our natural first reaction is to understand how it happened so that we can hopefully not step in the same trap, especially as there are a limited number of typical accident types.

The urge to developing an understanding of any particular accident fades with time. By the time the official report makes its way through the mill and gets released, the immediacy is no longer there. Typically the post report comment one sees in these forums is generally much less in quantity than in the weeks immediately after the accident which is another indication that interest has faded.

It is basic human nature to react more strongly to events in the last few weeks than a few years ago.

Preliminary data from accidents does help pilots reflect on what happened and what they need to keep in mind not to fall in the same trap. Much of that will reinforce lessons and SOPs already learned.

Eventually the conclusions and suggestions from the official reports are fed into the regulatory mill.

I have also had the misfortune to witness and attend an atypical fatal accident along with many other pilots at the same location. There was a lot of soul searching to gain some understanding of what went wrong and what we need to do to not have another one like it.

Exactly!
 

"find something more entertaining..." than speculation about the cause of air crashes. Well, yes! I don't find this sort of thing "entertaining" at all, one reason I am against it!

I find a lot of it ghoulish, in fact. It is exactly on the level of slowing down, way down, to gawk as you roll past the latest road accident. Back home you give it a few minutes of quiet speculation about what happened but that's all. Here, it gets quiet and it's "Hey! Where did everyone go?"

People on the NTSB are working with information provided by experts, not nudniks trying to guess if the pilot "hit an air pocket," say. When the deliberately low-toned report is published, guess who reads and, hopefully, uses it? "Experts," that's who. You can believe me when I tell you that I pay close attention to them.

Feel free to discriminate and filter as you wish. Safety investigators have at times looked into what has been said by "amateur specialists"... Sometimes they need to see what they've missed, what info has been leaked to them but not to the investigators etc.

However, investigators do not take them into account without investigating the alternatives either. COnclusions made here are not professional conclusion, but can be useful.
I agree with PBL on the following:
I extend such agreement throughout that post #292.

But trying to force down people's throats that the conclusions of "amateur specialists" are the right ones is a different matter altogether... and I don't agree to such intentions.

Yes, but they do need to improve those manuals and procedures as time goes by. Any improvements that is undertaken in a systematic manner should be welcomed, whether it would be adopted is subject to professional analysis.

Bingo! Couldn't have said it better myself...

The common interest here is safety improvement, and not to find the black sheep... and it does provide a measure to incite public interest into understanding what aviation is all about.

Sure, amateur specialists can be very wrong, but they can also come up with the right facts very quickly and accurately. On the accident analysis, the same thing can and has happened. But as I said above, even if it's correct, the official version does not necessarily mean the same... The nudniks aren't always dumb nudniks... some go about it very logically and systematically.

There have been cases where accident investigators have admitted "we know that's what happened, but we can't publish is... <insert reason here>"

I'd love to have the data they have, but I don't envy the official responsibility and the political pressures.

PK-KAR

Try the Third World!
 

There are many cases when, for one reason or another, the truth is left undiscovered or even concealed. Even the very high-profile Concorde crash led to allegations that maintenance errors caused a critical mis-alignment in the landing gear that went ignored in the official report for some reason.

Many accidents in the Third World go essentially un-investigated and under-reported. And? Guess why aviation there can be so dangerous.

I, too, watched with interest as that physicist just cut through all the palaver to swish the bit of o-ring around in the icewater and show how inelastic it had become, in the case of the Challenger accident. But bear in mind that there you had a brilliant mind at work backed up by many hours of expert investigation.

I guess I just get a bit testy from my day job. That primarily has to do with safety, efficiency and, way down the list, keeping the SLF happy. It is often so that the safety-related stuff makes the SLF rather UN-happy, when, depending on their social status, wealth, etc., they may let me know about that! As in, "I have a meeting in Charlotte and I need to know when we are ready to go!!!!"

"What, you think I have a remote control in my pocket that will make the fog at our destination disappear, you moron?" In my dreams! No, what I say is just, "Sorry, sir, we are working on that. Would you like another cup of coffee, perhaps? Doris!" The guy figures I am not very bright, not being able to answer a simple question with a direct answer. But, hey, if I were really, really smart then I would be a powerful and successful businessman, not just a humble airplane driver. Such is life, eh?

The problem often is that people try to extrapolate from what they know, often quite a lot, yes, to guess what it is we have to work with. That is entertaining, I guess. On the other hand, when some widget factory goes bankrupt, is it entertaining to try and guess what mistakes the Chairman made to cause that to happen?