First Air Crash Resolute Bay August 20 2011

[trey kule]

Pelmet...


How can something be non pertinent and relevant at the same time? If the personal details were felt to be the cause , then they are, in fact, pertinent. Good argument. Definitely a pertinent example to demand to hear every last word spoken.....for learning purposes, of course.

An exceptional example is always a good way to justify what you want.

[Rowdy]

Isn't there a sterile cockpit SOP/CARs reg for 705? Which would mean there shouldn't be any personal discussion at that point in the descent and approach?

I also agree that the actual CVR recordings should not be released in the PUBLIC report. A transcript of directly relevant communications, maybe.

[Canoehead]

As far as I know, in the US, sterile cockpit is a regulation. In Canada it is only company policy. I'd bet anything that it's been in First Air's SOP's for eons.

[pelmet]

Pelmet...


How can something be non pertinent and relevant at the same time? If the personal details were felt to be the cause , then they are, in fact, pertinent. Good argument. Definitely a pertinent example to demand to hear every last word spoken.....for learning purposes, of course.

An exceptional example is always a good way to justify what you want.

I'm afraid that you will have to ask the NTSB, a highly respected aircraft accident Investigation agency how they have been determining what is non-pertinent and what is relevant for many years. The NTSB contact number can be found on their website.

I suspect that they have a lot more credibility on the issue than someone who has just proven once again, that he did not read and understand what I posted.

There are a lot of very credible organizations out there focused on aviation safety. One of them is the Flight safety Foundation which has published many articles on safety issues and has an excellent publication called Aero Safety World. I have read many of their magazines and you should too. You will find in their analysis of accident reports that they quote the CVR recordings as appropriate for the articles they publish. Why do they do this? Because there is much to learn from them.

http://flightsafety.org/aerosafety-world-magazine

As far as I am concerned, hiding the flight related portions of CVR recordings completely, as is usually done in Canada and some other countries, is a detriment to flight safety in terms of learning from these accidents in order to prevent similar from happening again in the future. Not surprisingly, it appears that some highly respected aviation safety organizations feel the same way.

[john_seymour]

Pelmet...


How can something be non pertinent and relevant at the same time? If the personal details were felt to be the cause , then they are, in fact, pertinent. Good argument. Definitely a pertinent example to demand to hear every last word spoken.....for learning purposes, of course.

An exceptional example is always a good way to justify what you want.

+1

That's exactly the point. And if you did crater in, what are you worrying about? You're dead. It's kind of hard to worry about what people think of you when you're dead.

[john_seymour]

John Seemore, I find it very distressful that a pilot (if, indeed you are one?) would come out for what basically constitutes "spying" on a fellow pilot's last half hour of life. It's macabre, to say the least. There are other issues to whine about in regards to the TSB. Like the two to three years it takes to come up with report in the first place? Your priorities are out in left field.
Illya

Have you looked at any of these reports? They are not something drawn up in one afternoon. Their engineering reports the take a significant amount of time to complete, accident reconstruction, simulation, debris analysis (Swissair 111 broke into *millions* of pieces), etc. Just because they take time doesn't mean there isn't a reason behind it. Too bad you don't spend more time on some of your posts.

[Illya Kuryakin]

Gee Seemore, wish I had your wisdom.
Illya

[Edo]

Isn't there a sterile cockpit SOP/CARs reg for 705? Which would mean there shouldn't be any personal discussion at that point in the descent and approach?

I also agree that the actual CVR recordings should not be released in the PUBLIC report. A transcript of directly relevant communications, maybe.

And thats exactly what we have in this case, no need to hear the audio. If the crew had been discussing non relevant BS it would have been mentioned in the report.

Coglen was different the F/o was complaining of commuting, poor sleep, a cold, and inexperience to in ice....very revelant, but we still DO NOT need the audio released a transcript is fine. I read the report/transcript and thats enought to paint a very vivid picture and learn from it.

Frankly anyone who wants to listen the to final minutes of a CVR disturbs me.

[CFR]

If you want to listen to a CVR ... join the TSB!

[Old fella]

Correct me if I am wrong but I am not aware of any 1st world investigative body(NTSB, TSB etc) that releases actual CVR audio as part of their final reporting process. Transcripts yes, having said that there has been actual audio made available but not from an investigation, again do correct me .

[john_seymour]

Correct me if I am wrong but I am not aware of any 1st world investigative body(NTSB, TSB etc) that releases actual CVR audio as part of their final reporting process. Transcripts yes, having said that there has been actual audio made available but not from an investigation, again do correct me .

http://www.airdisaster.com/cvr/cvrwav.shtml

[Old fella]

Yes, I was aware of that site but question is/was were those audio recordings officially released as part of the investigation from NTSB etc and included in the final report. My understanding(and subject to correction) all of those audio CVR got into the public domain as a result of litigation from outside parties where the courts determined they were required to give a picture/sound of what really happened.

As far as I know, even in the NTSB public Docket, audio CVR isn't made available as part of that process, at least I didn't see any. To echo another poster, who is really interested in hearing the last min/sec of a persons life outside of persons in the investigation area or for that matter seeing actual pictures aftermath from a major crash. People with a morbid curiosity I would assume are into this, people who would watch the video of SOBs heaving out from the 80+ story 9/11 burning twin towers. But hey, whatever centers your needle.

[pelmet]

Frankly anyone who wants to listen the to final minutes of a CVR disturbs me.

I unfortunately listened to one a couple of months back for a fatal accident which I will not mention. It was an accident where I have never been able to find a report to this day so I wanted to see what happened. I have to admit that I was very shaken by the last several seconds that were after initial impact. There is really no need for the audio, just the transcript to read with non-pertinent items deleted as previously mentioned.

I'm fine with the trained accident investigators(at least in the more advanced countries) deciding what is pertinent.

[Still learning]

CVR recordings are privileged communications for many reasons.

As one bereaved I am already struggling to process the transcript provided and the sequence of events. The last thing I want is to hear or even read all. What we need has been provided.

[Mr. North]

Bad acting aside, there are plenty of lessons to learn from this.

https://www.youtube.com/watch?v=-1LuPTPwPus

[Trematode]

Am I alone in not understanding why descent was continued or even initiated in the first place despite not ever being established on the LOC?

They never really addressed this in the report, either. The findings dance around the fact with discussion of compass headings and autopilot modes -- leading captain to believe the LOC would be reintercepted -- but a basic rule of IFR flying is ignored by descending out of a safe altitude without being established on the localizer and there is no direct mention of it? All other factors aside, if they wouldn't have broken this simple rule there wouldn't have been an accident.

[FICU]

They failed to mention the completely unstable approach with late configuration and the PF being behind the jet most likely causing a helmet fire and tunnel vision.

[trampbike]

but a basic rule of IFR flying is ignored by descending out of a safe altitude without being established on the localizer and there is no direct mention of it?

Did you read the TSB report?

[Trematode]

Did you read the TSB report?

Yeah -- and I found the tone and focus of the TV re-enactment closely followed that of the report: Lots of in-depth analysis given to minutia like compass calibration and CRM issues of exact phrasing. Don't get me wrong, these were all things that could have saved them -- but nothing seems to highlight the elephant in the room, which is descending below a safe altitude, in IMC, outside of the required lateral parameters (ie. established on the localizer).

[trampbike]

9. The first officer indicated to the captain that they had full localizer deflection. In the absence of standard phraseology applicable to his current situation, he had to improvise the go-around suggestion. Although full deflection is an undesired aircraft state requiring a go-around, the captain continued the approach.

I thought they were clear enough on the subject, and to me it seemed to be the main point of the report.
They interviewed First Air FOs and many of them said that they were unlikely to take control over a captain not initiating a go around in such a situation. Very frustrating.

[Liquid Charlie]

If Mayday accurate it points out that not following SOP can have deadly consequences -- SOP states - unstabilized approach below 1000' - automatic "go around" and also full deflection of either G/S or localizer inside the FAF - automatic missed approach -- so 2 compulsory items calling for missed approach and yet they continued -- the F/O was voicing concerns but not in the SOP format (until last second) and not forcefully enough that's why the trigger words - in this case "go around" should have been coming out of his mouth loudly and and as many times as it took and eventually to grabbing the wheel and slapping captains hands toward the firewall -- this is industry standard -- this is an extreme case and I'm sure this scenario will or has been introduced into actual sim profiles - like I said before I always included the go around responsibilities to my F/O and told him that if he was at any time uncomfortable -- yell "go around" and we will get the fuc outa there and regroup and discuss it at a safe flight regime and modify our plans -- and yes it is up to the F/O to ask the question of his captain if there is any grey area in your mind about anything -- be safe out there

[Donald]

The Mayday video is fictional or incorrect in many places, if you truly wish to learn about this accident I suggest you read the TSB report.

http://www.tsb.gc.ca/eng/rapports-repor ... 1h0002.asp

[URC]

The TSB totally ignores the Captain's past training record and performance. Contrast this to the United States and the NTSB report on the UPS Birmingham crash.

The captain was hired by UPS on October 29, 1990, as a 727 flight engineer and transitioned to a 727 first officer in August 1994. UPS records indicate that the captain attempted to upgrade to Boeing 757 captain twice—in July 2000 and September 2002—but voluntarily withdrew from training during classroom instruction, returning to the position of 727 first officer on both occasions.

The UPS training department did not retain the training records for the captain’s two uncompleted 757 upgrade attempts. Records indicated that the captain also had multiple failures of home study programs in 1991 and 1992 and that he failed maneuvers validation in 2007. Further, the captain’s training records revealed multiple substandard elements related to nonprecision approaches (most recently June 2013).

Not sure why the TSB would choose to ignore these issues ? Perhaps it's something we can't handle being in politically correct Canada ?

[Meatservo]

I know it's just a side- issue but the repeated description of the ILS as "a system that uses the autopilot to land the plane so the pilots don't have to do anything" is annoying and speaks to the ability of the presenters to actually understand and present the facts. Especially since, if that was in fact what the ILS does, this would not have happened.

The TSB report is extremely lengthy and and detailed and brings up a lot of issues that are worthy of discussion... the Mayday show in my opinion is too technical for the layman to really understand what the issue was, but not technical or accurate enough for pilots to be able to really get anything helpful from, other than by some educated assumptions.

[godsrcrazy]

I believe there were things not put in this report by TSB. This would be to protect their brothers at Transport Canada. I say this as i have witnessed Transport inspectors doing audits. As many as 9 in a room at one time from different regions. The screaming that went on was unbelievable as none of them could agree on what the rules were. I was told this 737 had one of the oldest outdated TWAS systems in it. Some say that would have not been allowed be western region.