Turkish Airline crash at Schiphol, Final Report

[Jeroen Hoppenbrouwers]

http://www.onderzoeksraad.nl/docs/rapporten/Rapport_TA_ENG_web.pdf

[Avi]

Interesting, thanks
Amazing, the problems began long time before but the crew understood they have a problem only 15 seconds before the crash.
Sad.

[Richard McDonald Woods]

Very interesting.

I would have thought that an EICAS message showing that the radio altimeters are reporting different altitudes would be an easy modification. Then perhaps the horn should sound when the aircraft descends below 2000 feet RA.

Cheers, Richard

[Zinger]

1. Accidents are devastating to those directly involved and costly to many others.
2. Accidents should be prevented ahead of time by proper operations risk management (ORM).
3. Accident investigations should be performed professionally, and their reports written such that the knowhow obtained is useful and properly communicated  to prevent them from recurring.


I am writing the following with a background including chairman of air accident investigation boards, authorized investigator of a certain state CAA, and have completed US postgraduate technical report writing studies.
4. Without prejudice, the report is written such that it deviates from what I view as acceptable standards in this important line of business.  In doing so it is my impression that it fails to pass a clear message to decision makers. A proper format of accident report is for example used by the US Dept. of Transportation NTSB.
5. Excuse me for not reading through all of it, a decision maker needs to read the main conclusions and recommendations in a one page introductory summary. I closed the report on page 7 and might have missed some info.
BUT- the inverstigation in my humble opinion failed to pinpoint the primary cause of the accident. The primary cause of the accident was the failure of the crew to make a safe approach to landing, while flying with a failed RA. A main secondary contributor to the accident is the RA system failure, but the RA or the AFCS isn't the captain, whose primary responsibility I mentioned.
6. This adds to a number of essay messages I wrote about cockpit automation problematics.

[Robert Staudinger]

Hallo Zinger,

maybe you should read starting from page 81.

Regards Robert

[Zinger]

Pages after the executive summary are for non decisioin makers, 228 pages contain information for them. Decision makers read the executive summary,  hear experts and decide. This report main conclusion, vaguely at best discusses as main cause the failure of the cockpit crew to detect an RA system problem displayed in PFD, failure to detect and respond to IDLE/RETARD PFD notification, failure to establish the approach by FAF, failure to go around, responded too late and erroneously to stall warning and therefore crashed, killing crew and passengers.
.

Hallo Zinger,

maybe you should read starting from page 81.

Regards Robert

[Jeroen Hoppenbrouwers]

Come on. Decision makers listen to people presenting three powerpoint slides. They don't read any more, these days. They let other people do the reading.

http://www.edwardtufte.com/bboard/q-and-a-fetch-msg?msg_id=0001yB

[Zinger]

I have done a fair share of formal presentations, up to the minister himself, with and before PP.  No official makes a major decision before a document rests on his table. This is what investigation reports are for, but only the executive summary is studied by them.
My condolences to all who suffered the blow from the Libyan crash.

[Shiv Mathur]

That's a fascinating link, Hoppie ... thanks

[Jeroen Hoppenbrouwers]

My condolences to all who suffered the blow from the Libyan crash.

Thanks. The sole survivor comes from the same city as where I live. The rest of his family, father, mother, brother, all gone. 70 Dutch people in total, 3/4 of the passengers were Dutch.


Jeroen