Halifax crash report coming Thursday

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Re: Halifax crash report coming Thursday

Post by rookiepilot » Wed Jun 14, 2017 3:00 pm

Curious about something.

Did AC get input into the final report before release? How much?

Would 2 - plane -- "ABC bush Co" get the same input into a report affecting them?

One wonders......
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Re: Halifax crash report coming Thursday

Post by tbaylx » Wed Jun 21, 2017 4:10 pm

rookiepilot wrote:Curious about something.

Did AC get input into the final report before release? How much?

Would 2 - plane -- "ABC bush Co" get the same input into a report affecting them?

One wonders......
yes and yes
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Re: Halifax crash report coming Thursday

Post by Gilles Hudicourt » Tue Dec 04, 2018 7:18 pm

I decided to write a little piece on the AC624 Transportation Safety Board of Canada accident investigation report. I think the report is not to the standard one would expect of an Agency such as the TSB. Most of the ideas and opinion expressed in the article had already been expressed by me on this very thread, but I decided to put them all together with more detail. I hope it will catch someone's eye.

https://www.linkedin.com/pulse/transpor ... ublished=t
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Re: Halifax crash report coming Thursday

Post by Canoehead » Fri Dec 07, 2018 8:30 pm

Completely agree Gilles. I've become more and more disappointed with the TSB reports published over the last several years. In my mind the last well-written report (of a major accident) was SWR111. Now, the TSB is absolutely focussed on reporting superfluous details that quite frankly make me sleepy. I don't know why that is, but as a pilot, it's nauseating. I suspect part of it is a shift in the investigators' experience and background, some to do with budget and also an inclination to make these reports readable/understandable by "Joe Public" as their number one priority. In this case reports are not meeting what should be their number one objective; helping prevent accidents.

No offence intended to staff at the TSB, but the NTSB sets the bar in accident reporting, and Canada falls well short of that bar. In fact many countries with a much smaller aviation industry than Canada's are far superior. It's embarrassing.

But as long as everyone is happy and no feelings are hurt...
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Re: Halifax crash report coming Thursday

Post by rookiepilot » Fri Dec 07, 2018 8:34 pm

Canoehead wrote:
Fri Dec 07, 2018 8:30 pm

But as long as everyone is happy and no feelings are hurt...
...and no one is embarrassed. That's Canadian. Sweep it under the rug.
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Re: Halifax crash report coming Thursday

Post by Old fella » Fri Dec 07, 2018 10:33 pm

Well chaps, if yer accident investigation knowledge is that good/shit hot(I am not in a position to say one way or another), redress is quite simple isn't it.Apply on competitions at TSB and let them know how good ya are and how valuable your expertise is. Never know, they may take you up on the offer, perhaps they could use the help.
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Re: Halifax crash report coming Thursday

Post by pelmet » Fri Dec 07, 2018 10:43 pm

Canoehead wrote:
Fri Dec 07, 2018 8:30 pm
Completely agree Gilles. I've become more and more disappointed with the TSB reports published over the last several years. In my mind the last well-written report (of a major accident) was SWR111. Now, the TSB is absolutely focussed on reporting superfluous details that quite frankly make me sleepy. I don't know why that is, but as a pilot, it's nauseating. I suspect part of it is a shift in the investigators' experience and background, some to do with budget and also an inclination to make these reports readable/understandable by "Joe Public" as their number one priority. In this case reports are not meeting what should be their number one objective; helping prevent accidents.

No offence intended to staff at the TSB, but the NTSB sets the bar in accident reporting, and Canada falls well short of that bar. In fact many countries with a much smaller aviation industry than Canada's are far superior. It's embarrassing.

But as long as everyone is happy and no feelings are hurt...
No feelings hurt, but any examples would be welcome as proof.
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Re: Halifax crash report coming Thursday

Post by Schooner69A » Sat Dec 08, 2018 9:05 am

I have had some quibble with TSB from time to time about the wording in some of their reports.

F'rinstance: several years ago, a Piper Navajo came to grief while landing in Saint John, NB.

When the final accident report was released, I disagreed with some of their statements and went so far as to pen the following. However, I just filed it and never followed through...

My comments:



"First, there are several references to “crew” in the findings of the subject report. I am somewhat familiar with the accident in that I know both individuals who were on the aircraft and I would have some trouble categorizing them as a “crew”. Use of that word implies that both members of the cockpit were trained and qualified on the aircraft. I’m sure you found out during your investigation that the “co-pilot” was the Chief Flying Instructor from the local flight school who had nothing more than a nodding acquaintance with the aircraft: certainly he did not have a PPC on the aircraft. He was there as a second pair of eyes only and had no authority in the aircraft. For all intents and purposes, he was a passenger. Certainly, he could not have logged the time as “co-pilot” or “first officer” as the aircraft was certified as a single-pilot aircraft. Therefore, he could not be labeled as “crew”. That, then, makes redundant the slightly condemnatory comment that “…they did not have the procedures or training to operate as a crew in these conditions…” Of course, they didn’t: they were not a crew! This was a single pilot operation with a passenger in the right front seat who was to act as a second set of eyes.

Secondly, your use of the phrase “…were permitted to conduct the approach in reported visibilities that were below the minimum advisory values published for the ILS approach…” gives the impression that you are either against 1200 RVR approaches or have never flown same. The advisory values given in CAP are simply that: advisory only. Your phrasing gives the impression that the pilot was doing something slightly unseemly that night and “not quite kosher”. As the pilot continued the approach past the beacon, I must presume that he had at least a quarter mile visibility? My information indicates that the weather was very close to CAP. Indeed, talking to the pilot, I gather that they broke out close to CAP limits and never lost sight of the ground…

Further, I query your comment in “Findings As To Risk”: “The crew did not have the benefit of up-to-date in-flight weather conditions or knowledge that a Beech 1900 had just carried out a missed approach”. Was the Beech 1900 authorized 1200 RVR limits or CAP limits? If CAP limits, then the fact that they missed has no bearing on this accident at all. If the aircraft went around due to turbulence, then, again, no bearing on the accident.

As one who has executed many single-pilot ILS approaches in 1200 RVR conditions in the past to that runway, I do agree with your second finding that the pilot lost situational awareness during the latter stages (the visual phase) and was unable to …transition to a landing."


As the supposed "experts", there is no one to whack them on the "Mustnttouchit" with an admonishment...
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Re: Halifax crash report coming Thursday

Post by Gilles Hudicourt » Sun Dec 09, 2018 7:57 pm

Old fella wrote:
Fri Dec 07, 2018 10:33 pm
Well chaps, if yer accident investigation knowledge is that good/shit hot(I am not in a position to say one way or another), redress is quite simple isn't it.Apply on competitions at TSB and let them know how good ya are and how valuable your expertise is. Never know, they may take you up on the offer, perhaps they could use the help.
The TSB report makes a bunch of statements about the aircraft's distance in relation to the runway or the FAF, without ever stating what those measurements are based on, like it is not relevant. But the aircraft, unknown to the crew, ended up too low on its approach path, which is the very reason the crash occurred. So it is relevant to state what the crew used as far as instruments to determine its descent point, FAF passage etc. And it is also relevant for the report to state what data the investigators used to determine where the aircraft actually was during the approach. That is not revealed either.
The report does not even reveal what NAVAIDS were tuned and monitored, or what NAVAIDS were available.

It's like writing a detailed report on a belly landing but neglecting to state in the report whether the crew had selected gear down in the first place.
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Re: Halifax crash report coming Thursday

Post by C.W.E. » Sun Dec 09, 2018 8:01 pm

The TSB is a political joke and should be done away with.
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Re: Halifax crash report coming Thursday

Post by Old fella » Sun Dec 09, 2018 8:48 pm

Gilles Hudicourt wrote:
Sun Dec 09, 2018 7:57 pm
Old fella wrote:
Fri Dec 07, 2018 10:33 pm
Well chaps, if yer accident investigation knowledge is that good/shit hot(I am not in a position to say one way or another), redress is quite simple isn't it.Apply on competitions at TSB and let them know how good ya are and how valuable your expertise is. Never know, they may take you up on the offer, perhaps they could use the help.
The TSB report makes a bunch of statements about the aircraft's distance in relation to the runway or the FAF, without ever stating what those measurements are based on, like it is not relevant. But the aircraft, unknown to the crew, ended up too low on its approach path, which is the very reason the crash occurred. So it is relevant to state what the crew used as far as instruments to determine its descent point, FAF passage etc. And it is also relevant for the report to state what data the investigators used to determine where the aircraft actually was during the approach. That is not revealed either.
The report does not even reveal what NAVAIDS were tuned and monitored, or what NAVAIDS were available.

It's like writing a detailed report on a belly landing but neglecting to state in the report whether the crew had selected gear down in the first place.
And your point is........ outside of posting your observations on this public forum. If you feel the final report contained inaccuracies(as you see them) thus flawed in its Findings as to Cause and Contributing Factors outline such(if you haven’t already do so) officially to TSB stating your professional credentials/ curriculum vitae to backup your position. I would think, perhaps others as well this would be a reasonable course of action. Incidentally(certainly subject to correction) , I don’t recall reading anything in the public domain about Air Canada taking issue with this final report.
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Re: Halifax crash report coming Thursday

Post by Gilles Hudicourt » Mon Dec 10, 2018 7:58 am

Old fella wrote:
Sun Dec 09, 2018 8:48 pm
And your point is........ outside of posting your observations on this public forum. If you feel the final report contained inaccuracies(as you see them) thus flawed in its Findings as to Cause and Contributing Factors outline such(if you haven’t already do so) officially to TSB stating your professional credentials/ curriculum vitae to backup your position. I would think, perhaps others as well this would be a reasonable course of action. Incidentally(certainly subject to correction) , I don’t recall reading anything in the public domain about Air Canada taking issue with this final report.
1) I never wrote the report had inaccuracies.
2) I never wrote that the investigation was flawed in its findings.

I wrote that the report is mum on how they arrived at their finding. Not the same.

Do you just make things up to suit the point you want to make ?

And if Air Canada's didn't publicly condemn the report, it's good ? That is your argument ?
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Last edited by Gilles Hudicourt on Mon Dec 10, 2018 9:44 am, edited 1 time in total.

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Re: Halifax crash report coming Thursday

Post by altiplano » Mon Dec 10, 2018 9:38 am

C.W.E. wrote:
Sun Dec 09, 2018 8:01 pm
The TSB is a political joke and should be done away with.
Certainly more integrity than Transport Canada. What should we have in Canada? Nothing?

Although I wish they would be more like their US counterparts, more expediency, more transparency.
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Re: Halifax crash report coming Thursday

Post by Old fella » Mon Dec 10, 2018 12:31 pm

Gilles Hudicourt wrote:
Mon Dec 10, 2018 7:58 am
Old fella wrote:
Sun Dec 09, 2018 8:48 pm
And your point is........ outside of posting your observations on this public forum. If you feel the final report contained inaccuracies(as you see them) thus flawed in its Findings as to Cause and Contributing Factors outline such(if you haven’t already do so) officially to TSB stating your professional credentials/ curriculum vitae to backup your position. I would think, perhaps others as well this would be a reasonable course of action. Incidentally(certainly subject to correction) , I don’t recall reading anything in the public domain about Air Canada taking issue with this final report.
1) I never wrote the report had inaccuracies.
2) I never wrote that the investigation was flawed in its findings.

I wrote that the report is mum on how they arrived at their finding. Not the same.

Do you just make things up to suit the point you want to make ?

And if Air Canada's didn't publicly condemn the report, it's good ? That is your argument ?
Tell me something sir, have you corresponded with TSB to let them know in your infinite wisdom that you think as an airline pilot their final report in the AC crash in YHZ wasn’t up to the standard one would expect from such an Agency(your words), explaining of course the standards not met. You stated that “ I hope it will catch someone’s eye” well then, there is your chance.
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Re: Halifax crash report coming Thursday

Post by C.W.E. » Mon Dec 10, 2018 12:55 pm

wrote that the report is mum on how they arrived at their finding. Not the same.

Do you just make things up to suit the point you want to make ?

I am of the same opinion as Gilles.

I have had a fair amount of experience with the TSB and I don't have much trust in any of their so called investigations.
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Re: Halifax crash report coming Thursday

Post by pelmet » Mon Dec 10, 2018 6:04 pm

C.W.E. wrote:
Mon Dec 10, 2018 12:55 pm
wrote that the report is mum on how they arrived at their finding. Not the same.

Do you just make things up to suit the point you want to make ?

I am of the same opinion as Gilles.

I have had a fair amount of experience with the TSB and I don't have much trust in any of their so called investigations.
I don’t doubt you CAT but no details in my opinion is meaningless.

It would be interesting just to know why you have had any experience with them as you have mentioned your incident-free career both as a pilot and flight school owner. Something one can justifiably be proud of.

I assume it was due to something involving another pilot.
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Re: Halifax crash report coming Thursday

Post by C.W.E. » Mon Dec 10, 2018 6:56 pm

t would be interesting just to know why you have had any experience with them as you have mentioned your incident-free career both as a pilot and flight school owner. Something one can justifiably be proud of.

I assume it was due to something involving another pilot.
It was about a fatal accident during a water bombing flight.

The TSB interviewed me and asked my opinion on what the cause was.

I went into great detail on what I thought the cause was and even offered proof of what I thought the cause was.

They completely ignored what I told them even though they knew what I had said was 100% factual.

I was basically told by the company and the TSB to keep my opinion to myself if I wanted to keep working in the water bombing field.

Therefore it is my personal opinion they can not be believed in their investigations because they can be politically motivated.

Much like T.C. who I had a three and a half year legal battle with and in the case of T.C. I proved they were morally corrupt right up to the DGCA.
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Re: Halifax crash report coming Thursday

Post by EPR » Tue Dec 11, 2018 5:05 pm

This critique of the TSB report by Capt. Steve Last is quit an eye opener to say the least! :shock:
http://www.picma.info/sites/default/fil ... %201_4.pdf
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Re: Halifax crash report coming Thursday

Post by Canoehead » Tue Dec 11, 2018 8:02 pm

EPR wrote:
Tue Dec 11, 2018 5:05 pm
This critique of the TSB report by Capt. Steve Last is quit an eye opener to say the least! :shock:
http://www.picma.info/sites/default/fil ... %201_4.pdf
Thanks EPR. Very detailed, and much more than I considered, however many of the things noted in the above document were what I was thinking exactly.

No CVR information because "it's not pertinent"? Give me a break. But thanks for almost one full page on the Coffee Maker Assemblies. Just what I need to know about.
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Re: Halifax crash report coming Thursday

Post by Gilles Hudicourt » Wed Dec 12, 2018 8:29 am

Old fella wrote:
Mon Dec 10, 2018 12:31 pm
Tell me something sir, have you corresponded with TSB to let them know in your infinite wisdom that you think as an airline pilot their final report in the AC crash in YHZ wasn’t up to the standard one would expect from such an Agency(your words), explaining of course the standards not met. You stated that “ I hope it will catch someone’s eye” well then, there is your chance.
I posted my thoughts about the Report in an article which I posted on LinkedIn. The Article Stats tell me that 8 people from the TSB read it and this Gentleman left the following explanation:

Branden Murdoch, P.Eng.
Aerospace Systems Engineer at Transportation Safety Board of Canada
Please read section 1.16.1 TSB laboratory reports. You'll see reference to engineering report LP061/2015 - DFDR [digital flight data recorder] Download and Analysis. This report should answer your questions and resolve your concerns.
Here is what that section of the report says:

1.16.1 TSB laboratory reports
The TSB completed the following laboratory reports in support of this investigation:

LP061/2015 - DFDR [digital flight data recorder] Download and Analysis
LP071/2015 - NVM [non-volatile memory] Recovery - EGPWS [enhanced ground proximity warning system]
LP072/2015 - NVM Recovery - CPAP
LP073/2015 - Site Survey Report
LP076/2015 - Coffee Maker Restraint Examination
LP086/2015 - Shoulder Harness Assembly Examination
LP094/2015 - Photo Collection
LP110/2015 - Analysis of Material Transfer
But the Analysis of the DFDR has not been made public by the TSB, so his comment just means, "trust us, we downloaded and analysed the data, it's all been looked at"
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Re: Halifax crash report coming Thursday

Post by Old fella » Wed Dec 12, 2018 1:03 pm

Gilles Hudicourt wrote:
Wed Dec 12, 2018 8:29 am
Old fella wrote:
Mon Dec 10, 2018 12:31 pm
Tell me something sir, have you corresponded with TSB to let them know in your infinite wisdom that you think as an airline pilot their final report in the AC crash in YHZ wasn’t up to the standard one would expect from such an Agency(your words), explaining of course the standards not met. You stated that “ I hope it will catch someone’s eye” well then, there is your chance.
I posted my thoughts about the Report in an article which I posted on LinkedIn. The Article Stats tell me that 8 people from the TSB read it and this Gentleman left the following explanation:

Branden Murdoch, P.Eng.
Aerospace Systems Engineer at Transportation Safety Board of Canada
Please read section 1.16.1 TSB laboratory reports. You'll see reference to engineering report LP061/2015 - DFDR [digital flight data recorder] Download and Analysis. This report should answer your questions and resolve your concerns.
Here is what that section of the report says:

1.16.1 TSB laboratory reports
The TSB completed the following laboratory reports in support of this investigation:

LP061/2015 - DFDR [digital flight data recorder] Download and Analysis
LP071/2015 - NVM [non-volatile memory] Recovery - EGPWS [enhanced ground proximity warning system]
LP072/2015 - NVM Recovery - CPAP
LP073/2015 - Site Survey Report
LP076/2015 - Coffee Maker Restraint Examination
LP086/2015 - Shoulder Harness Assembly Examination
LP094/2015 - Photo Collection
LP110/2015 - Analysis of Material Transfer
But the Analysis of the DFDR has not been made public by the TSB, so his comment just means, "trust us, we downloaded and analysed the data, it's all been looked at"
Ok, that’s fair enough. Their(TSB Engineer Lab) response suggests to me they stand by the final analysis which is their prerogative.
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Re: Halifax crash report coming Thursday

Post by C.W.E. » Wed Dec 12, 2018 1:17 pm

Ok, that’s fair enough. Their(TSB Engineer Lab) response suggests to me they stand by the final analysis which is their prerogative.
How about those of us who believe the TSB has a bias in flavor of Air Canada?

Could we be subject to some form of punishment by the government?
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Re: Halifax crash report coming Thursday

Post by Gilles Hudicourt » Wed Dec 12, 2018 2:18 pm

Old fella wrote:
Wed Dec 12, 2018 1:03 pm
Ok, that’s fair enough. Their(TSB Engineer Lab) response suggests to me they stand by the final analysis which is their prerogative.
They are not a law firm or a lobby group. They are the TSB.

http://www.bst-tsb.gc.ca/eng/qui-about/ ... andate.asp
The Canadian Transportation Accident Investigation and Safety Board Act provides the legal framework that governs TSB activities. Our mandate is to advance transportation safety in the marine, pipeline, rail and air modes of transportation by conducting independent investigations, including public inquiries when necessary, into selected transportation occurrences in order to make findings as to their causes and contributing factors;
identifying safety deficiencies, as evidenced by transportation occurrences;
making recommendations designed to eliminate or reduce any such safety deficiencies; and
reporting publicly on our investigations and on the findings in relation thereto.
To instill confidence in the public regarding the transportation accident investigation process, it is essential that an investigating agency be independent and free from any conflicts of interest when investigating accidents, identifying safety deficiencies, and making safety recommendations. The TSB is an independent agency, separate from other government agencies and departments, that reports to Parliament through the President of the Queen's Privy Council for Canada and Minister of Intergovernmental and Northern Affairs and Internal Trade.
I am Airbus 330/320 qualified. This report has not instilled confidence in me. What are they hiding and why ?
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Re: Halifax crash report coming Thursday

Post by CD » Wed Dec 12, 2018 4:03 pm

Have you considered requesting a copy of the lab report? I suspect that may be what was being suggested. I have reviewed associated reports that were referenced, but not included, in the final report from other investigative bodies in the past.
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Re: Halifax crash report coming Thursday

Post by Old fella » Wed Dec 12, 2018 7:47 pm

C.W.E. wrote:
Wed Dec 12, 2018 1:17 pm
Ok, that’s fair enough. Their(TSB Engineer Lab) response suggests to me they stand by the final analysis which is their prerogative.
How about those of us who believe the TSB has a bias in flavor of Air Canada?

Could we be subject to some form of punishment by the government?
Personally I don’t subscribe to the notion TSB has a favour bias towards AC nor any airline or the aviation industry in general for that matter. However others such as yourself see it differently and that is fine and you are certainly entitled to express that.
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