For RJ Pilots and others

[Kip Powick]

This was passed to me by a respected and serving pilot.

For three and a half minutes on the night of Oct. 14, 2004, Capt. Jesse

Rhodes and First Officer Peter Cesarz were on top of the world. The two

Pinnacle Airlines pilots had pushed their twin-engine, 50- seat regional jet

to its maximum altitude and were now proud members of the "410 club ," an

unofficial society of Pinnacle airmen who've attained 41,000 ft. in a

Bombardier CRJ200.

Rhodes went to the galley to grab cold Pepsis tocelebrate. He was barely settled back in the cockpit when the plane's radio crackled.

"Are you a RJ [regional jet] 200?" inquired an air traffic

controller in Olathe, Kan. "I've never seen you guys up at forty-one there."

"Yeah ... we don't have any passengers on board so we decided to have a

little fun and come on up here," Rhodes replied.

The fun was short-lived.

Moments later, both engines flamed out.

The fate of Flight 3701 is the ubject of an intensive investigation by the National Transportation Safety Board (NTSB), which is expected to issue a final report on the accident in the next few months. Until then, neither Pinnacle Airlines, which operates connecting flights for Northwest Airlines, nor Bombardier and General

Electric--the airplane and engine manufacturers--can comment on the cause of

the accident. However, the pilots' taped cockpit conversations and

preliminary hearings last June suggest a scenario involving poor judgment,

insufficient training and the complications that can occur when a plane is

pushed beyond its capabilities.

TO THE LIMIT: Rhodes, 31, and Cesarz, 23, were on what

pilots call a deadhead, transferring an empty plane

overnight from Little Rock, Ark., to Minneapolis so it could

be ready for a morning flight. The Canadian- built CRJ200 is Pinnacle's

workhorse, making short and midrange hops mostly in the Midwest. From

wheels-up, it was clear that Rhodes and Cesarz intended to see what the

CRJ200 could do.

Four seconds after takeoff at 9:21 pm, the two pilots

did a "pitch up" maneuver that pinned them in their seats with 1.8 g's of

force and momentarily triggered an alert from the airplane's stall warning

system. Minutes later, Rhodes and Cesarz again yanked back on the control

column, rocketing the plane upward and generating over 2.3 g's of force

before they eased off the flight controls. After briefly leveling off at

37,000 ft., the crew set the autopilot to climb at 500 ft. per minute--more

than twice the fastest recommended rate--to the airplane's maximum altitude

of 41,000 ft. As the plane rose, it succumbed to the physics of high-altitude

flight: Thin atmosphere offers less lift and robs the engine of air. Stuck in

an aggressive climbing mode, Flight 3701's speed began to drop. To maintain

the rate of climb, the autopilot angled the nose of the aircraft up, slowing

it further. By the time the aircraft reached 41,000 ft. and leveled off, it

was flying slowly, at 150 knots indicated airspeed, and was perilously close

to losing aerodynamic lift--or stalling.

"This thing ain't gonna [expletive] hold altitude," Cesarz

said.

"It can't man," Rhodes replied. "We [cruised/greased] up

here but it won't stay."

The combination of high altitude and low speed once again triggered the

Bombardier's stall warning system. First, "stick shakers" rattled the control

columns and disengaged the autopilot to alert the crew of an imminent stall.

When the crew didn't lower the plane's nose to gain speed, "stick pushers"

forced the control columns forward. The flight data recorder shows that

Rhodes and Cesarz overrode the stick pushers three times and forced the

plane's nose back up. At 9:55 pm, as they pulled up for the last time, both

engines flamed out.

"We don't have any engines," one of the pilots said.

FAILED EFFORTS: While the altimeter spun downward, the crew hurriedly

reviewed their options for restarting the engines. At that altitude, there

were six suitable airports within reach for a forced landing. Despite the

serious nature of their predicament, the pilots did not notify air traffic

control (ATC) of their situation or request emergency landing clearance

First, they tried a "windmill restart" by diving to increase airspeed. The

maneuver is intended to force air into the engine housing, spinning the

rotors and creating enough compression for ignition. The procedure requires

at least 300 knots of airspeed. But at 20,000 ft. and only 236 knots, the

crew pulled up, and decided instead to try a second

option: Drop to 13,000 ft. and attempt to relight the

engines using the plane's auxiliary power unit (APU), which generates

pneumatic pressure to spin the engine's core.

Rhodes and Cesarz tried at least four times to jumpstart the engines using the APU. On each attempt theengine cores recorded no rotation. > > At 10:03 pm, the crew radioed ATC that they had a single engine failure. Five minutes later, at an altitude of 10,000 ft., and descending at 1500 ft. per minute, Rhodes and Cesarz were running out of options for restarting the engines. Finally, 12 minutes after

the twin flameout, they revealed to ATC that they had a double engine

failure. The plane's landing choices were now limited to two airports.

With the runway lights of Jefferson City airport in sight,

but altitude slipping away, Rhodes and Cesarz realized they were in big

trouble.

"Dude, we're not going to make this," Rhodes said. "We're gonna

hit houses, dude."

They crashed 2-1/2 miles shy of the runway--behind a

row of houses. On impact, the plane split apart, flipped over and caught

fire. Rhodes and Cesarz were killed. Miraculously, no one on the ground was

injured.

THE INVESTIGATION: An area of contention during the NTSB

hearings about Flight 3701 has been whether a condition called "core lock"

contributed to the fatal crash. Under normal conditions, the rotating parts

inside a General Electric CF34-3B1 turbofan engine slip by each other in a

finely tuned choreography. However, when an engine is shut down suddenly

at high torque , high altitude, and it isn't restarted immediately, metal

parts inside the engine begin to cool and contract at different rates. In

rare cases, metal can contact metal and prevent the core from rotating

freely-- core lock.

The Air Line Pilots Association suggests that core

lock, rather than pilot error, might have been the primary cause of the

accident. But, a review of the flight data recorder makes clear that the

pilots made a series of poor, and potentially fatal, decisions irrespective

of whether the engines experienced core lock.

The Bombardier has a41,000-ft. service ceiling. However, according to the climb profiles in the crew's flight manual, the maximum altitude for the 500-ft.-per-minute climbthe pilots set was only 38,700 ft., based on the atmospheric conditions andthe aircraft's weight that night. By operating outside the airplane's

performance envelope, Rhodes and Cesarz subjected the engines to tremendous

stress. The flight data recorder shows that soon after the crew ignored the

fourth stall warning, the core temperature of the right engine reached 2200

degrees--almost 600 degrees above redline.

When investigators pulled apart the right engine, they

found that the ends of the high-pressure turbine blades had liquefied,

resolidifying on the low-pressure blades behind them. This leads some

industry experts to question if the right engine ever could have restarted.

Whether the left engine locked up is still being investigated. GE helped

the NTSB disassemble Flight 3701's engines. Edward Orear, GE's former program

manager for the CF34-3B1 engine, testified to the NTSB that neither engine

showed evidence of core lock.

THE OBJECT LESSON: The data recorder shows

that the pilots failed to follow proper procedures for restarting a

flamed-out engine when they pulled out of their dive before reaching the

necessary speed to spin the core. Whether the apparently undamaged left

engine could have restarted if they had windmilled correctly may never be

known. It's also unresolved why the left engine didn't restart when the

pilots used the APU. Since the crash, Pinnacle has set a ceiling of

37,000 ft. for all CRJ200 flights. It has also added detailed climb profiles

to the pilots' quick reference guides. And the airline has modified its

simulator training program, incorporating dual engine failure and stall

recovery scenarios.

Although Flight 3701 ended tragically, it illustrates

how many safety features protect commercial passengers. The crew misused the

auto-pilot, took the plane outside its envelope and repeatedly overrode the

safety system. As one pilot said "It's an object lesson in how many things you have to get wrong in order to crash your plane."

[Guest woxof]

"The Air Line Pilots Association suggests that core

lock, rather than pilot error, might have been the primary cause of the

accident. But, a review of the flight data recorder makes clear that the

pilots made a series of poor, and potentially fatal, decisions irrespective

of whether the engines experienced core lock."

Isn't that typical for ALPA. It's always someone else's fault.

[canadairguy]

The article is taken from the Jan 06 edition of Popular Mechanics. It's also available at popularmechanics.com

[exGXer]

Isn't that typical for ALPA. It's always someone else's fault.

Just a little something they learnt from ACPA.

[Gumbi]

Isn't that typical for ALPA. It's always someone else's fault.

Could it be that they do it in order to protect their members until the final report is out?

I guess you're aware that everybody's quick on blaming the pilots, even their peers sometimes...

Obviously, this time (according to the DFDR and CVR in the article), it looks like they used poor judgment, but it's not always the case.

[Kip Powick]

Isn't that typical for ALPA. It's always someone else's fault.

Well think about it......if you had an accident wouldn't you expect your union to do all it could to clear you of any blame?? Isn't that what the union should be doing? How about the one at MidWay??.....the union is pushing that it the pilots are not wholly to blame when I would imagine there are a multitude of drivers out there that feel that what they got themselves into was their own fault.

The union reps have the resources and the expertise, (experts)......why not let them do what they can??

[Guest woxof]

I would expect the union to be unbiased and work for the truth. If I use extremely poor judgement and write off an aircraft, I don't think it is the union's job to deflect the blame. The Southwest accident at Midway is much different than the Pinnacle RJ accident. If I'm getting a bum rap, then it's the union's job to defend me. You know as well as I do that union's have a tendency to blindly defend incompetency and people who rightly should be fired. That's not the reason that union's were justifiably established in the first place.

[Kip Powick]

You know as well as I do that union's have a tendency to blindly defend incompetency and people who rightly should be fired.

I agree but we don't see too many fired do we? The reason we don't is extremely obvious but no one wants to confront it.

[handyman]

I would expect the union to be unbiased and work for the truth.

Would you expect your lawyer to be unbiased as well?

I think the union should support their members until the final report is published then they should decide where they stand with the findings.

[Guest woxof]

Would you expect your lawyer to be unbiased as well?

I think the union should support their members until the final report is published then they should decide where they stand with the findings.

Not sure what my lawyer has to do with this but hopefully his/her arguements in any case that I would be involved in would be factual instead of trying to blame another party. As we already know, the lawyers for one or both of the parents are suing Bombardier. It would appear the union has a similar thought process on who's fault this is.

Keeping in mind that this is a news article that started this thread, I would say that from this quote " The Air Line Pilots Association suggests that core lock, rather than pilot error, might have been the primary cause of the accident", it would seem that the union has already decided where they stand and are trying to influence the findings. Supporting your membership shouldn't come at the expense of the truth.

[UpperDeck]

Your lawyer better be "unbiased" if by that word you mean "objective".

If you were the accused, your lawyer would be doing you a disservice if his first tactic was to attribute blame to every other party in the neighbourhood. Your lawyer should engage in the search for truth if its discovery will exonerate you; elsewise, his job is to ensure your guilt is legally established. Again...that does NOT mean attempting to affix the blame to an innocent bystander.

In my opinion, the occupation is disserviced when individuals (and the union) give a "pass" to brethren they reasonably suspect are less than fully competent. Banding together in solidarity may give one a sense of personal comfort but it may well put others in jeopardy.

If the facts are clear and there is probable grounds for determining the existence of "pilot error" then there is much more to be gained from acknowledging the fact and learning from the experience than from turning a blind eye.

Better yet....when you KNOW that a fellow pilot is having trouble that might put him at risk, then he should be identified and assisted. That is where a union and a responsible employer can provide the most legitimate and effective intervention.

[UpperDeck]

Woxof...I agree. I was writing as you were posting.

[Don Hudson]

Kip, as you will know from your airforce background that there are always two responses to an accident...the investigative response and the representational response. My understanding of the airforce's methods was to always value the truth in any investigation regardless of where it went.

I realize that the process is never as clinical as we may idealistically conceive and that cross-pollination of agendas occurs but the intention was always to uncover truth regardless of where it may lead.

An SMS culture within a private corporation requires a similar approach. There is a substantial learning phase, accompanied by some natural reluctance within private organizations, in moving towards a non-punitive environment. The natural reaction to unexpected occurences, especially where high expectations and high stakes are involved is to punish. SMS requires that such reactions be set aside in favour of preventative approaches. It is not an easy thing to do especially when elements beyond the organization which do not understand these processes are clamouring for a more primordial response...

In the very recent past and even today, pilot organizations will defend their members (as they are required to in law) but not with flight safety data. The conflict between the two primary responsibilities, that of achieving the truth and that of speaking for the crew, will remain factors so long as there is a blame culture and an absence of legislation which sanctifies flight safety information, flight data recorder products and CVR information. It used to be that the pilot was the 10,000A fuse in a system which retained its aloofness. Early organizational studies, mainly into the nuclear energy industry, have correctly moved the focus off the individual and into systemic causes.

This is not to deny that people may be at fault, but the notion of "intention", ...relatively new to the conversation, has become part of the SMS dialogue. Fining, firing, suspending and otherwise blanket-blaming people has proven time and again not to be a solution to lowering the accident rate in high risk industries. Nor does this mean that "cause" cannot be discovered and assigned as it clearly was in both the Challenger and Columbia accidents. The issue is not about the avoidance of responsibility, but about the organizational handling of error.

That most major carriers now have Safety Reporting Policies which focus on learning by providing prosecutorial immunity to individuals who self-report or who are involved in an incident is a sign that this process has matured since the 1960s and '70s.

I think you will agree that where intentional and egregious behaviours are involved and not just those human helmet fires, the primary issue is no longer just a flight safety matter but a "human factors" issue with far broader underlying causes and accompanying solutions.

Unions must defend their members by law but, as ALPA and ACPA have both shown very well, they have significant professional roles to play in flight safety work. Much law, policy, technical and procedural change has been wrought by ALPA, not without substantial, expensive and long battles with Washington. ACPA is also there, facilitating change, engaging the safety process and taking its professional and not just its representational responsibilities seriously.

Again with reference to the airforce, my inexperienced though informed understanding is, even if a crew screwed up, the truth was sought no matter where it went. Whether someone "paid for it" was another issue entirely but that part wasn't (and couldn't be) a flight safety matter. The intention in flight safety work is to leave the politics to others, especially the representative issues, and let the flight safety people within the organization and the union get to the truth. Representatives don't belong at flight safety meetings and should not have access to flight safety reports and data in representational matters, and flight safety people don't belong in hearings regardless of the issues.

For many, including airline managements and pilot's unions, this requirement for a clinical separation between investigative and representational roles is still badly misunderstood or is only coming into focus now as the SMS process unfolds. The moment flight safety information cannot go where it must go regardless of where it leads, or the moment any prosecutorial/representational process involves the use of flight safety data to advance the cause of either party, the flight safety process is irrecoverably in conflict and is essentially over for both organizations.

The issues which arise out of the legal requirements for "due diligence" on everyone's part must first be resolved in law. Hopefully, Canadian legislation will ultimately support the SMS position as it does in Australia today. The protection of flight data for learning and investigation only, is needed to eliminate the conflict of interest presently built into the system.

[Guest woxof]

While I know ALPA has helped positively in accident investigations in the past, I lost confidence that they had any impartiality after a Business Express training flight crashed into the Atlantic in 1991.

http://www.avsaf.org/reports/US/1991-12-28...hcraft1900C.pdf

If anything, read the CVR transcript.

A captain-trainee in the left seat had his attitude indicator disabled yet still uncovered. They were doing a procedure turn over the ocean on a dark night. An engine failure was simulated and the trainee upon becoming disoriented asked the instructor to take control. The instructor refused and instead tried to coach the trainee to recover from an unusual attitude. The plane crashed killing all three on board.

The NTSB put the blame on spatial disorientation, lack of company oversight of it's training program and the instructor pilot's poor judgement.

To quote from earlier in this thread "...if you had an accident wouldn't you expect your union to do all it could to clear you of any blame?" That appears to be how ALPA works . They found a pre-existing crack on an engine truss and put the blame on structural failure. What a coincidence. At the same moment as the trainee's disorientation.

Read here...

http://www.iprr.org/COMPS/blockislandpfr2.html

This is defending someone at the expense of the truth. And now it is the fault of Beech.

[Kip Powick]

Kip, as you will know from your airforce background that there are always two responses to an accident...the investigative response and the representational response. My understanding of the airforce's methods was to always value the truth in any investigation regardless of where it went.

Don, that is very true but the big difference between Civil and Mil is that the Mil was more apt to call a spade a spade and if a guy screwed up, in other words proved to be incompetent, without sound judgement, or a constant rule buster ...he was gone. Certainly FS looked at all aspects of the accident in hopes of preventing another such incident but if the investigation pointed at the individual as the root cause of the incident...he was gone. Not so in civil, (airline), aviation.

You and I, as well as many others, can point to incidents in airline aviation where the pilot(s) should be "gone" but they are still here. Why is that? To me the answer is quite simple but no one will confront the issue because it is not polite to point fingers and everyone believes "crap" can't run uphill.

Again with reference to the airforce, my inexperienced though informed understanding is, even if a crew screwed up, the truth was sought no matter where it went

That too is true....and if you are talking about the crew and their competency that too is true.... and it is probably true to a degree in the airline industry but there are never any personal consequences for those that have failed to maintain the parameters that are set out for everyone in airline aviation...why ???

Don, I neither speak nor write at 125words p/min with gusts to 150, but I do tell it like I see it. Many may not approve the method or the medium but I know no other way to call it as I see it. You screw up...you pay the consequences and I feel we see too much of the 3D, (Deny, Distort,Deflect) effect in airline accident reports with respect to the "drivers".

I have been following the Midway overrun and I would imagine you have as well. Granted all the info is not in, the accident investigation is not complete, but based on my sources these guys screwed up big time...but you can bet the end result will not place a heavy emphasis on pilot competency.

How long have planes been going in there and yet only now will the brass hats start to blame ATC/Met reports/runway environment etc. It has even been reported by the driver that he couldn't get into reverse....funny but the aircraft checks out in perfect condition and a new "notice" has come out about pulling reverse on that aircraft type.......good grief.....don't all pilots flying that type know how reverse works, (the foregoing is Deflection)......funny how much of this info has not made the press.......about a poor decision to land in the first place and given the R/W conditions etc...they touched down away past the recommended T/D point......sound like AF ????

I am not prejudging these guys, I am not priviy to all the info but this will be a case where it seems pretty clear that the drivers screwed up but there probably won't be any reprecussions to those involved and we all know why...don't we?

[IFG]

Don, that is very true but the big difference between Civil and Mil is that the Mil was more apt to call a spade a spade and if a guy screwed up, in other words proved to be incompetent, without sound judgement, or a constant rule buster ...he was gone. Certainly FS looked at all aspects of the accident in hopes of preventing another such incident but if the investigation pointed at the individual as the root cause of the incident...he was gone. Not so in civil, (airline), aviation.

You and I, as well as many others, can point to incidents in airline aviation where the pilot(s) should be "gone" but they are still here. Why is that? To me the answer is quite simple but no one will confront the issue because it is not polite to point fingers and everyone believes "crap" can't run uphill ....

Kip - What SMS (and a non-punitive approach generally) is getting at is the prevention of future accidents, period. Can you say with substantiation that the removal of 'incompetent' pilots, of which you seem so proud, reduced the military's rate of accidents. There is a strong inclination in all of us to see a disciplinary action as a part of a solution. The evidence indicates quite the contrary, that the accumulation of knowledge about systemic weaknesses, related to safety, is seriously weakened in such punitive environments.

The question to ask is: are we better off tolerating a higher accident rate, satisfied that we occasionally but vigorously weed out pilots, or should we subordinate the disciplinary endeavor in favour of overall harm reduction? Unfortunately, the answer to that usually gets bogged down in a rehash of some tale of particularly egregious pilot inadequacy. I'll suggest that the wider empirical view should prevail over the narrow, anecdotal one, even tho' some of the anecdotes are perfectly true!

The accident chain is thankfully rarely closed. You can remove pilots after every accident, and there will still be plenty of other weak sisters out there who slipped thru' the net. Waiting for them to crash is inefficient from a safety POV. If this particular accident investigation actually points to core-lock issues, that's to the good, whether or not it was a primary cause. More appalling IMHO, regarding the apparent unawareness of the implications of a stall warning (!?), isn't it better to confront the possibility of other, unknown ignoramusses (sp?), and attempt a remedy of that, than engage in a posthumous rebuke?

Woxof - As far as ALPA representation goes (and thankfully for AC drivers, I'm sure this goes for ACPA as well), Yer damn tootin' I want to see 100% passionate defence of any pilot after an accident, most particularly the dead ones. After all, they can't speak for themselves. If that is unpalatable for you, by all means take up accident investigation in a non-representational role. It's perfectly honourable to make judgements about serious matters, but if you are unable to forbear it, leave the representation to others. If the case against the pilots is so clear, the best defence will be for nought.

Cheers, IFG

[IFG]

While I know ALPA has helped positively in accident investigations in the past, I lost confidence that they had any impartiality after a Business Express training flight crashed into the Atlantic in 1991. .... 

The NTSB put the blame on spatial disorientation, lack of company oversight of it's training program and the instructor pilot's poor judgement.

  To quote from earlier in this thread "...if you had an accident wouldn't you expect your union to do all it could to clear you of any blame?" That appears to be how ALPA works . They found a pre-existing crack on an engine truss and put the blame on structural failure. What a coincidence. At the same moment as the trainee's disorientation ....

This is defending someone at the expense of the truth. And now it is the fault of Beech.

Hi again, woxof - Interesting reading. All 80 or 90 pages . Indeed, ALPA's petition looks like a stretch, but they did submit evidence, which the NTSB chose to disregard (correctly we'd likely both agree). More trivially, what better time for a suggested structural failure than during an unusual attitude recovery (altho' they weaken their own case with the assertion that the pilots were never disoriented ). In representing an interested party before a tribunal searching for the truth, that's advocacy, not lying as you seem to infer.

IAC, It is the NTSB, or TSB in our case, which impartially makes the findings. We do not pay our association dues for a needless duplication, we pay for advocacy in our defence. You may rest assured that the other 'parties', manufacturers, other victims etc, are not engaged in a collegial endeaver. The last thing pilots will need is their advocates colluding with the groupthink wherever it may be leading (likely to the most convenient and vulnerable scapegoat). ALPA was a positive influence in the past precisely because they didn't abandon their members. A classic:

Report: TWA 260 - Albuquerque, 1955

The cause was put down as an intentional deviation from course (presumably to go direct) leading to a CFIT accident. ALPA persistance eventually showed how a gyro stab failure could have led to it, and at least struck out the "intentional" part. Sadly, not every painstaking and rigourous defence turns out to be a heroic vindication of the innocent, but without the inclination and the wherewithall to undertake them, the occasional heroism is stifled. And, don't forget that this is not some monolithic bureaucracy accomplishing this, it's generally work done by, and driven by passionate volunteers (in that 1955 case, primarily of Larry DeCelles). How many here, who vilify the pilots discussed at the top of this thread, or those BEX guys (both cases with probable justification when all the cards are turned up) would have been in the comfortable majority excoriating the late Capt Ivan Spong in 1955?

Cheers again, IFG

[Kip Powick]

Can you say with substantiation that the removal of 'incompetent' pilots, of which you seem so proud, reduced the military's rate of accidents

Well , IFG you read what you want into my comments but you are stretching my intent it by insinuating that I am " so proud" of the fact that there were consequences in the Mil when it was proven beyond a shadow of a doubt that a guy screwed up and he was gone. I was not “proud” but I, like others, was satisfied that the individual was gone/grounded and taken out of the equation. Your question as to "substantiation of proof" if this method lowered the accident rate is without answer, as you well know. How can one "substantiate the future"? However a decision to “cease flying” was made in the "interests of the future" and I see nothing wrong with that.

My point is that there were consequences to your action in DND, and there are seldom consequences in the airline industry.....just look around at some of the individuals we still have… who possibly shouldn't be here.

More appalling IMHO, regarding the apparent unawareness of the implications of a stall warning (!?), isn't it better to confront the possibility of other, unknown ignoramusses (sp?), and attempt a remedy of that, than engage in a posthumous rebuke?

Your comments concerning attempting to remedy a problem through the investigative methods and the dissemination of new information is valid but in doing so you seem to indicate that the fact that the pilot(s) screwed up should not be emphasized....why? What is the "pilots should never be criticized, nor should we say they were wrong" ( well we do say, at times, they are wrong but in very, very small print), attitude that seems so prevalent in this industry ? “Posthumous rebuke??”…..that the individual is dead is regrettable for all concerned but once again the trend in the airline industry is to dance around the fact that the individual screwed up…why??..is it out of respect for the individual or is it the fact that some pilots feel that their “Godlike” qualities, (in their minds), are beyond reproach, whether they are alive or dead?

If you think I want to thwart the investigative process and end results with the dismissal of valuable knowledge gained you are wrong. If you think I just want and cast "rebukes" on pilots just for the sake of saying they were wrong....you are wrong..... If you think that I want the pilot community to understand that there is nothing wrong with telling one of their peers that they are not competent and are going to be let go/grounded...you are right....that's all my point is...where/what are the consequences for being stupid/incompetent ??? (other than death).

[Guest woxof]

Woxof - As far as ALPA representation goes (and thankfully for AC drivers, I'm sure this goes for ACPA as well), Yer damn tootin' I want to see 100% passionate defence of any pilot after an accident, most particularly the dead ones. After all, they can't speak for themselves.  If that is unpalatable for you, by all means take up accident investigation in a non-representational role.  It's perfectly honourable to make judgements about serious matters, but if you are unable to forbear it, leave the representation to others.  If the case against the pilots is so clear, the best defence will be for nought.

Cheers, IFG

Well the 1900 instructor pilot got the 100% defence that you advocate. ALPA contends that the instructor did not use poor judgement by not only disabling the trainee's attitude indicator(yet remaining uncovered) on a dark overwater flight, but dimming the lights on his own attitude indicator so it couldn't be used as a backup as well as simulating an engine failure at the same time. As well, Alpa says the instuctor never lost situational awareness of the flight altitude. Instead there was a stuctural failure which the NTSB in the petition rejects.

So what are the potential consequences of "100% passionate defence of any pilot after an accident" that IFG advocates. The NTSB changes the final report to reflect ALPA's petition. The probable cause is structural failure. An expensive AD affects all 1900 operators for structural upgrade. Beech's reputation is impacted affecting sales of 1900's and worker's jobs . Not only that, they lose a major lawsuit from the grieving family(although that could happen anyway). Perhaps many commuter airlines are affected with a decrease in pax count after a major network does a primetime story on those small planes breaking up. And then there is the future pilot trainee's in a similar scenario. Perhps their company would have reviewed their training procedures after seeing what happened to Business Express but instead that was some structural failure, not anything caused by faulty training. No mistakes are learned from and more people die. I prefer a 100% passionate defence of the truth.

I realize there can be many grey areas.

These are some of the potential consequences of tossing aside the truth and that is what is "unpalatable " to me. In this case it was stretched to absurd levels and will have to be once again in this Pinnacle RJ case in order to to exonerate these two fellows.

[J.O.]

So what are the potential consequences of "100% passionate defence of any pilot after an accident" that IFG advocates. The NTSB changes the final report to reflect ALPA's petition. The probable cause is structural failure. An expensive AD affects all 1900 operators for structural upgrade. Beech's reputation is impacted affecting sales of 1900's and worker's jobs.

I think that professionl investigators like TSB / NTSB deserve a little more credit that you appear to be giving them. They can't be bamboozled quite that easily.

[Mitch Cronin]

Woxof,

That 100% defence of the truth you speak of is the job of the investigators, and so it should be. The idea of learning from the mistakes of others depends, obviously, on knowing their mistakes. But in that pursuit of truth, there is also room for the union's role of defending their members... they could, and undoubtedly do, on occasion, add information to the whole picture that helps to illuminate more of the contributors to an accident chain... all of which is valuable in future prevention.

Likewise the manufacturers, as they defend their products, will be likely to help provide a more complete picture of the truth.

Truth doesn't necessarily come readily from undefended assertions. It's when the analysis gets more in depth, through challenges to assertions and thorough examination of those challenges, etc. that truth begins to gain in clarity. How many accidents would be incorrectly attributed to simple human error if no one had defended the people involved, we'll never know, but it's a safe bet that it would have happened from time to time, and we'd be less aware than we are today of the truths.

So maybe core lock wasn't a factor at all in the RJ accident, but if nobody had suggested it as a possible defence, would the examination of the possibility have been so complete? Maybe... Then again, maybe we'll learn yet that it was a factor and changes/additions to some procedures will come that will possibly save others from similar results? (though that doesn't sound likely at this point)

In any case, I don't see anyone willing to "toss aside the truth", but I do see lot's of value in defence. I also believe (in answer to Kip's concerns) the knowledge that the defence will be there also helps honesty to come forth more readily... and in fact, as has been discussed here previously, when people make mistakes and they know the lesson value for others in their mistakes, if they also know they're protected from punitive retribution (but will receive corrective training or assistance where due), those lessons can indeed be shared.

Mitch

[Guest woxof]

I think that professionl investigators like TSB / NTSB deserve a little more credit that you appear to be giving them. They can't be bamboozled quite that easily.

I'm not trying to downplay the integrity of these investigating agencies at all. You have misinterpreted what I have posted and if you read or re-read my posts, you will see that I have not questioned any safety board activities. In fact, as you can see, the NTSB went into thorough detail to show how the petition for reconsideration was incorrect.

What I am trying to show the outside influences that are thrown upon these ageencies and give the possible ramifications if they are successful. These outside influences range from what has been discussed on this thread from pilot's unions in the 1900 case to manufacturers and airlines in the American A-300 case and many others.

There are times when a pilot does need the help of the union in an accident investigation. But when ALPA does what it did in the 1900 case, it loses credibility in future cases where it has legitimate concerns and that only hurts who they may be representing in the future which could be you or myself.

I prefer a scenario where when ALPA approaches an investigating agency representing a pilot, the first thing that goes through the investigators mind is....these guys are straight talking fellows who want to get to the real reasons for this accident instead of thinking that these fellows first priority is to blame anyone but the flight crew. Coming up with scenarios like the 1900 case creates the impression of the latter.

As for Mitch...Your post sounds quite reasonable. You talk about the core lock and that it was brought up as a possible defence. My initial post was based on an article(however reliable that is) saying that " The Air Line Pilots Association suggests that core lock, rather than pilot error, might have been the primary cause of the

accident." Primary cause? If they really believe that, They are losing even more credibility.

[canadairguy]

Certainly FS looked at all aspects of the accident in hopes of preventing another such incident but if the investigation pointed at the individual as the root cause of the incident...he was gone. Not so in civil, (airline), aviation.

Kip, no Canadian Forces pilot was ever punished as the direct result of a flight safety investigation. The CF flight safety system is - and always has been - totally non-punitive. If a commander thought that action should be taken against a pilot because of an accident, he had to convene a "collateral board" to gather information and make recommendations. The collateral board was totally separate from the flight safety board of inquiry and had absolutely no access to the flight safety investigation.

[Guest rattler]

"Standing on the ground, looking up."

Without the availability of a strong defence, all we would see would be kangaroo courts that would take the path of least resistance when assigning blame. Proper accident investigation can only be successful if those involved keep asking "what if". It is all too easy to have a preconceived outcome in which pilot error is the only answer.

Once fault is determined then there should be no holding back regarding corrective action whether it results in the end of a pilots career or expensive modifications to correct aircraft component faults. On the other hand, we also must keep in mind that humans do learn from their mistakes so even if the pilot is to blame, corrective action can be taken in that regard in the same manner as we allow modifcations to correct a problem with the aircraft.

The grounding of an aircraft type only occurs if there is no fix for the problem, the ending of a pilot's career must be given the same consideration.

[Mitch Cronin]

Primary cause? If they really believe that, They are losing even more credibility.

Agreed. Very hard to understand why anyone would suggest it was a "primary" cause!