For RJ Pilots and others

[Kip Powick]

KIP (one of these days remind me to ask you why it is you put a person's name in bold caps?  )...

I owe you an explanation .... Many eons ago I took a speed reading course. I consider myself a voracious reader and, as we all know, if we read from the moment we were born until the moment we die, we could not read all that is in print. The course intrigued me so I took other speed reading courses and I think I have developed my own speed reading technique. One thing I do when going through manuals, well I don’t do it but my eyes do, is hang, momentarily, on BOLDFACE print as that normally indicates a new section or something very important. BOLDFACE print is a “sign-post” that indicates that I should spend a few more seconds on this section. From that came the habit of applying BOLDFACE ,when writing certain documents, or indicating to another reader that I am attempting to get their personal attention. Old habits die hard and I shall attempt to drop BOLDFACE when referring to another’s post.

Mitch….. This statement leads me to believe that you, like some others, feel that I want to fire everybody who makes a mistake. I have no idea why everyone is reading that into my posts. I have said and will say again I am referring to pilots and I stand by my conviction that if the investigating board has weighed all the evidence and the “root” cause of the accident is incompetence or a flagrant violation of the parameters we have been set, then the individual must go. I have no idea why individuals on this forum feel that by voicing my comments on this matter I should be labeled as Attila the Hun when it comes to dealing with accidents. I seem to be one voice in the wilderness, but I did note that my supposed attitude has come to the forefront in another thread concerning a game. I can take the heat, I don’t mind that at all. I did not survive my time in airplanes by always bending to the majority. All pilots, to a degree, are opinionated and so be it and if mine is away out in left field…well I can still live with that as well.

You stated that “where punitive approach is the rule of the day”. I have never advocated that. Read what I have written, my opinion, of where and when consequences for actions must be deemed necessary. Every situation has to be dealt with on its own merits but in my opinion there is a time when the individual crosses the line and punitive action must be taken………but the trend in this industry is not to do that… I disagree with that trend…that’s all.

but how the hell would we ever know if you were to just go ahead and fire everyone who ever screwed up? Ya think you'd get any good insight into what might have led to their screwup if they knew the more they said, the more rope they were handing out for the hangman?

Again, you have misunderstood my opinion…… and once again you seem to insinuate that I am advocating the gallows for every and all accident/incidents. Please give me a little credit for not having such a parochial view about human nature. Anyhow, I have no idea why I am still trying to make my point as it would appear that no matter what I espouse as my opinion concerning consequences for specific actions as it is just not palatable to many these days…well, so be it……..

Gotta go..time’s up.

regards.

[Kip Powick]

Does this definitively prove that a punishing culture doesn't work and that a nurturing culture does? Maybe not. All I can say is that I'm seeing a similar culture begnning to develop where I work, and I believe we all will benefit over time. Will we continue to discipline people for flagrant disregard of the rules & regulations? I believe we will, but I also believe that a true safety culture will reduce the number of violations, as people realize that the desired standard is the safe and legal one.

Hi Jeff,

Please read my post to Mitch.... Y'know I can't, for the life of me. see where I have posted that I advocate the "death penalty" to those that screw up. I don't have a problem with developing a FSCulture that is going to enhance the safety in the industry, only a fool would say that is not a good plan. I do have a problem with the punitive line becoming blurred to the point of non existence, that and only that is my point. I do feel your comments above, (the quote), is what I too would like to see but there seems to be a big problem for many to actually say where the line is.

I respect Don H and his valuable work and of course his opinion.....but ........I know he has been back to this thread and I can't help but wonder why he would not comment on the simple question...and in my mind an excellent scenario, put forth by woxof. It was not a trick question, it was an honest question with an individual asking for an honest answer but so far....everyone has chosen to ignore it...why??? The scenario could have happened yet no one will commit to a course of action...why??

Anyhow, thanks for your comments, as usual it is a pleasure to butt heads

G'night.

[Mitch Cronin]

Kip, when you're time is back....

Ahhh shooot. I didn't wanna upset you... the crack in that game thread was meant for fun, you know that! Don't you? ... I hoped you'd laugh... it sure got me chuckling... I sincerely apologize if that was at your expense.

I think I do know where you stand, and I can't honestly argue very well against that stance. Though I wouldn't see very much that you've seen in the cockpit, I've seen my share of incompetence elsewhere that makes me wonder why and how some people have managed to keep their jobs... and I would imagine that pilots, being - at least so far - human beings, can be just like the rest of us at times.

There really is something to the other side of the coin though... I've seen that too, from personal experience! I've screwed up in ways that might have got me fired elsewhere, or at least "disciplined", but instead, other things have happened that have made me a better mechanic. Like Bob Hoover's fueler, I won't ever make those mistakes again! And as an added bonus, many of the folks I work beside, with whom I can tell my tales of mishap, have also benefitted from the wisdom I've gained out of the experience. (and hence, so has my employer)

I don't suppose anyone would argue that discipline of some sort shouldn't be forthcoming for those who display a wanton disregard for what's right, ... or that those who simply can't do the job shouldn't be removed from the job... but there are undoubtedly many instances where a person has been unfairly disciplined, or fired from jobs that they can do, and would do even better, if another approach to error correction had been employed.... and the company loses much when they dispose of that individual.

I think it's entirely possible that your viewpoint, and that of those with whom you feel your views on this topic have been unpallatable, are not as far apart as it may at first appear. The "You've screwed up and now you're toast!" response has it's place, but as in the examples J.O. has given above, there are many times when that's not going to do anyone any good. Even the best folks can mess up at times. Isn't that why there are usually two of you folks in the cockpit?

...Now do me a favour and have another look at that silly game thread, and see if you can laugh this time, dammit!

Canadairguy....

I think I know exactly the individual you're speaking of, and he wasn't fired, but he later left of his own accord. He was indeed a damn good mechanic and it was an error of overconfidence, complacency and haste.... I didn't understand at the time, but I've long since come to the realization that not firing him was the correct response, even though it was a decision made for the wrong reasons. He was a very competent man, who could be forgiven, one time, for forgetting he could occasionally forget the interelationship of various actions....

But that the union wouldn't let him speak is total BS. He could have chosen to ignore their advice and proceed without them.

[ccairspace]

If it makes you feel any better Kip, you're in good company.

Judge Gomery expressed his amazement last year that former bureaucrats had not been sanctioned for their misdeeds.

"Sometimes you get people who just more or less deliberately disregard the law, and from what I could see, you can't even fire these people," Judge Gomery said during public hearings last May.

"If [managers] find an employee who is short of being outright corrupt, who is simply totally incompetent and totally careless in doing the job, there is nothing really that you can do with that person except to move them out of that job and into another job where probably that person will be equally incompetent or equally incapable."

http://www.theglobeandmail.com/servlet/sto...OMERY30/TPStory

I think there will always be a place for dismissal, but, to mind, only for wilful acts of destruction or illegal activity. Most mistakes are "unintended" and as we all know, the lessons that we learn from our mistakes are the ones that stay with us forever.

When push comes to shove, I think we are all on the same page: Safety first and foremost.

ccairspace

[Don Hudson]

Kip, as you know, I am involved in an FDA Program as a pilot association gatekeeper. For me, it wasn't a simple question, otherwise I would have responded as I usually do. I avoided the question because of the greater need to protect the FDA Program. I can't offer specific opinions on crews' behaviours and expect to retain the objectivity and the trust of the piloting community which I serve.

Kip, I've been torn over the last few days whether even to go this far as it will likely open a side-controversy about asking questions and then not being prepared to answer them myself. I think made a mistake asking the original question.

I apologize for appearing to ignore woxof's, and your question but I felt I had good reason to do so. I hope you'll understand.

Its still a great thread!, and thanks once again for keeping it going.

Cheers,

Don

[Kip Powick]

the crack in that game thread was meant for fun, you know that! Don't you? ... I hoped you'd laugh... it sure got me chuckling... I sincerely apologize if that was at your expense

Mitch...I certainly was not upset...as stated I can take the heat and the ribbing because as you well know, I dish it out all the time. I should have mentioned that I did chuckle as well.

I think it's entirely possible that your viewpoint, and that of those with whom you feel your views on this topic have been unpallatable, are not as far apart as it may at first appear.

Based on JOs last post I think you are absolutely correct...just some folks, initially, went off on another tangent.

Isn't that why there are usually two of you folks in the cockpit?

Of all people, what with you being an AME of distinction etc, I am surprised at that statement. There are two in the cockpit for balance, Mitch. If there was only one, the lonely pilot would have to compensate for the weight differential with copious amounts of aileron trim !! (unless the cockpit was redesigned to fighter specs and some of us would love that !!!)

Don H.... appreciate your candor and your reply and yes, I do understand. Had I had an incident during my career, there is no one I would like more in my corner. As always, a pleasure.

[Tango Foxtrot]

An automotive mechanic I knew once made a mistake working on the family doctor's car. The doctor was not impressed.The mechanics response to the M.D. was..

" You know the difference between a Doctor and a Mechanic? Doctors bury their mistakes!"

Kip, not only did others not answer woxof's question, you didn't either! Who could? Honestly we would all like to think none of those things ever happen, but we all know they do.

Tony!

[Kip Powick]

Kip, not only did others not answer woxof's question, you didn't either!  Who could? Honestly we would all like to think none of those things ever happen, but we all know they do.

Tony!

The question was put to Don H. Don H made his reasons known for not answering, that's good enough for me.

However..if you are asking me.......if I had the cold hard facts supported by FDR and CVR and the aircraft was destroyed, I would probably answer the question by saying "about 1/2 way down the list".There would be no room in my organization for individuals who show that much disrespect for the rules coupled with wanton destruction of Company equipment.

Flame on

[J.O.]

Kip:

I admit that I glanced over woxof's post without responding. There are a few reasons why I didn't at the time (which I'll not get into). But seeing as how you asked, I'll try to address it.

1. a 1.8g pull-up shortly after takeoff to stickshaker warning.

2. Seats exchanged at 14,000 feet.

3. At 15,000 feet, a 2.3g pull-up to 17° nose-up followed by a -0.3g pushover.

4. Large rudder inputs left and right during climb

5. Through FL 240 the contol column was pulled back and released a few times over 30 seconds with rates of climb up to 5,000 fpm for several seconds.

6. Climbing at too high a rate and too slow speed for their weight to FL410 arriving at 0.57 mach instead of the 0.70 mach listed in the climb planning charts.

7. Much laughing at the aircraft's inability to hold altitude, nose up attitude and full ball deflection.

8. According to the original post in this thread, fighting the stick pusher three times.

9. Misleading ATC as to the nature of their problem.

10. Destroying the aircraft and very nearly other lives on the ground when they crashed in a residential area.

Of course Pinnacle didn't ever prohibit flying at FL 410. I'm sure they prohibited flying outside the envelope. Core lock was an unexpected event so would a company discuss something that is likely only familiar to design engineers. If you stall an airliner bad things may happen. Training, SOP's and company culture are legitimate things to look at of course, but at some point self-responsibility has to enter the picture.

If they had survived, at what point in the list from 1-10 would you as chief pilot say that they should be fired?

I am probably going to appear evasive, but I simply don't have enough information. The last line (# 10) isn't a fair question, because as a result of the destruction of that aircraft, these guys are no longer with us.

First of all, no Chief Pilot should fire someone without a thorough investigation. I'm not a chief pilot, and I don't have the benefit of a full investigation yet, so any opinions I express could change.

Up until and including item # 6, and possibly even as far as # 9, I'd have to ask how a Chief Pilot would have come to know it occurred? Most FDA programs that I am familiar with don't include notification to management when such incidents appear on the FDA reports. They are reviewed by the Gatekeepers, who then decide if further action is warranted. Maybe Don can speak to that. Given the atmosphere in the cockpit, which appeared to be quite cavalier, I doubt that either of these pilots would have self-reported.

What if this crew had been able to recover from the loss of power problem shortly after it began and land without further incident? It is possible that unless ATC reported them for an altitude deviation, that I would never have known. But if I did find out, as a minimum, this crew would have been grounded, and sent for some serious further training, followed by a "come to Jesus" meeting, where I put all of my cards on the table, including the fact that the Captain is no longer a Captain for some time.

It's highly likely that this crew (at least the Captain) would be fired by many companies. Would I? I cannot say, because I haven't had the benefit of sitting down with this crew to see where their heads are at. I have no knowledge as to their past performance in training and check rides, and I don't know if these guys were otherwise good guys, idiots, or somewhere in between. I need that information before I make such an important decision.

Let's suppose for a moment that I do decide to terminate these pilots. Have I eliminated the risk to the travelling public? I don't think so. All I've done is transfer the risk onto someone else's shoulders. I have no ability to remove their license priveleges, and it's highly likely that they will get a job somewhere else. The courts have frowned upon managers who bad-mouth former employees during reference checks, so when the call comes, I will offer as little information as I can. The USA is a big country (as is Canada), and somewhere out there is a company that will hire these guys, many without performing a reference check at all. If they truly were idiots, it is totally possible that they will once again find themselves in a situation they can't handle, only this time there may be passengers on board.

There have been several accident reports written where a pilot with consistently poor performance has bounced from company to company, each time barely squeeking by, set free on the line and eventually having a major accident. What responsibility do Chief Pilots have to the travelling public? Does it end the moment that a problem child is no longer on your payroll? We may never know until someone sues a former employer for not speaking up. But how do I speak up? Is there a legal requirement for me to do so? I'm not aware of any such law. And if I do speak up, will I then be sued by my former employee? Some would say that I should worry about my own arse and my own company first, but if I am truly to behave in an ethical manner, do I not have a broader responsibility?

So, to wrap it up, I am glad that I am not a Chief Pilot facing a crew who screwed the pooch this bad and survived it. I'd have alot of things to think about and alot of work to do. I can promise you that they would never touch one of my aircraft again unless and until I could be satisfied that they've had a serious mea culpa and have learned their lesson big time. It is very possible that such a moment would never come for me.

Jeff

[boestar]

KIP:

I hear what you are saying. I understand. I have just chosen to keep my mouth shut as many of the posts here are much better than anything I can write.

I for one am a supporter of the non punative SMS systems of today. Now we just need to get EVERYONE on board with it.

B

[GTFA]

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.

Hmmm...

You're not a lawyer are you.

[Kip Powick]

KIP:

I hear what you are saying. I understand. I have just chosen to keep my mouth shut as many of the posts here are much better than anything I can write.

I for one am a supporter of the non punative SMS systems of today. Now we just need to get EVERYONE on board with it.

B

Bull crap... I have read your posts on this forum, you are just as well versed in the English language as me and the vast majority. Go for it, tell it like you feel, your opinion may differ from others or may come to roost with the majority but what is important is that you enter the fray...how else can we, as evolving beings, truly undestand the intricacies of human nature other than through intelligent conversation........ besides I believe you actually said what you wanted in your contribution.

Have a great week.

[Kip Powick]

J.O.

I am probably going to appear evasive, but I simply don't have enough information. The last line (# 10) isn't a fair question, because as a result of the destruction of that aircraft, these guys are no longer with us.

I think it is a fair question. woxof put a caveat at the end of his post where the "answerer" was to assume they were still on the planet

Jeff, I know where you are coming from and I also know what your job is and your feelings on "punitive" issues...I don't have a problem with that, it is your right to feel/act/think the way you do. All I think woxof was wanting was a definitive answer to the question "assuming" you had to "can" someone/them.

Regardless of your answer, or non answer I just feel there comes a time when it is better to have made a decision, be it erring on the side or caution, rather than not to have made a decision at all. There is a "line" for all of us and at some time in your life you may have to decide if the individual in question has crossed the line and consequences must come to bear...it is not easy, I know, and after you have made the call you will probably lay awake at nights wondering if you did the right thing....that's just one of the burdens of a supervisory position.

Good luck.

KP

[UpperDeck]

GTFA....

Yes, I am. Four murder trials; all acquittals or reduced included. Many, many other "serious" cases in the early years. Reasonably successful insurance defence in later years. I have some notion whereof I speak at least on some, though not too many, subjects. I can also reasonably discuss golf and boating.

A lawyer who knows his client is guilty in fact and who attempts to divert suspicion to another in the defence of his client is guilty of obstruction of justice.

A lawyer who puts his client on the stand knowing the accused to be guilty in fact and aids that client by questioning to elicit his false testimony is similarly commiting an offence.

A lawyer who too closely aligns himself with his client's cause loses the objectivity that is required to properly and ethically serve the interests of his client.

[GTFA]

Ok,

Busted for a bad joke.

But to the topic being discussed...

In the new and rising SMS culture with it's emphasis on "safe reporting" one of the concerns is obviously at what point can some authority take the stand that there is punishable conduct?

I don't know if this has been tested yet but a company and or a regulating body has the right to take action against a pilot for neglegence. I currently understand that the test for fairness will be the courts application of "just culture" philosphy.

I.E. Some level of negligence can be expected based on culture, past practice and industry standards etc. but at some point someone has to step up and say WHOA boys.

Human factors experts get involved to investigate the reasons for the negligence and again, this will be tested in the court if the complainant is still not satisfied.

I am not sure how far this process can go but at some point an individual may be held liable for his own bad decision.

GTFA

[Don Hudson]

Though perhaps I'm wrong, I sense that the SMS issue here has somehow been skewed. There seems a partial misunderstanding that SMS disqualifies ownership of culpability and that it masquerades as perhaps a get-out-of-jail process. Of course, it does not and is not.

Negligence and egregious behaviour never left the picture, legally or professionally. In fact, in some ways criminal negligence responses are increasing as we have seen.

What has happened is, as the accident rate reduced (quite dramatically) from the 1950's to today through the process of dealing with the prime causes of accidents...those that were technical (eg piston engine vs turbine reliability), navigational (radio range nav vs gps, tcas, gpws), meteorological (wind shear) and airport (ndb approaches vs ILS/GPS, lighting etc), the accident rate, though reduced, remained stubbornly stalled. The one arena which remained a challenge was the human element in the system and those approaches which addressed the problem, human factors, arose.

In a professional, high-stakes system accustomed to punishing for mistakes (such as aviation and medicine), the same errors kept re-occurring even though improvements in technical craft occurred. The way to encourage people to tell the truth is to remove threat and provide safe harbour.

Clay Foushee, of Northwest Airlines along with a number of others including Helmreich, Heinrich and Reason realized this and created "CRM", (now actually being looked at for the first time by the medical profession) as well as legitimizing the notion that accidents have antecedent causes, - human systems.

Straightforward CRM evolved to behavioural models of command structures and a whole realization (recognition, really) of the human aspect of technical craft was created in the mid-80's.

The embracing of such a powerful tool naturally gave rise to unbridled enthusiasm as problems could be demonstrably resolved. As this occurred the notion of "blame" was excised from the conversation ostensibly to encourage fertile ground for these new ideas to flourish.

That the notions of blame and enforcement appear dichotomously opposed to the "new" approach, SMS, is an accident of history, not actuality. Many of us here know from experience, personal or through knowledge of colleagues', that no pilot "escapes" an incident or accident untouched by the process. "Punishment" has never left. What has occurred is the introduction of a systematc approach to the truth while still encompassing those extremely rare occasions when a crew truly behaves unprofessionally. The systems do not mutually exclude one another.

The same should be true of the medical profession. Frankly, our record should serve as a shining example of openly dealing with human error.

[IFG]

Though perhaps I'm wrong, I sense that the SMS issue here has somehow been skewed. There seems a partial misunderstanding that SMS disqualifies ownership of culpability and that it masquerades as perhaps a get-out-of-jail process. Of course, it does not and is not.

I think you're right, Don, but you can't get around the fact that one of the rewards or inducements for openness in a SMS culture is some expectation of 'freedom from prosecution' as it were (kind of like turning state's evidence? ). It does get in some peoples' craw, and I know it can be a stumbling block to getting it accepted. It's hard to get folks to take a wide-angle view, a how-will-this-work-in-thousands-of-situations picture, when they fixate on one particularly egregious, individual one. It's a bit like arguing against capital punishment in the general sense, and being accused of sympathizing with Paul Bernardo or Clifford Olsen. Therefore, it must also be reinforced, as you have been doing, that professional standards remain, in hiring, training, oversight etc.

To woxof, I don't think anybody's tried to avoid your question (and initially I also thought it was directed at Don). It's a hypothetical, but obviously every reader here would likely agree that conduct like that can't continue - if there is a reasonable expectation that it will, out the guy goes. I don't see where Don or anybody else marking there spot on your list advances the discussion. I figure if the thread had merely said figuratively, what a pair of putzes those guys were, they didn't belong in the profession etc, there would not have been a single voice of disagreement. It's frustrating to be accused of wanting to tolerate that sort of conduct. My contention with you was on the proposition you seemed to make that an assigned defender (ALPA in this case) of one facing possible disciplinary action (or I guess in the specific case you cited, the estates?) owed an allegience more to the judge's obligations than the interests of the client. It is there that we part company.

Most of us who have bought into the idea of SMS will no doubt occasionally, but I'm sure rarely, find ourselves uncomfortable that somebody "gets away with something". This discussion seems to have aligned a couple of accidents where the crews perished with a discussion of how hypothetically surviving pilots should get treated . Suffice it to say that the two series of actions, as outlined here, are pretty damned egregious FWTW. But in general, as long as future re-occurences of reported discrepencies can reasonably be discounted, the openness achieved by putting penalty aside as much as possible will be worth it. If there was a systemic tendency for bad practices to be tolerated or excused, then the system would have failed. That simply does not seem to be the case

Cheers, IFG

[J.O.]

Don / IFG:

Gentlemen, you both nailed it. Thanks for putting an exclamation point on what we've been trying to convey.

Jeff

[Guest woxof]

To woxof, I don't think anybody's tried to avoid your question (and initially I also thought it was directed at Don).  It's a hypothetical, but obviously every reader here would likely agree that conduct like that can't continue - if there is a reasonable expectation that it will, out the guy goes.  I don't see where Don or anybody else marking there spot on your list advances the discussion.  I figure if the thread had merely said figuratively, what a pair of putzes those guys were, they didn't belong in the profession etc, there would not have been a single voice of disagreement.  It's frustrating to be accused of wanting to tolerate that sort of conduct.  My contention with you was on the proposition you seemed to make that an assigned defender (ALPA in this case) of one facing possible disciplinary action (or I guess in the specific case you cited, the estates?) owed an allegience more to the judge's obligations than the interests of the client.  It is there that we part company.

Looks like the thread is coming to an end. In the end my question was more rhetorical in order to make a point. Answers range from firing the crew to a non-punitive approach to not responding for reasons unwilling to be divulged and admitted evasiveness. Plenty of good responses though.

As for ALPA's role, by coincidence I am just starting to read an old NTSB report on a serious incident many years ago to a TWA 727 that almost crashed after mysteriously losing control at altitude.

http://www.avsaf.org/reports/US/1979.04.04...oeing727-31.pdf

http://iprr.org/COMPS/pet727/B727_7840.html

http://iprr.org/COMPS/pet727/PFR1.html

http://iprr.org/COMPS/pet727/PFR2.html

I have read brief articles over the years about it and I know it was very contoversial with the crew blamed by the NTSB and of course defended by ALPA with a detailed petition for reconsideration. which I also have. Sadly for the crew, as I read the NTSB report, the petition and then the response to the petition from the NTSB, in the back of my mind I will know that ALPA has in other investigations tried to deflect blame to innocent parties(i.e. the previously discussed 1900 case). This it seems to me is extremely unfair to the TWA crew who may very well be blameless.

However, as always I, like many here, will keep an open mind and use common sense and rational arguements in the search for the truth.