IAA reports

adam88

Hi all.

I used to find it easy to find the reports published by the iaa regarding incidents but can't seem to locate them now on their website. I'm looking for the united airlines report regarding the false airspeed incident. Any help??

lintdrummer

Perhaps you're looking on the wrong website as it's the AAIU that hosts the occurence reports here: http://www.aaiu.ie/reports/aaiu-investigation-reports
I believe this is the report you're looking for: http://www.aaiu.ie/node/921

smurfjed

You can also sign up to their subscription service and get reports whenever they are issued.

lintdrummer

That was an interesting read. It seems from the tone of the report the Captain wasn't wholly co-operative with the investigation. I also found the following extract intriguing:

When the AAIU subsequently removed the recorders from the aircraft, it was determined that while the FDR had been preserved, the circuit breakers for the CVR were not pulled. The download of the CVR confirmed that the relevant cockpit recordings were overwritten and the CVR was of no use to the Investigation.

In his written report to the AAIU, the Co-Pilot advised, inter alia, that:

A lady from Dublin (I assume she was an agent) came to the cockpit and asked us to pull the CVR and FDR circuit breakers. As there was other personnel in the cockpit speaking to the captain who was on the phone with dispatch at the time, I proceeded to locate and pull the breakers. At this time there were at least four persons in the cramped cockpit and with difficulty I tried to locate the breakers to be pulled. It was late and just getting light and we were tired and very busy attempting to manage all of the duties placed upon us at that moment with coordinating with the company, the medical personnel, the maintenance staff, the flight attendants and the Irish Safety Authorities. I finally located the FDR breakers but apparently I had completely missed the CVR breakers. I advised the Agent and the Captain that I had pulled the breakers thinking that I had pulled all of the breakers asked of me. I didn t even realize this mistake until the next day when the agent present on our outgoing flight mentioned that the CVR tapes were not usable due to the breakers not being pulled. At that time I searched the circuit breaker panel and found the CVR breakers and realized that I missed them the night before. This was not done intentionally .

Call me a skeptic, but to me that is nothing short of an effort to thwart the investigation. Even considering the circumstances I find it hard to believe that he somehow forgot to pull the CBs for the CVR and yet managed to pull the FDR ones.
The importance of using these devices to learn from mistakes and make aviation safer can not be understated. Preserving data after this kind of event should be akin to remembering to put the gear down on landing.

Dardania

That is bollocky behaviour alright, and wouldn't encourage me to fly United TA again...

Tenger

Would the accident investigation body not be in a position to check that the CB's were pulled for the FDR and the CVR themselves. Each cockpit had these in a specific position therefore should be relatively easy for the rep to ensure that the flight crew pull the relevant CB before leaving.
In some more serious circumstances the flight crew could be shaken or already in shock. (So perhaps having their own IAA flight crew manually pull the CB themselves would be best)

smurfjed

Considering the age of the 757, its quite possible that the CVR only recorded 30 minute loops. So it would be worthless.

Tenger

Tenger wrote: »

Would the accident investigation body not be in a position to check that the CB's were pulled for the FDR and the CVR themselves. Each cockpit had these in a specific position therefore should be relatively easy for the rep to ensure that the flight crew pull the relevant CB before leaving.
In some more serious circumstances the flight crew could be shaken or already in shock. (So perhaps having their own IAA flight crew manually pull the CB themselves would be best)

I thought that too, or at least an international requirement to have it observed that the pilot pulls the CBs rather than just telling them to do it.

Irish Steve

The AAIU or IAA could make such checks, but the timescale is the limiting factor, the CVR in particular needs to have the CB's pulled as soon as possible after an event to avoid the recording being over written, and the nature of these things is that the AAIU or IAA are not normally "on scene" until some time after the event, so leaving it for them to take action, rather than check that the action was performed could result in critical information being lost.

From a technical aspect, the time factor relating to overwrite time on the CVR goes back historically to times when digital recording was not available, with the availability of cheap solid state memory, it would now technically be feasible to have a much larger time period stored, and it would also be technically feasible to have a "save event" option, triggered either by a specific switch that's crew accessible, or by FDR out of normal events, which would allow a period of time to be protected for even longer, which could be significant in some incidents, given the length of time that could elapse between an incident and the subsequent landing.

John_Mc

I thought exactly the same myself when I read the report. Even their attitude and cooperation in the interview with the AAIU just after landing, you can read that they didn't want to say anything incriminating without aligning their stories first.

That's my reading between the lines in the report anyway.

Terrible behavior and they obviously did a terrible job if they are trying to cover it up.

cml387

I imagine any captian would have concerns about a third party enetring the cockpit and throwing switches.
It should be the captain's responsibility. Indeed from the SOP's of the company the captain was forbidden to pull any recording without first contacting the company.

Tenger

cml387 wrote: »

I imagine any captian would have concerns about a third party enetring the cockpit and throwing switches.
It should be the captain's responsibility. Indeed from the SOP's of the company the captain was forbidden to pull any recording without first contacting the company.

Understandably. Hence my query about the IAA/AAIU have a rap onaite able to visually check that this had been done or to verbally query this with the flight crew before they exit the aircraft.

smurfjed

Interesting report and one that I'm sure will find it's way into CRM training, I do however have one question, "Where was the Captain?"

Aircraft descent continued, peaking briefly at 12,000 fpm.. (and VMO +30kts)

I think that the CVR would be extremely interesting, however, I wouldn't expect an American crew to allow access to it without representation from their union.

martinsvi

there's one thing I don't understand - in theory FDR/CVR's should stop recording as soon as the plane is unable to move under its own power, at least that's what the books say. If the incident happened at 5:05, plane being on the ground at 5:22, does that mean they kept the engines running for nearly 2 hours after that (at least)? Is that normal?

smurfjed

[font=Open Sans, Arial, Helvetica, sans-serif]Taken from the B757 FCOM[/font]
[font=Open Sans, Arial, Helvetica, sans-serif]CVR - All inputs are recorded continuously when electrical power is supplied to the aircraft.[/font]
FDR - On the ground either engine must be running.

Its quite likely that the CVR was only a 30 minute version so by 5:35 it was done, although I believe that it is possible to retrieve overwritten information down to 4 levels, however it's expensive and most likely this sort of incident wouldn't warrant the expense.

cml387

cml387 wrote: »

I imagine any captain would have concerns about a third party entering the cockpit and throwing switches.
It should be the captain's responsibility. Indeed from the SOP's of the company the captain was forbidden to pull any recording without first contacting the company.

That's why I said it should be observed, as in IAA told by AAIU after its reported, to contact the handler and require them to tell the crew to pull the CB's and that they are required to observe this.

You can surmount Union/Company objections by making it an ICAO requirement.

The report at points reads like a short text message as in you could read into it what you want, you could easily take away from it that something untoward happened that they didn't want heard. But, in fact nothing happened, the CB was just forgotten about. I don't know if that was the intention of the report but it's just what I came away with.

martinsvi

smurfjed wrote: »

[font=Open Sans, Arial, Helvetica, sans-serif]Taken from the B757 FCOM[/font]
[font=Open Sans, Arial, Helvetica, sans-serif]CVR - All inputs are recorded continuously when electrical power is supplied to the aircraft.[/font]
FDR - On the ground either engine must be running.

Its quite likely that the CVR was only a 30 minute version so by 5:35 it was done, although I believe that it is possible to retrieve overwritten information down to 4 levels, however it's expensive and most likely this sort of incident wouldn't warrant the expense.

cheers for that, I guess it makes sense.. I did read that since 2010(?) FAA requires all airliners to carry CVRs that can hold minimum of 2 hours worth of recordings. I think in EASA land older aircraft can still get away with 30 minutes, but from 2020 it's going to be 20 hours.

smurfjed

Taken from the Honeywell Maintenance Component Manual
CVR part number 980-6005 Recording time is 30 minutes
CVR part number 980-6020 Recording time is 30 minutes
CVR part number 980-6022 Recording time is 120 minutes

I have no way of knowing if the solid state CVR was installed in this aircraft, or was it required by rectoactive certification.

cml387

I guess the real concern of the investigation (as was emphasised towards the end of the report)was that it seems to be another case of an IAS disagree causing the crew to overcorrect flight inputs.