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In their efforts to not place blame...

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Thu March 27 2003, 11:22 AM
BF
In their efforts to not place blame...
The TSB came off a little foolish. Just my thoughts on that. I noted in the introduction the chairman of the TSB, Camille Th�riault, expressed concern about not blaming those responsible in an air crash. He said that swissair was no exception to their philosophy regarding blame/air crashes. I maintain that swissair is THE EXCEPTION. Just look at Gary Stoller's accurate articles and you will see that.
Thu March 27 2003, 03:28 PM
rv8
I beg to differ. I have been on both ends of aviation accident investigations - I was the pilot of a military aircraft that crashed due to an engine failure, and I have been assigned to be part of an NTSB accident investigation board. If the aim of an accident investigation is to determine the cause of the accident, so as to make changes that would prevent similar future accidents, we must keep the focus away from assigning blame. As soon as you start to try to assign blame people who have important information will start to ask themselves whether they will make themselves look bad if they tell you everything they know.

The current process works. Accident investigations get excellent cooperation from aircraft operators, manufacturers, flight crew, ground personnel, aviation regulators, etc. We have the courts to try to assign blame. Lets keep the courts and the accident investigations separate.


Kevin Horton
Thu March 27 2003, 04:32 PM
BF
rv8 You are certainly entitled to your opinion, however I stand by what I said. Thanks for your comments.
Thu March 27 2003, 09:14 PM
BF
Rv I just felt I should explain more clearly what bothered me in the TSB's statements today. At one point Gerden kept saying (during a q&a period with the press) that the tragedy couldn't have happened had there been no mylar to fuel the fire. Fine enough. Agreed. But when a couple of reporters asked whether he felt that way about the IFEN wiring he kept dancing around that point. The answer was obvious-his goal obvious, but it came off as being ridiculous. I felt that his quest not to blame came off a little overboard at that point.

Overall I think the TSB did a thorough investigation. I still want to read the report in it's entirety which will certainly take a while. BTW welcome to the site- hope you'll stick around.

Barbara
Fri March 28 2003, 09:21 AM
Mary
I got the same impression about Gerden -- he seemed to be trying too hard not to name the IFEN as the cause.

I can understand not wanting to assign blame, but that may have to come out when announcing the cause -- isn't that what we've been waiting to find out? Maybe they really don't have enough evidence to prove that the IFEN started the fire. I guess I'll have to wait to read the final report. It would be nice to read the draft report too, in case that would shed more light. But, I doubt that will ever be available to family members.
Fri March 28 2003, 10:22 AM
BF
Mary I completely agree with what you are saying. I also think it is crucial that family members have access to that draft report. It is my belief that the draft report leaves NO doubt as to what caused that crash-the entertainment system-not that we don't know already. There is simply no reason not to allow those affected by this terrible tragedy to see that draft now that the final report is out. I think there is probably far more evidence of the cause in that draft. They've said all along that they don't want to place blame so it was very clear from the beginning that they wouldn't be forthcoming if they had discovered a cause (ignition source) which I believe they have. The draft has the answers.
Fri March 28 2003, 12:06 PM
Dagger Dirk
A common thread that runs through many of these post Final Report media articles is the misrepresentation of arcing as a unique phenomenon by referring to it as sparking (or more commonly as "a spark"). It's a pity because that imparts a completely incorrect picture/image and does not convey the concept of arcing as a destructively explosive process at all.

It's obvious that since the TSB were unable to "involve" Kapton conclusively in the initiating event, that the FAA/ATA and Boeing coterie of lawyers insisted that any such inferences be removed from the "corrected" Draft Report. The TSB's claim that "if it hadn't been for the MPET, the accident wouldn't have happened" is also hard to swallow. An explosive arc-tracking event running along a wire-bundle (particularly a vertical one) can incapacitate whole systems in a cascading series of failures that can overwhelm the pilots and affect the aircraft's controlability.

A well-orchestrated low-keying of the WEBCAST public presentation has now taken the pressure off dangerous wiring insulation. But I don't think we've heard the last of aromatic polyimides. There's too much of the stuff around not to have it rear up and bite again. As it ages, it dries out, embrittles, loses top-coat via flaking, micro-cracks and soaks up moisture hygroscopically. Its potential lethality isn't cured by removing the MPET blankets - but that isn't going to happen anyway, not for a few more years. More than any other threat its message continues to be: "Watch this space. I'll be back".
Fri March 28 2003, 12:37 PM
BF
Great comments Dagger and exactly on the mark.

Not being told the ignition source because the TSB doesn't want to assign blame is kind of like this to me. Let's say my daughter had been killed by some irresponsible person who had been drinking & driving. The police investigate and tell me that they have evidence that Joe Smith did it while probably intoxicated , but in the interest of not assigning blame they have concluded that his brakes were not up to par so they are going to blame that and ignore the fact that he was extremely drunk when operating a vehicle. They tell me that the accident wouldn't have happened if his brakes were ok. That would kind of miss the point wouldn't it? Joe has a serious drinking problem and should really face some consequences or he will go out and do it again, don't you think? I believe that those involved in the entertainment system should also have to face justice because that is a very important way for us to deter people who's actions are irresponsible and lead to the death of innocent human beings. What's to prevent these individuals from doing this again? Shouldn't we be concerned with that? How are we going to send the message out there to others who would take advantage of a weak system (the FAA) for their own gain who might endanger passengers if we just let this go and pretend that they have no responsibility in this tragedy? Joe fixes his brakes and maybe pays a fine, but do you feel safe with him back on the road? Has he been sent the right message? Have the police accomplished deterring others that would get behind the wheel when drinking?
Fri March 28 2003, 04:44 PM
BF
I should mention that Mark's perception from being in Halifax is that the TSB came down very hard on the installation and the certification of the IFEN and doesn't feel that the TSB left much doubt for what probably caused the crash. In other words Mark feels that the TSB has gone much further than we would have expected in indicting the IFEN as an ignition source. He says there is quite a bit of talk about the certification problems as well. I'm hoping that he will have an opportunity to do a short report of his experiences in Halifax and his thoughts on the results of the investigation, but it may be a while as he is unfortunately pretty busy right now. He has some interesting comments but I don't want to take a chance and report them inaccurately.
Sun March 30 2003, 02:24 PM
Anon_Insider
RV8 stated:
-----------------------
"If the aim of an accident investigation is to determine the cause of the accident, so as to make changes that would prevent similar future accidents, we must keep the focus away from assigning blame. As soon as you start to try to assign blame people who have important information will start to ask themselves whether they will make themselves look bad if they tell you verything they know. The current process works. Accident investigations get excellent cooperation from aircraft operators, manufacturers, flight crew, ground personnel, aviation regulators, etc. We have the courts to try to assign blame. Lets keep the courts and the accident investigations separate.
-----------------------

I disagree, and would like to take Barbara's response one step further:

Why don't we just invite drunk drivers back to the scene of the accident the following day, and ask them to cooperate with police investigators
to recreate the events of the hit-and-run. As long as information is shared freely, then there's no need to blame anyone, right? If drunks are fearful about speaking out freely to investigators, the investigators must necessarily take longer, and may not even succeed in identifying safety deficiencies - like worn brake pads.

Luckily, society doesn't allow this sort of situation to occur, or at least not when it involves individuals. But for some strange reason, when large corporate interests are involved, the rules magically change. This is why lawyers representing airlines and manufacturers have hijacked the investigative process.

The information sharing process you describe works well when we're talking about a mechanic who accidentally leaves a wrench lying around somewhere that it shouldn't be. But what about situations involving possible criminal negligence? What if somebody makes deliberate decisions, based purely on profits, to shortcut established procedures that directly endangers the lives of passengers? The Swissair IFEN certification project doesn't fit the mold, but is treated the same way.

You say that, "We have the courts to try to assign blame."

But how is that possible? How can the courts act on cases of gross or criminal negligence when the investigating and oversight agencies are so determined to keep that type of information out of their reports? (i.e.: TSB final report, and FAA SCR report)

The Transportation Safety Board of Canada has the discretionary power to pick which safety related items fall within the scope of its investigation; which ones should be deferred back to the guilty parties to address; or which items need to be suppressed entirely.

Normally this wouldn't be an issue if the process was open -- but it isn't. The Canadian Access To Information and US Freedom of Information Acts prove that.

That's why it's so important for the draft report to be released.

Predictably, the Transportation Safety Board of Canada couldn't quite bring itself to placing full blame on the entertainment system. If I interpret the report correctly, the IFEN got off on a technicality - a single wire that couldn't be positively identified, even though that one too might have belonged to the entertainment system.

I was pleased with the Transportation Safety Board of Canada's final report in general, but disappointed in Vic Gerden's staged presentation where he held up a piece of Mylar covered insulation and boldly declared that without it, there wouldn't have been a crash. Well, Mylar doesn't self ignite, so just as accurately, there would not have been a crash without that entertainment system.

The gimmick briefly showed that the investigators, who'd like the public to think that they take fairness and impartiality to a religious level,
aren't above resorting to spin.

Anon_Insider
Sun March 30 2003, 02:55 PM
rv8
quote:
Originally posted by Anon_Insider:
[qb]I was pleased with the Transportation Safety Board of Canada's final report in general, but disappointed in Vic Gerden's staged presentation where he held up a piece of Mylar covered insulation and boldly declared that without it, there wouldn't have been a crash. Well, Mylar doesn't self ignite, so just as accurately, there would not have been a crash without that entertainment system.

The gimmick briefly showed that the investigators, who'd like the public to think that they take fairness and impartiality to a religious level,
aren't above resorting to spin.

Anon_Insider[/qb]
I wouldn't be so hard on Vic Gerden here. He quite clearly believes that the issue of flammable materials in aircraft is a huge problem that must be fixed ASAP. The release of the report was a golden opportunity to push that agenda, and he would be doing the public a disservice if he didn't take advantage of it.

Yes, there would not have been a fire if there had not been an initial arc. But it is going to be a lot easier to get rid of combustible material than it will be to get rid of all ignition sources. The ongoing studies of the state of wiring in older aircraft clearly shows that this is a huge problem that will be very difficult and expensive to fix. The problem of wiring must be addressed, but in the meantime there will continue to be a disturbing potential for arcs, etc. We have to get the combustible material out of the aircraft ASAP.

As far as establishing the cause of the accident, I'm not sure what else TSB could have been reasonably expected to say. They conducted an exhaustive search for the remains of the aircraft. They performed an amazing piece of detective work to extract as much information from the debris as they did. They have stated the facts quite clearly, and drawn what conclusions can be supported by them. Should they have said that the IFEN was solely responsible for the fire, even if they don't know what that wire arced against? That would not be technically honest.


Kevin Horton