Posts about: "Annex 13" [Posts: 27 Pages: 2]

Or did the F/O call for the gear up, the Captain still looking outside, did an action with his right hand, both pilots felt and heard the engines wind down, The F/O looking down realised what had happened, the Captain looked down and couldn't reconcile his intended action (bringing the gear up) hence the "I didn't do it " comment, then selected the FCO switches back to run but it was to late for the situation to be recovered. The only action they could take that they felt they had some control of was to broadcast a MAYDAY.

For me the prelim report just reveals an unintended consequence of relying on muscle memory to carry out an action that has been performed multiple times without confirmation. It happens a lot but rarely with such a tragic consequence. I have turned the ignition switch to Normal during an engine start when asked to set the park brake during a pushback. There have been multiple occasions where an A320 park brake was set when a flap setting was commanded. On more than one occasion the flaps have been raised when "gear up" was commanded. This may not have been the first time the FCO switches have been selected but definitely the first time it wasn't picked up early enough to reverse the action.

As to the CVR recordings, I will repeat what I have often stated previously. There is no inherent right of the public to receive a full transcript of the CVR in order for them to form their own opinion of what happened. It is up to the Indian AAIB to conduct an investigation under the requirements of Annex 13 and possibly a fuller transcript of the CVR will be published in the Final Report to help the reader gain an understanding of what happened.

My belief is that CVideoRs, with robust protections and legislation around their use, will help accident investigations immensely by answering some of the what questions that the FDR and CVR don't seem able to. It doesn't have to be set up like the many Go-Pro images that are on social media. All that is needed is an image of the center console and the engine display and EICAS/ECAM screens .There would be no need to have images of the pilots faces.

It also is both possible without imagining things, and consistent with - shall we call it "best practices" under Annex 13 - for the person or persons who wrote and approved the preliminary report to have taken into consideration the attention their report would receive from many audiences, not only aviation professionals.

The prevalence of the 787 type. The quite recent travails of Boeing and the pace of its recovery (and some doubters that it can or will recover). The orders of magnitude increase in information, as well as misinformation or even disinformation, about this accident compared to .... well, compared to the UPS accident in Birmingham in 2013 (Flight 1354), cited as it was the first "current" accident occuring as of my stumbling across this forum and its threads. Sure, not a dramatic passenger aircraft accident but still valid for comparing the information environment then, and now.

The persons responsible for this report, I think, did not act improperly if they included information not strictly necessary for the purpose of keeping aviation cognescenti updated about what is known with some (imprecisely defined) level of certainty and clarity. Such other information items could be intended to make some effort at mitigating ("minimizing" would be hoping for too much) the volumes of noise emanating from all over.

Then there's the point about the report source knowing who did what, and when, but not providing specifics. Perhaps forensic analysis of the voice recording is ongoing, perhaps an analysis was completed but with reason to examine more closely. Regardless, I do not find it an affront either to solid, long-established principles of the Chicago Convention and Annex 13, or to the general ideas about advancing aviation safety, for the report sources to not treat the 30-day rule for preliminary reports as some "complete download demand function." Given what is reported about the fuel cutoff switches moving and the summarized cockpit statements, either way the final facts resolve will be tremendously impactful for the airline, the CAA of India, and the country (including but not only in its role as a major aviation Member State).

I wouldn't hold this view if it was a question of deception. I see it instead as a matter of reasonable discretion, about both ..."what to leave in, what to leave out" (with apologies to Bob Seeger, "Against the Wind", 1980).

The French prosecutor wasn't running an Annex 13 investigation. The Indian AAIB is.

Perhaps it follows that Annex 13 investigations aren't the 'be-all-and-end-all' of accident investigations? Are you able to identify any error in the French prosecutor's investigation or how it did damage to anyone that should not have been done?

No, however:

While I have not studied France's law applicable to aviation accidents generally or investigations in particular, it is my understanding that French law does allow earlier, or more direct, participation - or both - in aircraft accident investigations. Annex 13, on the other hand, does not contemplate determination of blame or liability which are substantially the same thing as sought to be determined by prosecutors (albeit in a different form of court proceeding).

Also, one of the most fundamental principles, if not the most fundamental principle, underwriting all of what ICAO does - at least within its traditional or historic remit and not drifitng off into DEI or strident environmental causes - from the Convention through the Annexes and SARPs, is standardization. Obviously criminal investigations will not be, and could not become, standardized across the States which are active in the international civil aviation sector.

At the time of the Alaska Airlines door plug incident and its aftermath, long-time aviation policy worthies decried the way in which the status of the NTSB investigation had been dragged into the criminal matter against Boeing pending in federal district court in Texas. Their reasoning was that accident investigators must have access as unfettered as possible to sources of information, and the presence of criminal processes necessarily makes people reluctant to speak or provide information otherwise. With this reasoning in mind, it could be agreed that although Annex 13 and pertinent SARPs are not the ultimate in investigatory enlightenment, criminal inquiries (and the French version of same) are not an inherently better approach.

Of course, when reasonably specific and articulable facts point to potential criminal conduct, that is a very different matter.

Of course they aren't the "'be-all-and-end-all' of accident investigations." And whether or not I can identify errors in the prosecutor's investigation \x97 and indeed whether there were any errors \x97 is entirely irrelevant to the issue here.

Annex 13 investigations are the way international aviation, via the ICAO, has agreed to investigate accidents. The Annex provides for procedures, rules and standards. The integrity of the investigations, generally, is undermined when parties step outside that framework. Whether or not the French prosecutor's actions in the Germanwings case did particular damage to "anyone," and whether or not there were errors in that criminal investigation cannot be the basis for an assessment and/or rejection of the Annex 13 provisions and procedures \x97 because sensible and deliberate analysis of systems is not based on single elements or incidents.

The CVR "MAY" indicate the "WHAT", it does not give the "WHY", and it is myopic to jump to a conclusion of any action conducted by a human as being deliberate. Our systems assume black and white operation exists, and nothing is further from the truth at any time, location, or situation.

Our training assumes that we always act in the manner that we trained, and that is an optimistic view of life. A review of most serious incidents and accidents leaves an impression that we are all subject to error and action slips. It is also quite true that in more events, the human is the variable that is able to adapt due to the ability to apply heuristics and occasionally intuitive responses to a condition that is outside of their training. Those are the saves, and they tend to be overlooked in our rush for judgement and certainty, and to have some level of assurance that an event cannot occur to us. The defence against error is monitoring system performance, to confirm that when we turn off a say, fuel pumps on an A340-300 to balance fuel (needless action, but sometimes eyepleasing is assumed to be better than leaving stuff alone) and accidentally turn off the HYD pumps, leading to a wild ride, our deliberate actions and cross checking of our movement of any switch, lever, coffee cup etc., is followed by the correct response. All of that is fine, until we do not have time to correct an accidental movement of a system control. FCS are considered to be "irreversible" due to the time to correct an action, and the criticality of the response to the system change, and so we have great checklists and design to ensure that procedurally we check before actioning a switch. That kind of works for engine failure and fire checklists, it gives little comfort to the case of selecting the gear up instead of flaps up, etc., and here is my concern with our assumption of intent from evidence of action.

It may well be that the investigation provides irrefutable and overwhelming proof that the FCS were placed to cutoff. That is looking likely. That in itself does not give the reasoning as to why that occurred.

Collectively we have been flicking the wrong switches (A340 wild rides) and levers, (DC8 etc.,) with lousy outcomes, for quite some time, presumably that is why we take inordinate efforts to check/verify actioning of irreverible systems, and yet, we also misplace keys, put wallets into fridges, etc as we are human. It is one thing to be human, most (not all of us) are, but it is another to understand what the intent of the person involved was, and that means we are a long way from assuming malfeasance or deliberate aforethought.

I do a fair amount of flight testing, and that involves some odd activity, and I don't trust myself to not make slips or errors, to the extent that for one aircraft, I carry a tennis ball that fits neatly over the end of the emergency shutdown handle of the engines that I am not intending to shutdown and subsequetly relight. I don't expect that alone stops making an error, it is simply a procedural step and an opportunity to differentiate between systems that may be worthwhile. We have had similar guards on FCS in the past, due to congnitive lapses leading to red faces, the P3 fuel and ignition switches being an elegant example. The intent of a guard that takes deliberate action is to increase the time available to comprehend what is about to occur, just as putting a post-it note over the LEM jettison is not a bad idea for the late senator of Colorado to have done on Apollo 13.

Just because something happened, doesn't give the reason why, and without that, there can be no "mens rea". It is appropriate to work to understand the why, that is the whole intent of Annex 13.