Remembering Pilots

[Doc]

Deaths do not occur because of poor investigations. I know your situation, and I can sympathize with you. However, none of the "excuses" you gave have ever brought an aircraft down. And, while we know about the "chain" of events leading up to an accident, the bottom line is with the pilot. He/she was at the helm when the aircraft went in, and the option of not crashing, of going around, not pushing weather, of not being overloaded is always there. I want pilots to learn this simple FACT.....not hide their heads in the sand of excuses. I don't want to hear.."The company forced him to fly in bad weather." Because it's an excuse. The pilot is the one who makes the decision, the final decision. Let's stop killing ourselves and our passengers by letting other people make our decisions for us. And let's admit, as a pilot group, that WE are the one's to blame for this record...not TC's buzz words. Not the famous "chain"....because they are excuses.

[safetywatch]

All the facts are going to be revealed but unfortunately we may have to wait until October 14, 2008. That is the trial date for the Sonicblue crash claims presided over by Judge Williamson and it is scheduled to last an unprecedented 60 days. That is very long for a trial of this type. In the next two months all the statements of claim and defense will be filed in court and will then be public records that will be posted here. A lot of key documents will remain under wraps by court order until the trial begins. There is no doubt that some fairly sensational revelations are going to be made about those involved but we have to wait 18 months to publish the best, or rather worst of them.

[Hedley]

Our culture is simply bizarre. We worship bubble-brained youth (eg Britney Spears) but discount experienced guys like Doc. I get the feeling you 200hr wonders think you have little to learn from experienced guys like Doc and ..

Let's take a look at the death of a very good friend of mine that I previously mentioned, which enraged the children here. The homebuilt he was flying (but didn't build) shed a wing in flight - the spar broke - it was cracked. But why was the spar cracked? The accident investigator noted a peculiar, fresh abrasion on the lower outer portion of the wing that departed the aircraft - it was discolouring during the first few days.

Best that anyone can figure out, he groundlooped the homebuilt taildragger - I'm pretty sure it had toe-out - and cracked the spar. Then he made the decision to take off. If he had stopped to inspect the damage, he surely would not have taken off.

Pilots sometimes make bad decisions to fly poorly-maintained aircraft. Sometimes they get away with it, and sometimes they don't.

[Widow]

He/she was at the helm when the aircraft went in, and the option of not crashing ... is always there.

Huh??? I think you better take that "always" out. What about when a blade flies off, or the engine throws a cylinder - how is that the pilot's fault?

I expanded on what could have led to the pilot error's you described, I don't agree that they are excuses. And it is TSB's job to prevent future similar accidents as it is WCB/OH&S's responsibility in other industries. If there are an inordinate number of commercial crashes due to pilot error - then the root cause of that needs to be found. Deaths do not occur because of poor investigations, but contributing causes may re-occur because of poor investigations.

[Blue Side Down]

Huh??? I think you better take that "always" out. What about when a blade flies off, or the engine throws a cylinder - how is that the pilot's fault?

I'd venture the comment here that while neither of those occurances are controllable- materials fail, any engineer will admit that; and few will fail abnormally, it's a given- neither carry certain demise with them. The outcome of a flight after such an occurance depends on the pilots reaction and quick thinking.

[Doc]

I think I may just have covered events like "blades flying off" in my remark about catastrophic airframe failures??
In my not so humble opinion, TSB isn't worth crap.
SMS, CRM, PDM, and whatever other buzz terms so adored by Transport Canada, might as well be on a spool in front of your toilet, for all the good they do if the pilot insists on making excuses for their fu*k ups!
I descended below minimums because I'm depressed.
I flew into bad weather because my boss made me.
I didn't take enough fuel because I stink at math.
I skidded off the runway because I ignored the braking report.
I flew a perfectly good airplane into the ground because I was sleepy.
I departed from the wrong runway because it was dark, and unlit.
I continued an approach into windshear and 40 knot gusts because I'm good.
I crashed in the middle of the city because my wings were contaminated.
I flew a 737 into a bridge because nobody told me to ignore gage indications.
I wrote off an RJ because I wanted to get to FL410.
I flew my Caravan into the ground because I ignored black hole effect.
And Widow, until we can say.."I did these things because I screwed up. ME, not TC, Not TSB, but ME!!!!!" these deaths will continue. Until we pull our collective heads out of our asses and admit that WE ARE THE PROBLEM, we will continue to hide behind excuses, and blame everyone but ourselves.
And that's just what YOU are doing here.

[safetywatch]

If any of you have ever read a legal case from 1991 regarding Wapiti Aviation Ltd. the trial judge blamed Transport Canada for failing to protect the passengers and it is very clear that the judge did not consider the tragedy that followed to be pilot error, but rather accused the TC Regional Director and his staff of unprofessional conduct.

We haven't learnt much in 15 years have we. If anyone wants to read the case I can e-mail you the pdf file if you want to see it.

[Hedley]

I might mention that machinery (props, engines) talks to you. Some pilots choose to listen, others do not.

Your example, prop blades. During pre-flight inspection, how badly was it nicked? How deep a nick is acceptable? How many degrees of angle play was there? How much blade shake was there? How much is acceptable? I routinely tumble aircraft end over end, which stresses the prop blades, hubs, and crank flange more than any straight-and-level ops.

I've had a stick jam (elevator seized) in an unfamiliar aircraft during a vertical downline - the push-pull tubes jammed. Who's fault was that? MINE - I should have pulled the inspection panels and checked the tail for foreign objects before I pushed any negative G. If I had crashed, I would have expected the verdict to be PILOT ERROR - INADEQUATE PREFLIGHT.

[Doc]

Safetywatch, that one accident was 23 years ago. Refresh my memory for me. The aircraft was flown into the ground? Was it not? Was the judge on board? Is he a pilot? Was he even an adult at the time? Was there a pilot on board? Did the aircraft suffer a catastrophic airframe failure? Could the pilot have made a bad decision? Did his boss force him to fly? Did he say "No"?. He could have....and that's my point.

[Cat Driver]

" but rather accused the TC Regional Director and his staff of unprofessional conduct. "

Gees, I sure hope whoever is bringing the Sonic Blue case in front of a Judge remembers to ask me for the stuff I have to support exactly that senario in the Pacific Region of TCCA....

...there is a lot that few are aware of that goes on behind the scenes and is kept hidden from the public.....

...sure hope Mr. Huggett doesen't forget to ask for my stuff.

Hope he reads this forum..............................

It will be a slam dunk to show this is the case here in this region.

. E.

[tripleittt]

[
Ever heard of SATOPs? Interestingly enough, even Transport Canada disagrees with you.

Don't patronize me!!!!!

Quote:
"When an accident occurs, often the pilot is the only one held accountable. While the pilot may be at fault for having made a poor decision or series of decisions that led to the accident, other questions have to be asked…Were there any systemic problems in the company? What was management’s role in the accident? What did management do to prevent the accident? What is management doing to prevent a recurrence? Management must be accountable for the safety of the day-to-day operations. When management is held responsible for an accident, they will become more proactive in promoting safe operating practices. "

That is some good bullshit way of making pilots sound like little immature brats who can't stand up for themselves.

Don't you think that maybe it is a mistake for a pilot to accept a trip he is uncomfortable with. It is my life. It has happend to me in the past. My employer said "do the trip or pack your bags!!" Do you know what my response was "F#CK YOU!!!!" did he fire me, no it was an empty threat and he knew that I would have gone to a higher authority with my story if he did follow through. Pilots need to strap it on and stand up for themselves. Why would anyone accept a trip that was beyond his capability or outside of the flying envelope. Why would a VFR 703 pilot accept a trip into poor weather? I know why, because "I need the time, If I don't do it, someone else will so I may as well do it" Not once have I accepted a questionable trip or pressure from an employer. I have a family and even if I didn't I would feel the same way. I am not going to go die for some ma and pap operation so they can go to Mexico on a vacation or buy that nice little fishing boat.

[pushyboss]

If you go to the Flight Safety Foundation website you'll see that in the the last 20 years almost all aircraft accidents have been caused by human factors. Whether we label it pilot error or not is something I'll leave to people smarter than myself. But Doc is correct in that just about every accident the PIC could have done something to stop the error chain from continuing. There have been a couple of accidents in northen Alberta recently that can only be blamed on human factors. Sure the weather was crappy but pilots can say no...or "Go-Around".

Gliding into Gimli, gliding into the Azores...sure they had mechanical issues but in the end pilot error (human factor) resulted in the final excitement.

[Hedley]

http://rwebs.net/avhistory/fate.htm

Anyone else here old enough to read Ernie Gann?

[drifter]

Back to the original question by widow.

April 22, 2005. Comox, BC. Wesley Payne and Geoff Smulders.

Don't try to call that one pilot error.

[Widow]

Huh??? I think you better take that "always" out. What about when a blade flies off, or the engine throws a cylinder - how is that the pilot's fault?

I'd venture the comment here that while neither of those occurances are controllable- materials fail, any engineer will admit that; and few will fail abnormally, it's a given- neither carry certain demise with them. The outcome of a flight after such an occurance depends on the pilots reaction and quick thinking.

Assuming the weather and aircraft position are in his/her favour, then yes, he/she may get the plane down safely. But it doesn't always happen that way. Gee, the landing gear could be in disrepair and cause an incident to become an accident. It happens.

[Doc]

Drifter....nobody said EVERY accident is caused by pilot error. Or, did ya miss that?
Widow...landing gear problems don't tend to kill people..just their pride.

[Hedley]

Any time there's an accident, it's because:

1) a human being didn't design something correctly, or

2) a human being didn't manufacture something correctly, or

3) a human being didn't maintain something correctly, or

4) a human being didn't operate something correctly.

Does anyone else know any accident which doesn't
fit into one of the four categories above?

[Doc]

You know, I could read the Joy Of Cooking, The Better Housekeeping Cookbook, the whole "Company's Coming" series. But, I still can't actually cook. But I could come across with all the answers on a forum about cooking? Perhaps one must strap on an airplane to realize what decisions should be made, and when? Because, if you've never poached and egg, you can't make Eggs Benedict?
Was that rude? I don't care.

[Widow]

As for those of you who keep going on about pilot error, I'll let Living_Sky anwer for me, since he/she is much more qualified than I. From the Bill C-6 - Act to Amend the Aeronautics Act thread:

A lot of great points have been raised in this thread, from a lot of established points of view. None of us are wrong... but then, none of us are completely right (myself included)

Quoting Widow:

Again, I agree that pilot error is often the last link in the chain of events leading to an accident. Perhaps the pilot isn't experienced, or educated enough to make the right decision

Pilot error is not the last link in the chain of events, as much as it is the investigators first cop out. Somewhere down the line every accident comes down to a flaw in the Safety Management System.

For example...

The following is a ficticious scenario - Prop spun off the engine resulting in a forced approach over rocky terrain killing all on board -

Some might feel its sufficient to say the cause of the accident was the fact that the prop separated from the aircraft, forcing the pilot to make a decision to land without power.

why...
Investigation of the crank showed broken prop bolts at 4 locations
Conclusion is therefor that the prop seperated due to sheared prop bolts

why...
Tests of the remaining 'bolt' segments show rotational stress at the point of fracture indicating they may have been over-tightened
Conclusion therefore is that the prop separated from the aircraft because the prop bolts sheared off, because they had been overtightened

why...
Reveiwing the maintenance logs, the AMO was contacted and further investigation ensued. Speaking with the AME logged as having worked on the aircraft, investigators found the actual torque wrench used. Upon testing, investigators find the wrench is calibrated 50lb lighter than it should be.
Conclusion therefore is that the prop separated from the aircraft because the prop bolts sheared off, because they had been overtightened because the torque wrench used was calibrated 50lb lower than true

why...
Investigating the AMO's SMS, Investigators find record of several reported instances of faulty or inadequate equipment; but no indication of equipment repair, training, maintenance or replacement.
Conclusion therefore is that the prop separated from the aircraft because the prop bolts sheared off, because they had been overtightened because the torque wrench used was calibrated 50lb lower than true, because the company had an inadequate management system in place to replace, maintain or inspect equipment.


Now this was a ficticious scenario, however... I don't beleive in Pilot Error, nor do I beleive in 'Human Error' as its called in other industries.
- uneducated pilot decisions = SMS has failed to provide proper orientation/education
- unforseen circumstances = SMS has failed to encompass all available situations
- pilot 'Bad Attitude' = SMS has failed to provide disciplinary guidelines
- Faulty Equipment/Facilities = SMS has failed to put proper inspection system in place to identify needs.
- and so on.....

The key word is system... Safety Management System and no matter what type of situation... 9 times out of 10... no... 99 times out of 100, it's the system that has failed!

I am an occupational Health and Safety Coordinator with 15 years experience in the patch... drilling rigs which started out as one of the most dangerous places to work, and which, through use of SMS's have now grown into one of the safest. (AB WCB Statistics 1995)

The SMS systems presented by TC are terrific... some may find this odd.. but using parts of their system, I am likely the only airshow performer in NA with a safety manual. In presenting us with the system however... TC needs to focus training on their own personnel to allow for uniformity and understanding requirements of Employers as well as employees as they relate to SMS's, The Aviation OH&S regs, as well as The Canada Labor Code.

We need the same informed answer from the first TC phone... as the next.

[elgrande]

All the accidents that I remember have been from cheap maintenance and shady employers. I guess its human error if you fly that crappy plane because your starving huh?
gee doc, hop in an old Sonicblue or Navair plane and show me how its done.....you wont?....well your fired then.

nuff said

[drifter]

Drifter....nobody said EVERY accident is caused by pilot error. Or, did ya miss that?

Wasn't try to get at anything you said Doc. It's just that people keep saying that accident was pilot error even after the facts have come out and TSB pointed the finger at lycoming. I agree with you that most accidents are caused by pilots in one way or another.

elgrande your an idiot. Did you ever fly for Nav Air? Didn't think so.

[Doc]

elgrande....did you actually hit the "submit" button on that one?? Is there something about an old, somewhat ratty aircraft, owned by a less than stellar company, that REQUIRES you to CRASH? You can always say "NO", but I'd guess you are somewhat lacking in the "BALLS" department?

[Widow]

You know, I could read the Joy Of Cooking, The Better Housekeeping Cookbook, the whole "Company's Coming" series. But, I still can't actually cook. But I could come across with all the answers on a forum about cooking? Perhaps one must strap on an airplane to realize what decisions should be made, and when? Because, if you've never poached and egg, you can't make Eggs Benedict?
Was that rude? I don't care.

If this is directed at me, I've never claimed to have "all the answers". I come here trying to find answers because a whole bunch of people f'ed up and killed my husband. If that pilot hadn't been flying that plane that day, another one would have and my husband would still be dead. Because the engine still would have fouled, there still would have been no way to send a mayday, there still would have been smoke and fog and glassy water, there still would have been crap floats (landing gear) that weren't even resealed after the last ditch repairs, the "flight-follower" still wouldn't have called SAR for almost four hours after knowing the plane was missing. How is it the pilot's fault?

Blaming this one on the pilot is unacceptable.

[Doc]

Did anyone actually say, that this one was the pilot's fault?

[tripleittt]

"Just say no!!!" It is that easy.

"I had to fly a piece of shit because if I didn't I would have gotten fired" OOhhh my god!!!

"I have to risk my life and fly a piece of shit or I will lose my job and not get on at AirCanada!!"

Think about it. What are you willing to sacrifice to "move forward" in your career. If everyone said "NO" maybe they'll stop asking and do things according to regulations. You don't have to be flying to commit pilot error. I think it is pilot error to accept a trip in an aircraft not suitable for the trip or to accept a trip into adverse weather when you aren't qualified. When I was flying for questionable companies (I worked for 3 of them) I always stood my ground and not once did I lose my job....I gained the respect of my fellow pilots who then followed suit and I even gained the respect of an operator who changed his ways after we had it out. Individually you may feel weak but collectively we can change the industry. Say no, that is all it takes.