From here
How many accidents are there each year in which there is no one left alive (pilot or passenger wise to ) to tell the tale?
For instance here we have both an FFAREX and a FFPLUM REX whereby pilots relate an incident that happened to them to inform others. The REX (return/ report of experience) might well be added to by another pilot or instructor in the aircraft. An analysis is added by a safety committee along with recommendations for perhaps avoiding such an incident in the future.
More serious incidents and accidents will become a CRESAG (compte rendu d’événement security Aviation General or an account of a event relating to the security of GA). Basically this is the method to meet the EU requirement to report accidents or incidents involving damage to aircraft, people or airfield equipment.
The BEA are therefore left to investigate accidents or incidents where there is no one left to tell what really happened.
They piece together bits of information which might possibly have led to the accident happening, including from witnesses. It is not their job to apportion blame but just to say what they think did happen. Sort of expert witnesses forensics if you like.
They might say that a wrong bolt was used and what should have been used. They may even identify from logs etc when that bolt was changed and by whom.
It is not their job to say that Mr X put the wrong bolt in and therefore caused the death of X people. That is for a court to decide if someone wants to take it to court.
Although in reading reports we might draw our own conclusions in most cases, no one can be 100% sure that that is what caused the accident. That is as true for most accident investigators and even more true for us reading accident reports which can only contain what the investigators can say this is what they believe based on what they know.
It’s why I believe REX are more useful to learn from than BEA reports.
This accident happened in the UK (BEA is French) but both AAIB and BEA (more the BEA I would say) are reluctant to criticise “the system”.
Not relevant here though since no ATC or airspace issues apply.
In the UK the AAIB and the CAA are part of the same employment merry-go-round, along with the RAF, NATS, and to a lesser extent the airlines. The people in important roles all know each other and everything happens in the context of people having one eye on their next job and not wanting to cause any problems that might affect their future prospects. This is the ‘system’ and AAIB reports do not criticise it. Sometimes they even appear to assist it.
A recent examples is the Sala crash where they left the wreckage on the sea floor, perhaps because conclusive proof of CO poisoning would be unhelpful to the CAA narrative regarding the incident and the prosecution that followed.
Another is one where an old pilot crashed either while landing or going around (I forget). With no evidence whatsoever, the AAIB report strongly hinted at a medical cause due to the pilot’s advanced age. It is hard to ignore that bizarre publication and its timing, as the CAA is attempting to roll back many of the freedoms granted by the Pilot Medical Declaration, perhaps due to under-the-table lobbying from AMEs. A particular feature of our system is that any doctor leaving the RAF looks forward to doing medicals as a retirement job, nice work if you can get it at a few hundred £ each time for a brief physical and a few minutes form-filling.
For the French equivalent, look no further than the Concorde crash.
full agreement on many points. In some places you can add that the wheels are not as smooth as in the UK or France, but rather trying to fight each other, with the TSB trying to impose policy onto CAA’s which they disagree with, by directly or indirectly accusing the CAA of inaction or compagnionship with the organisation which had the accident. Or to undermine EASA directives easing maintenance and overhaul requirements, such as suggesting that “on condition operation” is a hazard and that there was “no reason” that private GA should not be following the same overhaul regimes as commercial ones. I’d compare that to the UK’s reluctance to accept the medical self declaration.
The Concorde report (as well as the investigation) was one of the most spin-doctored report I’ve ever seen, but not surprising after other stories coming out of France when their products are concerned. Thankfully there were plenty of withnesses around to tell the real story of that accident such as the BA people who were able to get own eye proof of the facts before they were swept under the carpet.
There was a time when I aspired working for TSB’s either as an investigator or associate or outside expert. Nowadays, I must admit I prefer to take an outside role via investigative journalism or live fact gathering following accidents, to make sure that they are out there and can’t be ignored or swept away. In recent years I have become frustrated a lot about several of those reports, in particular the conclusions and safety recommendations, which very often were purely political and in some cases even contradicting the otherwise excellent investigative work. I hope that some of the more ballant examples will get exposed in the future and that TSB’s step off policy making in favour of returning to the spirit of Annex 13.
One friend I work with and whose opinion I value recently said to me that he thought Annex 13 needs to be updated to the point where national TSB’s need to step aside the moment where an airplane manufacturer or airline of national importance in the same country is concerned. I tend to agree with that, up to the extent that ideally any accidents like that should be investigated by a totally neutral TSB, if that exists.
I think you have to be careful of claiming conspiracy theories on by Aircraft Accident Investigation Branches
1/ They can only report what they know and what they have been told.
2/ If Air France told lies to the BEA then those lies unless able to be disproved are included in reports or preliminary reports.
3/ The blame not from the BEA but by Air France was put on Continental Engineers
4/ Continental were taken to court for bad maintenance leading to the accident
5/ Continental were exonerated following a legal case in 2012
6/ Even in 2019 ex Concorde pilot John Hutchinson was being well paid to give speeches making what at the time were astonishing claims and conspiracy theories implicating everyone and his dog. Including him losing his job because Air France put pressure on Airbus not to sell parts to British Airways so that they had to terminate Concorde.
7/ if his claims are true or if even one or two can be proven to be true, do you not believe that the families of the victims will want their day in court.
8/ if they do have their day in court John Hutchinson will be asked to justify his claims.
9/ This may all yet happen. But it is easy to sell conspiracies to a receptive audience. Much more difficult to prove those accusations in a court of law.
10/ The families of victims of the Concorde disaster would more than likely be a receptive audience and their advocats would love to here anything that resembles positive proof of Air France, Airbus or any other large organisation conspiring to hide the truth. Including the BEA. In this case it would be far more likely as the President of France and his wife narrowly missed death in the accident, according to Hutchinson.
I am not saying that John Hutchinson is wrong or denying that Air France were involved in a cover up but I am surprised that with the sort of allegations made AFAIK, only Continental Engineering has so far been taken to court and they were exonerated.
Remember French courts will prosecute anybody from ex presidents and prime ministers to heads of multi national French companies.
Yep, and in that other thread @Peter wrote
Fascinating stuff on the investigation of the French Concorde crash, and vanishing evidence and all that stuff
… which brings back some memories of the same flavour such as the 1998/A320-111/Habsheim/AF296Q crash for example. It’s investigation raised more than a doubt as to it’s partiality and credibility.
I find it sad that people interested in aviation read a book and put so much in store by what it says without checking the facts. Then they use it as a stick to beat the investigators of the BEA.
UK Concorde captain John Hutchinson said that the fire on it’s own should have been eminently survivable.and that the pilot should have been able to fly his way out of trouble. He did not believe the accident was due to a series of operational errors and negligence by the maintenance department.
In a speech in 2019 John Hutchinson was still expounding the theory that there was no piece of titanium metal and the damage was caused due to the aircraft being overweight and the captain using the run off area to gain more runway. Between the run off area and the runway proper there was a lip and it was that lip which caused the damage. The BEA report does say that the aircraft was overweight.
AFAIK Mike Bannister was never part of the official investigation. He was not an investigator. IiUC he was called to give expert evidence for a 2nd report. A 60 page report by French Concorde pilot Jean Marie Chauve and Concorde flight engineer Michel Suaud. The report was submitted to the investigating judges. It concentrated on 2 factors that the BEA had found to be of negligible consequence to the crash.
Their conclusions were disputed by the BEA.
Mike Bannister UK Concorde chief pilot claimed there is evidence to suggest that the fuel tank transfer pump that fed the ruptured fuel tank was left running causing fuel to be pumped overboard and subsequently feeding the fire and that the fuel tank was 30% full at the time of the crash rather than empty if the pump had been off.
I make no comment on who is right and who is wrong.
So in 2023 in order to sell books Mike Bannister claims that when they went into the warehouse IIRC at Pontoise, where everything was laid out, usual practice for air accident investigation teams, that people stood in their way trying to hide things and were not helpful.
Now perhaps from the investigating team point of view here are people who turn up to check their team’s homework. They were not air accident investigators. Things might well have been different if they were part of the UK AAIB.
Plus they may well have no knowledge of procedures needed and chain of evidence to be followed and minuted. The investigation team may simply have thought that these non investigators had an arrogant manner and wanted to rummage in the wreckage to try and prove theories that they already put forward. Which is not the way aircraft investigators work.
It may also be that the investigating team thought “who the fxxk are these people, keep them away from everything”
Now I repeat I am not making judgements on who is in the right and who is in the wrong but I just find it sad when pilots on here automatically believe one writer trying to sell more books and buy into idea that behaviour was bizarre and that they doctor reports due to political or corporate pressure and describing their reports are completely useless because of it.
I really like their reports. It’s true that fundamentally they are fact collectors, but they do come to conclusions (“probable cause” and contributing factors) and, even though their role is clearly not to lay the blame (in the judiciary sense) they are clearly entitled to point out what went wrong in the chain of security. So they don’t just state the facts. In a lot of smaller accidents, there is not much to say because the probable cause is unknown.
Saying they don’t criticize the system is a bit much IMO. They did make UPRT training mandatory after AF447. It’s part of their recommendations in the report. Their prerogative is CLEARLY to criticize the system and its flaws (primarily EASA). I have no opinion about the Concorde stuff but I don’t think we can say they went easy or protected the state of things during AF447. The cause for this is stated as :
Of course, there are many more much smaller accidents which lead to less interesting reports (this is really their “big one”).
I’ve heard more about NTSB reports than BEA (thanks to the various vulgarization YT channels), and things can sometimes get pretty heated between them and the FAA, precisely because the FAA is cutting too much slack. The Boeing debacle was a humiliation for the FAA, and the NTSB clearly put some of the blame on them (again, not in the judiciary sense but towards improving safety and fixing systemic loopholes).
I really appreciate their reports, although REX are more frequent.
