China Eastern MU5735 crash (Boeing 737-800)

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#2891809 25-Mar-2022 08:22

tdgeek:

Not ideal

The investigation is being led by China but the United States was invited to take part because the plane was designed and manufactured there.

However, the U.S. National Transportation Safety Board said on Wednesday it had not determined if investigators would travel to China given strict visa and quarantine requirements, and Chinese officials declined to say whether or when NTSB officials would be invited.

"Our work priority is still on search and rescue, and at the same time, carrying out evidence collection and fixation work in the early stage of accident investigation," said Zhu Tao, the CAAC's head of aviation safety.

"However, when we enter the accident investigation stage, we will invite relevant parties to participate in the accident investigation according to relevant regulations," he said.

I don't find anything concerning here.

Annex 13 is being applied and China will be running the investigation, they are meeting their obligations under Annex 13 as the state of occurrence and registration. NTSB can request access to the accident site as the state of manufacture. The NTSB have requested, but they still have to comply with the quarantine requirements. Nothing in Annex 9 means the NTSB can circumvent the customs and quarantine requirements of the inbound country.

But the NTSB will still be involved conducting the investigation by providing the information from the manufacturers to China and will have a seat on the investigation. Having a seat in the investigation doesn't necessarily mean that someone must be in the state of occurrence for the entire investigation process. It is also clear in Annex 13, that the investigation must not wait until all the accredited representatives have arrived in to the state of occurrence, so the Chinese are able to commence surveying the accident site while the NTSB accredited representative is still in quarantine.

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#2891815 25-Mar-2022 08:33

empacher48:

I don't find anything concerning here.

Annex 13 is being applied and China will be running the investigation, they are meeting their obligations under Annex 13 as the state of occurrence and registration. NTSB can request access to the accident site as the state of manufacture. The NTSB have requested, but they still have to comply with the quarantine requirements. Nothing in Annex 9 means the NTSB can circumvent the customs and quarantine requirements of the inbound country.

But the NTSB will still be involved conducting the investigation by providing the information from the manufacturers to China and will have a seat on the investigation. Having a seat in the investigation doesn't necessarily mean that someone must be in the state of occurrence for the entire investigation process. It is also clear in Annex 13, that the investigation must not wait until all the accredited representatives have arrived in to the state of occurrence, so the Chinese are able to commence surveying the accident site while the NTSB accredited representative is still in quarantine.

Quality of the investigation and bias

empacher48

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#2891817 25-Mar-2022 08:44

tdgeek:
Quality of the investigation and bias

Why?

NTSB still have a seat at the table and have access to all the same data and information as CAAC.

The NTSB will be involved in writing the final report and will be signing their name at the end of it.

In situations like this, very limited information is available right now, the survey of the crash site and where locations of wreckage will be important, but the NTSB is not required to be there. The cause of this accident won’t be found out from the scene examination.

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#2891820 25-Mar-2022 08:59

empacher48:

Why?

NTSB still have a seat at the table and have access to all the same data and information as CAAC.

The NTSB will be involved in writing the final report and will be signing their name at the end of it.

In situations like this, very limited information is available right now, the survey of the crash site and where locations of wreckage will be important, but the NTSB is not required to be there. The cause of this accident won’t be found out from the scene examination.

Investigation is investigation not just the site. Bias. Asian culture is about honour. There is a difference between working together physically and working together remotely. The purpose is to locate where the blame goes, so processes can be put in place to avoid a similar accident. Its better to have a side by side evaluation of all aspects rather than a biased local investigation, where potentially a compromising fact might be put aside in order to get a more satisfactory blame result

empacher48

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#2891831 25-Mar-2022 09:18

tdgeek:

Investigation is investigation not just the site. Bias. Asian culture is about honour. There is a difference between working together physically and working together remotely. The purpose is to locate where the blame goes, so processes can be put in place to avoid a similar accident. Its better to have a side by side evaluation of all aspects rather than a biased local investigation, where potentially a compromising fact might be put aside in order to get a more satisfactory blame result

Have you been involved with a fatal aircraft accident investigation before?

By the fact, you've stated "The purpose is to locate where the blame goes" shows that you probably haven't. There is never ever blame written into an aircraft accident report. Ever. Never, ever.

I will quote from paragraph 3.1 from Annex 13, which is the bible for how States conduct investigations:

"OBJECTIVE OF THE INVESTIGATION

3.1 The sole objective of the investigation of an accident or incident shall be the prevention of accidents and incidents. It is not the purpose of this activity to apportion blame or liability."

I'm not sure what you think happens during an investigation either. But the NTSB aren't just some "side part" of the investigation, but they will be actively involved and there will be not just "some local investigation". Having been involved with CAAC in various investigations, I have found them to be very competent, open and have the same safety goals in mind as we did, anything we asked for was provided both in their English translation and local languages of those crew involved, so we can get our own translations done.

The issue of the NTSB not being able to have access is purely down to the quarantine and customs requirements for entry to China. Nobody has the ability to by-pass that in any country, no matter what. Annex 9 allows aircrew and investigators the ability to enter a country without hinderance or delay and using special visa classes unavailable to the public. They still have to comply with customs and quarantine requirements, people entering countries under Annex 9 are quite often under closer customs and quarantine inspections than the general public.

I've lost count the number of times I've been pulled aside entering any country and have had all by belongings emptied out, catalogued, x-rayed, when I've been operating. I've never had that done as a passenger.

tdgeek

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#2891834 25-Mar-2022 09:29

empacher48:

Have you been involved with a fatal aircraft accident investigation before?

By the fact, you've stated "The purpose is to locate where the blame goes" shows that you probably haven't. There is never ever blame written into an aircraft accident report. Ever. Never, ever.

I will quote from paragraph 3.1 from Annex 13, which is the bible for how States conduct investigations:

"OBJECTIVE OF THE INVESTIGATION

3.1 The sole objective of the investigation of an accident or incident shall be the prevention of accidents and incidents. It is not the purpose of this activity to apportion blame or liability."

I'm not sure what you think happens during an investigation either. But the NTSB aren't just some "side part" of the investigation, but they will be actively involved and there will be not just "some local investigation". Having been involved with CAAC in various investigations, I have found them to be very competent, open and have the same safety goals in mind as we did, anything we asked for was provided both in their English translation and local languages of those crew involved, so we can get our own translations done.

The issue of the NTSB not being able to have access is purely down to the quarantine and customs requirements for entry to China. Nobody has the ability to by-pass that in any country, no matter what. Annex 9 allows aircrew and investigators the ability to enter a country without hinderance or delay and using special visa classes unavailable to the public. They still have to comply with customs and quarantine requirements, people entering countries under Annex 9 are quite often under closer customs and quarantine inspections than the general public.

I've lost count the number of times I've been pulled aside entering any country and have had all by belongings emptied out, catalogued, x-rayed, when I've been operating. I've never had that done as a passenger.

It is not the purpose of this activity to apportion blame or liability

Yes, its not the purpose, but its the result. Once you find the result, i.e. who or what was the cause you can use that to prevent further occurrences. If you feel the CAAC acting more or less alone on site and off site in China will be totally unaffected by cultural pressure or political pressure, then that's good.

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empacher48

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#2891853 25-Mar-2022 10:03

tdgeek:

It is not the purpose of this activity to apportion blame or liability

Yes, its not the purpose, but its the result.

I fear that you may have been watching too many NatGeo Air Accident Investigation documentaries.

I have never read an accident report that does place "blame or liability" anywhere. That is for the courts or police to do, with their own investigation either concurrently or after the Accident Investigation.

An aircraft accident report will find all incidental links in the chain, which cause the accident. Then will provide recommendations to prevent those incidental links from happening again.

Take an example of a LAME who fails to comply with a task, that causes an engine failure on an aircraft. The accident report will end up with a conclusion along the lines of:

"The engine failure situation was found because the LAME conducting the task was using an incorrect task sheet, that was two months out of date. The updated task sheet from the manufacturer was received by the organisation but was not actioned in to the maintenance manual. The day the update was received the manual controller was sick and did not action the manual change or did not send the confirmation of the change to Manufacturer X. It was observed the manual controller is a sole responsibility position with no support staff to manage the workload.

“Manufacturer X had a system to follow up with organisations who failed to respond to manual changes in a timely manner. This change cycle it was observed that 40% of maintenance organisations had failed to respond to the manual change.”

The investigation would continue to find out why Manufacturer X’s systems had failed. There would be no blame placed on the LAME, nor the manual controller, nor anyone in Manufacturer X. But all those latent failures will be fixed so they don’t line up again.

If there is blame or liability, then that is up to the police for criminal prosecution to decide, or the courts in a civil suit. But they cannot use the Aircraft Accident Report to do that, their investigation must be conducted separately.

Unfortunately New Zealand has become one of the few countries in the world, where the courts have used Aircraft Accident Reports to try and apportion blame or even discredit the Air Accident Investigation Process because it didn't lay blame. They have even tried to use devices from aircraft accidents to prosecute flight crew, that under international law are absolutely forbidden from being used in prosecution.

tdgeek

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#2891866 25-Mar-2022 10:26

Ok. Blame is my word. If an accident is Pilot Error. While the investigators are not in the role to prosecute, or fire the pilots, they are in the role to find the cause. If its Pilot Error, that's inherently blame. If a mechanic didn't check a part correctly for wear, that's blame. If the final report says its pilot or mechanic's error, that's basically blame. What others do for those employees is of no concern for the investigators

All I'm saying is that it's human nature to not want to blame me or the cause to be me. Or my company, or my country, or the aircraft I manufacture. IMO the culture in some countries has a very high honour content. And the outside pressure of that

frankv

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#2891869 25-Mar-2022 10:30

tdgeek:

The purpose is to locate where the blame goes, so processes can be put in place to avoid a similar accident.

Blame is the wrong word. The purpose is to find the cause of the accident. There may be no-one to blame -- everyone may have followed the correct processes, and the processes may have been believed by everyone to be correct. The classic example of this is the DH Comet crashes in the early 1950s. Everything was best-practice, but the effects of fatigue on aluminium structures and pressurisation were simply not known.

Nevertheless, the results of air accident investigations are often used to blame someone.

[Edit]

As per the earlier posts, it's simplistic to say that "pilot error" is the fault of the pilot. If the pilot has been trained wrongly, or not been trained at all in a particular scenario, that may be the fault of the airline. Or, as in Erebus, it may be the fault of the airline in changing the flightpath without informing the flight crew. Let's not forget that that was labelled as "pilot error".

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#2891872 25-Mar-2022 10:37

frankv:

Nevertheless, the results of air accident investigations are often used to blame someone.

Which is understandable when you have lost 130 odd innocent souls and an expensive aircraft.

Insurance will want to know who is to 'blame' before paying out.

empacher48

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#2891887 25-Mar-2022 10:56

tdgeek:

Ok. Blame is my word. If an accident is Pilot Error. While the investigators are not in the role to prosecute, or fire the pilots, they are in the role to find the cause. If its Pilot Error, that's inherently blame. If a mechanic didn't check a part correctly for wear, that's blame. If the final report says its pilot or mechanic's error, that's basically blame. What others do for those employees is of no concern for the investigators

All I'm saying is that it's human nature to not want to blame me or the cause to be me. Or my company, or my country, or the aircraft I manufacture. IMO the culture in some countries has a very high honour content. And the outside pressure of that

You won't see "pilot error" or "mechanic error" as you're looking at the reasons why the error was made, was it external threats? poor training? poorly written SOP? Poor resourcing? lack of knowledge? If you take for example, poor training, you'll then ask where did the pilot do their training? was it standard training? who was the person conducting the training? how were they trained? what resources were available to both the trainer and trainee? Was the individual meeting the required standards?

So if the error was made worse because of issues with their training, then who do you want to blame, is it the individual that made the error? the instructor who didn't pass on the knowledge? the instructor of the instructor who didn't pass on the knowledge? the training department who developed the course?

An error never ever happens in isolation, there is always things that will force you into making an error. It happens to everyone, every day in every task we do. 99% of the time those errors don't cause serious issues, but you can't blame someone from making an error. You can only blame an individual for an intentional act and Just Culture takes care of that.

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tdgeek

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#2891889 25-Mar-2022 11:00

frankv:

Blame is the wrong word. The purpose is to find the cause of the accident. There may be no-one to blame -- everyone may have followed the correct processes, and the processes may have been believed by everyone to be correct. The classic example of this is the DH Comet crashes in the early 1950s. Everything was best-practice, but the effects of fatigue on aluminium structures and pressurisation were simply not known.

Nevertheless, the results of air accident investigations are often used to blame someone.

[Edit]

As per the earlier posts, it's simplistic to say that "pilot error" is the fault of the pilot. If the pilot has been trained wrongly, or not been trained at all in a particular scenario, that may be the fault of the airline. Or, as in Erebus, it may be the fault of the airline in changing the flightpath without informing the flight crew. Let's not forget that that was labelled as "pilot error".

As I stated, blame is my word. However you name it, the purpose is to find the cause, and the cause will show a shortcoming, and that shortcoming needs to be addressed. The shortcoming is a failure.

As for the rest your going off on a tangent. I used Pilot Error as one example in an investigation, of "blame" Not of this incident. In your eaxmple

" If the pilot has been trained wrongly, or not been trained at all in a particular scenario"

That's not pilot error.