Rescue 116 Crash at Blackrock, Co Mayo(Mod note in post 1)

irishgeo

never heard of a report being held back in other countries because it might apportion some fault to an individual.

skallywag

irishgeo wrote: »

never heard of a report being held back in other countries because it blames someone.

You are right.

In this case a lot of sensitivity is being given to the family of the crew. Perhaps some things come out that are not palatable. etc.

Strumms

It’s a tough one, certainly IF there was blame to be apportioned it would in no doubt be of benefit to the wider aviation community to be shared I wonder ? Should the ‘sensitivities’ of family members outweigh the value of publishing to the wider aviation community ?

Also, because they were state employees, would the same courtesy have been extended to Mr/Ms xyz who crashed on attempting a landing of a Cessna 162 into Weston.. ? If an error was made, history can’t be rewritten but the fact that it’s been withheld, does seem strange..

Topgear on Dave

I don't think they are strictly state employees, more employees of contractors (CHC)?

Iv had a look at the AAIU website for the PC-9 crash a few years ago. The accident was Oct '09 and the report was ready for publication Oct '11.

"An interested party served a notice of Re-Examination on the Minister for Transport, Tourism and Sport regarding this Report."

"The Minister, having considered the matter at length, concluded that the grounds set out in the Notice to challenge the findings and conclusions reached in the Final Report were not sufficient to undermine the validity of the conclusions reached. Accordingly, the Minister requested the AAIU to publish the Final Report on the 24 January 2012."

http://www.aaiu.ie/node/299

Strumms

Strumms wrote: »

It’s a tough one, certainly IF there was blame to be apportioned it would in no doubt be of benefit to the wider aviation community to be shared I wonder ? Should the ‘sensitivities’ of family members outweigh the value of publishing to the wider aviation community ?

Also, because they were state employees, would the same courtesy have been extended to Mr/Ms xyz who crashed on attempting a landing of a Cessna 162 into Weston.. ? If an error was made, history can’t be rewritten but the fact that it’s been withheld, does seem strange..

The nature of these reports they don’t apportion blame. They state facts and produce causal factors only.

his safety investigation is exclusively of a technical nature and the Final Report reflects the determination of the AAIU regarding the circumstances of this occurrence and its probable causes.
In accordance with the provisions of Annex 131 to the Convention on International Civil Aviation, Regulation (EU) No 996/20102 of the European Parliament and the Council, and Statutory Instrument No. 460 of 20093, safety investigations are in no case concerned with apportioning blame or liability. They are independent of, separate from and without prejudice to any judicial or administrative proceedings to apportion blame or liability. The sole objective of this safety investigation and Final Report is the prevention of accidents and incidents.
Accordingly, it is inappropriate that AAIU Reports should be used to assign fault or blame or determine liability, since neither the safety investigation nor the reporting process has been undertaken for that purpose.

Please note the above very carefully.

prunudo

[Deleted User] wrote: »

The nature of these reports they don’t apportion blame. They state facts and produce causal factors only.



Please note the above very carefully.

Is that the case in all jurisdictions or just how the aaiu operate?

Roger_007

irishgeo wrote: »

never heard of a report being held back in other countries because it might apportion some fault to an individual.

It is not the job of the AAIU to apportion blame or responsibility but it is their job to determine the the cause, or causes, of an incident in order to prevent a similar incident occurring in the future.
If an incident is caused by someone’s inappropriate actions or inactions, then they have to state that. Obviously, that means that the actions and decisions taken by the various personnel involved which led to the incident have to reported in full without fear or favour. They also have to include any contributing factors which may have played a part. Most reports of air accidents which I have read point to numerous contributory factors like inadequate training, poor management, pilot fatigue, etc etc. There is rarely just a single cause.
Unfortunately, where there are fatalities involved, families are often going to feel aggrieved if they judge that the report seems unfair to their family member. However the truth, however painful, must be told; otherwise the whole investigative exercise is pointless.

smurfjed

However the truth, however painful, must be told; otherwise the whole investigative exercise is pointless.

what an excellent statement.

smurfjed

Unfortunately I believe that once the report is released, the court cases will begin.

irishgeo

Having watched many series of aircraft crash investigations shows its never a single factor or someone direct fault. While i feel for the families i don't think lessons can be learned from an unpublished report.

smurfjed

Having watched many series of aircraft crash investigations shows its never a single factor or someone direct fault

Seriously?

irishgeo

smurfjed wrote: »

Seriously?

Its usually a series of events that cause an accident.

sasta le

The families dont want the report out?

smurfjed

@irishgeo,

Not always, look at this report, the finger of blame lies with the crew, both of them in this case, not just the Captain

https://www.ntsb.gov/investigations/AccidentReports/Pages/AAR1503.aspx

Or this one.

https://aviation-safety.net/database/record.php?id=20120713-0

There are many others just like that.

irishgeo

smurfjed wrote: »

@irishgeo,

Not always, look at this report, the finger of blame lies with the crew, both of them in this case, not just the Captain

https://www.ntsb.gov/investigations/AccidentReports/Pages/AAR1503.aspx

Or this one.

https://aviation-safety.net/database/record.php?id=20120713-0

There are many others just like that.

in the first one it says

According to Gulfstream, the interlock mechanism was intended to limit throttle lever movement to a throttle lever angle (TLA) of no greater than 6° during operation with the gust lock on. However, postaccident testing on nine in-service G-IV airplanes found that, with the gust lock handle in the ON position, the forward throttle lever movement that could be achieved on the G-IV was 3 to 4 times greater than the intended TLA of 6°.

i could argue that the interlock mechanism was faulty as well therefore a series of events.

prunudo

prunudo wrote: »

Is that the case in all jurisdictions or just how the aaiu operate?

You need to re read that post and the answer is clearly contained within.

prunudo

[Deleted User] wrote: »

You need to re read that post and the answer is clearly contained within.

I thought it was a reasonable question but thanks for your reply.

Stovepipe

All AAIUs sign up to the same protocol about assignation of blame; it's not about blame from the very start to the finish of the investigation and the Irish AAIU are always at pains to point this out and in several cases, have had to point out to people that they are not the IAA. This has caused confusion and disbelief even within the ranks of experienced airline people and it has had to be repeated more than once; blame is not going to be apportioned by an AAIU investigation. Findings will be made but no AAIU report will apportion blame, ever.

Nijmegen

Stovepipe wrote: »

All AAIUs sign up to the same protocol about assignation of blame; it's not about blame from the very start to the finish of the investigation and the Irish AAIU are always at pains to point this out and in several cases, have had to point out to people that they are not the IAA. This has caused confusion and disbelief even within the ranks of experienced airline people and it has had to be repeated more than once; blame is not going to be apportioned by an AAIU investigation. Findings will be made but no AAIU report will apportion blame, ever.

I'm not sure many lay people (and potentially families) would see the difference between findings that relate to, for example, pilot error and apportioning blame. If (and I caveat with a big if) the families are not happy with the report, it may relate to some finding that they feel (rather than that it does) apportions blame to their loved one.

CJhaughey

Same thing with the maritime equivalent.
MCIB will look at all the factors involved and produce a report, They just report the facts as they stand.
Accident-Causation-Recommendation is how they are usually structured.

Stovepipe

Well,if the AAIU or an equivalent body, published a report that stated outright that Pilot x or mechanic Y was fully responsible for a crash,then they had better be prepared to stand over it in court, especially if the supposedly blamed person was killed in the crash. Some authorities are prepared to say so but most aren't, because every single report would be contested in court and nothing would be achieved. In some countries, the AAIU is independent of the aviation authority/military/govt but in a lot of cases, they are not and are under political and military pressure to deliver reports that suit certain agendas. In Ireland, the AAIU are independent and it's all the better for our aviation that that is the case. As for blame, there's nothing stopping the IAA from taking action after any report is published,especially if they feel the need to take away a person's license. Nothing prevents families from taking legal action against the airlines or the Air Corps or any pilot or engineer or ATC0. Air accident reports avoid the apportioning of blame,so that the industry can learn from mistakes. It may not be popular or palatable, but it means that people will find out what happened and the manufacturers can make safer aircraft or pilot training might have to be changed or engineers retrained and so on.

Gadgetman496

Stovepipe wrote: »

Well,if the AAIU or an equivalent body, published a report that stated outright that Pilot x or mechanic Y was fully responsible for a crash,then they had better be prepared to stand over it in court, especially if the supposedly blamed person was killed in the crash. Some authorities are prepared to say so but most aren't, because every single report would be contested in court and nothing would be achieved. In some countries, the AAIU is independent of the aviation authority/military/govt but in a lot of cases, they are not and are under political and military pressure to deliver reports that suit certain agendas. In Ireland, the AAIU are independent and it's all the better for our aviation that that is the case. As for blame, there's nothing stopping the IAA from taking action after any report is published,especially if they feel the need to take away a person's license. Nothing prevents families from taking legal action against the airlines or the Air Corps or any pilot or engineer or ATC0. Air accident reports avoid the apportioning of blame,so that the industry can learn from mistakes. It may not be popular or palatable, but it means that people will find out what happened and the manufacturers can make safer aircraft or pilot training might have to be changed or engineers retrained and so on.

General Disarray

The final draft of the report was released by the AAIB. Anyone who is directly referenced/quoted/inferred is automatically reserved a right of reply to any of the statements or findings therein.

The draft report is provided to these people before official final publication so that they can reply to any of the findings. Any replies will be taken into account before the official final report is released.

This is all normal procedures inline with ICAO recommendations.

There's no "conspiracy".

mr.anonymous

The AAIU won't apportion blame or liability. But every word of their draft report will be laboured over by a wide range of interested and referenced parties.

What their final report states could form the basis for millions in lawsuits against the aircraft manufacturer, life jacket manufacturer or other parties.

I'd imagine the IAA would want any criticism of their oversight sanitised given the extent of what they regulate. This will be the most significant report since the Cork accident report.

General Disarray

Having read the final draft report myself, a lot of early posters who were heavily criticised in this thread, will be fully vindicated.

L1011

And "I told you so" posts are still not allowed, so drop it.

easypazz

General Disarray wrote: »

Having read the final draft report myself, a lot of early posters who were heavily criticised in this thread, will be fully vindicated.

Post #449 is well worth another read.

easypazz

easypazz wrote: »

Post #449 is well worth another read.

here here

Storm 10

http://www.rte.ie/news/ireland/2020/0109/1105424-r116-helicopter-crash/

Steve

Total bucket or ' it wasn't me'

It also emerged that Blackrock island was not included in a database designed to warn the crew they were in danger of hitting land.

It was designed for CA, nor for SAR.