We all have faith in machines. Such faith has taken us to the depths of the oceans, to the Moon and back. Associated risk to these endeavours has been mitigated by knowledge of risk, reliability, and subsequent acceptance of remaining dangers involved.
As pilots, we all depart in faith that the aircraft will not catch fire, have a catastrophic failure, nor suffer the effects of danger we as pilots can interject. (CFIT, mid-airs, misuse, etc.) Faith negates the inherent risk of flying in our minds.
The effect of a severe challenge to faith is often fatal. So, we depart in a trust founded in knowledge of risk and reliability of the machine, and ourselves. (sometimes referred to as “experience”.)
There is probably not a person reading this who has not departed with some kind of component failure or known unreliability which could mitigate against safety.
The easiest example at hand is the automobile. Cracked windshields, worn tires, u/s tail lights and turn indicators, faulty brakes are all items that we have all endured but which could contribute to an accident if Fate steps in.
Even the introduction of Minimum Equipment Lists is an official acknowledgement that machines can be operated at less than 100% serviceability.
Where does the line between acceptable and unacceptable lie?
It is blurred because we cannot know all the challenges that may face us on a flight. A broken prop synch will never bring you down. A huge assortment of other problems might well. Especially if they gang up on you. Eliminating all possibilities does not get the job done. Advice from the profit-oriented owner may not be the best available. Insistence of the prop synch repair before flight may well result in dismissal.
The first time you fly an aircraft not 100% serviceable, you have become pragmatic about certain matters. You have stepped on a slippery slope. Continued pragmatism leads to conditioning and accustomed behaviour, until it becomes an habitual trait. Similarly, the decisions we make are subject to the same process. Faith could tell us that the same amount of fuel as last week will get us where we want to go tomorrow. Faith is not a fuel.
If there was any wisdom in this, surely people would not continue to die. We buy into the culture of a company in faith that yesterday’s decision will stand up today. We stop thinking for ourselves.
It is all about conscious decision-making.
Faith in the machine
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snaproll20
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Commonwealth
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Good post Snaproll. Your experience shows in what you have written.
If anyone out there has the trick to not making "lazy decisions", or to making the safest decisions all the time I would love to hear it. I guess it is probably different for everyone. Myself, I notice a big change in my willingness to accept risk when I am stressed or tired. These factors are hard to control, for me anyway. I know this because when I come back from a little time off, or a good long vacation, my thought processes are clearer and my decision making sharper and safer. I guess what I am trying to say is that we should make a conscious effort to take better care of our person; practice things like good nutrition, exercise or maybe even spirituality. I guess that is what separates the men from the boys (sorry ladies, I can't think of a better expression), being able to draw a line between who we are and what we do as our contribution to society.
I realize what I have written is a lot harder in real life.
Any comments? I would love to hear about what others do to keep there heads clear.
Commonwealth
If anyone out there has the trick to not making "lazy decisions", or to making the safest decisions all the time I would love to hear it. I guess it is probably different for everyone. Myself, I notice a big change in my willingness to accept risk when I am stressed or tired. These factors are hard to control, for me anyway. I know this because when I come back from a little time off, or a good long vacation, my thought processes are clearer and my decision making sharper and safer. I guess what I am trying to say is that we should make a conscious effort to take better care of our person; practice things like good nutrition, exercise or maybe even spirituality. I guess that is what separates the men from the boys (sorry ladies, I can't think of a better expression), being able to draw a line between who we are and what we do as our contribution to society.
I realize what I have written is a lot harder in real life.
Any comments? I would love to hear about what others do to keep there heads clear.
Commonwealth
The pressure from peers and from "authority" can be way, WAY more effective on us, than we care to admit.Commonwealth wrote:Good post Snaproll. Your experience shows in what you have written.
If anyone out there has the trick to not making "lazy decisions", or to making the safest decisions all the time I would love to hear it.
...snip....
I realize what I have written is a lot harder in real life.
Any comments? I would love to hear about what others do to keep there heads clear.
Commonwealth
If you are not already familiar with the "Milgram Experiment", do a google search.
Human behaviour is very disturbing.
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desksgo
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I couldn't agree more. The self-imposed pressure to be "that guy/gal that always seems to get the job done" is an incredible motivator to do a great job, but also to get yourself into some pretty lousy situations.Icebound wrote:The pressure from peers and from "authority" can be way, WAY more effective on us, than we care to admit.Commonwealth wrote:Good post Snaproll. Your experience shows in what you have written.
If anyone out there has the trick to not making "lazy decisions", or to making the safest decisions all the time I would love to hear it.
...snip....
I realize what I have written is a lot harder in real life.
Any comments? I would love to hear about what others do to keep there heads clear.
Commonwealth
If you are not already familiar with the "Milgram Experiment", do a google search.
Human behaviour is very disturbing.
...
Been there.
Great thread,
There is definately pressures in all levels of Aviation, which is very unfortunate.
Probably the least pressure is when learning to fly. WX terrible you dont go.
Its very easy to be an arm chair umpire and sit back and say "I would not have gone..."
The pressures never really stop. In the airline industry we are continually exposed to numerous pressures. On time departures I have found is ine of the biggest ones faced a lot of the time.
Turning up to an aircraft with MEL;s all over the place and having to work through them to ensure all is as it should be and the flight can depart legally is a hige time consumer. Especially as you only sign on 1 hour prior to departure.
One Captain told me of a flight where the engineers were putting pressure on him to take the plane and go. After a while and trying all the "diplotmatic" ways of communication he told the engineer "See these four bars mate, they stand for : this is my aircraft, now @#$! off"
Probably not the most recommmended approach but effective none the less.
Always remeber that the buck stops with the P.I.C
Some old salt onec said "this is the order of importance: life, licence then job"
True
There is definately pressures in all levels of Aviation, which is very unfortunate.
Probably the least pressure is when learning to fly. WX terrible you dont go.
Its very easy to be an arm chair umpire and sit back and say "I would not have gone..."
The pressures never really stop. In the airline industry we are continually exposed to numerous pressures. On time departures I have found is ine of the biggest ones faced a lot of the time.
Turning up to an aircraft with MEL;s all over the place and having to work through them to ensure all is as it should be and the flight can depart legally is a hige time consumer. Especially as you only sign on 1 hour prior to departure.
One Captain told me of a flight where the engineers were putting pressure on him to take the plane and go. After a while and trying all the "diplotmatic" ways of communication he told the engineer "See these four bars mate, they stand for : this is my aircraft, now @#$! off"
Probably not the most recommmended approach but effective none the less.
Always remeber that the buck stops with the P.I.C
Some old salt onec said "this is the order of importance: life, licence then job"
True
I don't think the pilot should have to be worrying about whether everyone else has done their job effectively before he/she departs. For instance, it should be "guaranteed" by the maintenance department, that there are no snags - that the aircraft is "airworthy".
Former Advocate for Floatplane Safety
Widow,
Pilots currently must accept the aircraft, prior to flight, in an airworthy state. Most Company Operations Manuals detail the methods that they will use and follow to technically dispatch an aircraft. However, it is not the pilot's function to do a maintenance inspection prior to a flight to determine airworthiness. He/she will determine from the aircraft's journey logbook whether there are any unservicabilities or repetetive inspections that require immediate attention. Of course a "walk-around" is also required but rarely would that determine "airworthiness". It may however, determine un-airworthiness.
Licensed engineers are the only ones qualified to make the determination of airworthiness, and based on their signing the aircraft out, I assume (until I see otherwise) that their determination is valid.
Pilots currently must accept the aircraft, prior to flight, in an airworthy state. Most Company Operations Manuals detail the methods that they will use and follow to technically dispatch an aircraft. However, it is not the pilot's function to do a maintenance inspection prior to a flight to determine airworthiness. He/she will determine from the aircraft's journey logbook whether there are any unservicabilities or repetetive inspections that require immediate attention. Of course a "walk-around" is also required but rarely would that determine "airworthiness". It may however, determine un-airworthiness.
Licensed engineers are the only ones qualified to make the determination of airworthiness, and based on their signing the aircraft out, I assume (until I see otherwise) that their determination is valid.
This is my point. Why hasn't someone before the PIC picked up on these "unservicabilities or repetetive inspections that require immediate attention"? Or that the aircraft is "un-airworthy"? Besides, you know as well as I that log books are not always factual. I can provide proof that this was the case with CGAQW. It's like an audit, rather than an inspection. It just looks at the paper. I have heard many stories of pilots complaining about a maintenance issue with an aircraft (or the weight, or the weather, etc.) and being "pushed" into flying irregardless. The PIC's paycheck should not depend on doing what he/she is told. SATOPs pointed that out. Yet if something goes wrong, it is the PIC who takes the wrap. SATOPs pointed that out too.pushyboss wrote:He/she will determine from the aircraft's journey logbook whether there are any unservicabilities or repetetive inspections that require immediate attention. Of course a "walk-around" is also required but rarely would that determine "airworthiness". It may however, determine un-airworthiness.
Former Advocate for Floatplane Safety
Widow,
Often times it is only the pilot who determines unservicabilites. Something "breaks" during a flight and is subsequently reported to maintenance. As for repetetive inspections, how is a mtc department supposed to track them if not by the pilot informing them of when the next inspection is due, as indicated by the time in the aircraft journey log. Our logbooks have both the next major inspection listed(either the hour limit or the calendar limit) and the next minor repetetive inspection. Our pilots are to maintain situational awareness regarding these inspections and let our dispatch know what time is remaining. This is done daily.
As for falsified records....That is criminal.
Pilots must learn very early in their careers that NO is often not only the correct answer but the only answer. If a pilot accepts a mission knowing the aircraft is U/S and/or that the weather is extremely marginal or beyond their particular capability, then yes I would consider that pilot error. Regardless of the "push" they were receiving from management or ownership. I have counselled many a new pilot that at the end of their career, when they are bouncing their grandchildren on their knee, that the cancelled flight in 1984 to East Armpit Saskatchewan, did not and does not matter.
Often times it is only the pilot who determines unservicabilites. Something "breaks" during a flight and is subsequently reported to maintenance. As for repetetive inspections, how is a mtc department supposed to track them if not by the pilot informing them of when the next inspection is due, as indicated by the time in the aircraft journey log. Our logbooks have both the next major inspection listed(either the hour limit or the calendar limit) and the next minor repetetive inspection. Our pilots are to maintain situational awareness regarding these inspections and let our dispatch know what time is remaining. This is done daily.
As for falsified records....That is criminal.
Pilots must learn very early in their careers that NO is often not only the correct answer but the only answer. If a pilot accepts a mission knowing the aircraft is U/S and/or that the weather is extremely marginal or beyond their particular capability, then yes I would consider that pilot error. Regardless of the "push" they were receiving from management or ownership. I have counselled many a new pilot that at the end of their career, when they are bouncing their grandchildren on their knee, that the cancelled flight in 1984 to East Armpit Saskatchewan, did not and does not matter.
It wasn't the journey log that was not factual in our case, it was the maintenance logs (sorry I didn't make that clear, but if the journey logs tell the pilot that the aircraft had it's xx hr inspection, but not that all airworthiness directives, etc., had been adhered to, then the journey log book doesn't really mean much) . The pilot cannot be responsible for that.
Former Advocate for Floatplane Safety
Valid points raised by pushyboss and widow.
But it IS is the PIC that signs foe the "keys" at the end of the day.
If maintanace doctor records then that is criminal.
It has happened in the past, sometimes with terrible consequences. Those people have ended up in jail, no it does not bring back loved ones.
Fortunately these are rare cases.
A quote i heard once: "the only gurantees in life are taxes and death"
But it IS is the PIC that signs foe the "keys" at the end of the day.
If maintanace doctor records then that is criminal.
It has happened in the past, sometimes with terrible consequences. Those people have ended up in jail, no it does not bring back loved ones.
Fortunately these are rare cases.
A quote i heard once: "the only gurantees in life are taxes and death"
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binderdundat
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Widow the way I read it ... the maintenance for that airline was done by another company rather than and in house mechanic. If I remember correctly it was sealand aviation that did the maintenance on their ac. What would sealand have to gain by falsifying documents. Wouldnt it just take money out of their pockets and for what gain to Sealand. And another point... with the investigation after the accident wouldnt it be brought to sealands attention that there were inconsistencies in the maintenance log and what would sealand have to gain by knowingly covering up someonelses fraud. Dosnt make sense to me.
This is from the TCCA Inspection Report on CGAQW dated December 20, 2006:
This inspection was done because the TSB said they were "finished", and the families were still insisting that the floats be looked at by someone who knew something.
PS. Please edit out the company name. I've tried very hard never to name them.
You tell me why they did it.Due to concerns regarding technical records an enforcement action has been initiated with a Detection Notice alleging that major repairs were performed without required data and without required certification.
This inspection was done because the TSB said they were "finished", and the families were still insisting that the floats be looked at by someone who knew something.
PS. Please edit out the company name. I've tried very hard never to name them.
Former Advocate for Floatplane Safety
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binderdundat
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binderdundat
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It's public knowledge who did their maintenance I cant imagine the guys at sealand doing anything illegal or underhanded. If you say that the maintenance was done incorrectly people automatically read between the lines and know who you are talking about. It doesnt matter whether you name the company people know who you are slandering.
TCCA sent this report directly to me. I'm sure they have their own copies you could access through Access to Information and Privacy. It did not come to me with any disclaimers. They also took plenty of photographs.
I have prefered not to use the name. As you say, those in the know, already know. I still ask that you remove it.
If you disclose to me who you really are (you can do it privately), I may be willing to send you a copy of the report.
They weren't happy about writing it ... they took almost all our questions and distorted them to make us look stupid, but in the end, what was there was there, and could not be ignored. As it states, an enforcement action has been initiated. Or so the report claims.
I have prefered not to use the name. As you say, those in the know, already know. I still ask that you remove it.
If you disclose to me who you really are (you can do it privately), I may be willing to send you a copy of the report.
They weren't happy about writing it ... they took almost all our questions and distorted them to make us look stupid, but in the end, what was there was there, and could not be ignored. As it states, an enforcement action has been initiated. Or so the report claims.
Former Advocate for Floatplane Safety
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Mitch Cronin
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Widow... forgive me please, I haven't yet read the rest of the thread, but it appears from this comment that you don't really understand the world of aircraft maintenance...Widow wrote:I don't think the pilot should have to be worrying about whether everyone else has done their job effectively before he/she departs. For instance, it should be "guaranteed" by the maintenance department, that there are no snags - that the aircraft is "airworthy".
The serviceability of the aircraft is guaranteed by the folks who release the aircraft. Our signature is that guarantee. All of us strive for that to be the guarantee you'll never need, most of us help to make it exactly so.... ...and some of us know that all of us suffer when one of us screws up.
There are tales of unscrupulous bosses, ...who push for production, and scrimp on supplies of parts and/or downtime, and intimidate employees into co-operating with such nonsense.... tales we're all certain are true...., but you can be sure there would be no flying done if pilots couldn't trust us.
Not all is as bad as you have seen.
...and while I'm here...
... If I thought an apology for whatever our * contribution to your husband's death was would even have the remotest chance of putting a touch of warmth in your heart, I'd offer one in an instant, as sincere as any could ever be... but I rather think such a thing would ring somewhat hollow in your mind, so I'll not put you in that place.... but please know the want exists....again I feel compelled to say thank you for your persistence.
* our aircraft maintenance brotherhood - so to speak...
Cheers,
Mitch
PS. I really think you oughta find a hairbrush before your next tv interview.
M.C. I by no means believe that this is the case with even a minority of maintenance facilities. I, like you, believe that probably damn near all the time the maintenance folk do do the very best job they can. But when they don't, and especially when that don't results in someone getting hurt, then they should be held accountable.
I don't know why the maintenance facility for MJM didn't do their best work on CGAQW. As I understand it, they do some very fine work. But not always. Certainly in the case of CGAQW they were not doing their best. Perhaps the owner of the AMO had no knowledge of what was going on, although when he came to look at the wreckage, it is odd that he didn't see the same things that the TCCA safety inspectors later did, such as "numerous repairs to all the deck combings". Maybe someone working for the AMO was friends with the owner of MJM or used to work for MJM and this somehow affected his/her judgement.
PS. Yeah, I haven't got a hairdresser on my expense account.
I don't know why the maintenance facility for MJM didn't do their best work on CGAQW. As I understand it, they do some very fine work. But not always. Certainly in the case of CGAQW they were not doing their best. Perhaps the owner of the AMO had no knowledge of what was going on, although when he came to look at the wreckage, it is odd that he didn't see the same things that the TCCA safety inspectors later did, such as "numerous repairs to all the deck combings". Maybe someone working for the AMO was friends with the owner of MJM or used to work for MJM and this somehow affected his/her judgement.
PS. Yeah, I haven't got a hairdresser on my expense account.
Former Advocate for Floatplane Safety
