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was a pulling out of the CVR circuit breaker.
The information presented in paragraph (c) regarding the CVR is
redundant. Because no conclusions are drawn, it is not necessary to discuss this
information again.
In addition, as noted in the summary, this section should address the fact
that the captain was in the process of leaving the cockpit at the time the CVR
stopped recording. It should provide a description of the position of the CVR and
DFDR circuit breakers in relation to the captain’s seat, the door, etc. Finally, the
information about the captain’s previous CVR event (in June 1997) should be
emphasized.
NTSC’S COMMENTS:
The PIC’s previous CVR event has no bearing on this
accident. The location of the CVR circuit breaker is
provided in in-flight documentation.
2.13.2 ATC Recordings
The data transcribed from the ATC communications recording of the air-to-ground
conversation indicates that at 09:10:26, or 5 minutes and 10.4 seconds after the CVR
stoppage, the F/O acknowledged the “abeam Palembang” call from the ATC. The F/O
was positively identified by voice analysis examination. This confirms that the F/O was in
the cockpit when the aircraft was abeam Palembang. However, it is not possible to
conclude whether the PIC was in the cockpit at the time. It was also not possible to
determine events or persons present in the cockpit from the time of the last transmission
to ATC.
The absence of a distress call could suggest that the pilots were preoccupied with the
handling of an urgent situation. However, it is not possible to conclude on the reason for
the absence of a distress call.
N-49
The NTSC’s conclusion that the absence of a distress call likely indicates that
the pilots were attempting to “handle an urgent situation” is misleading because it
implies that the pilot(s) perceived the situation as an emergency. The discussion in
this section should be modified to make clear the possibility that the absence of a
distress call could suggest that the pilot(s) did not consider the situation a condition
of distress, that is, the airplane was doing what a pilot commanded it to do.
NTSC’S COMMENTS:
Just as it is not possible to conclude that the pilots
perceived the situation as an emergency, it is also not
possible to conclude that the airplane was doing what a
pilot commanded it to do.
2.14 Specific Human Factors Issues
In this section, the specific, personal, financial backgrounds and recent behavior of the
PIC and the F/O are examined.
2.14.1 Personal Relationships
Evidence obtained from family and friends of both the PIC and F/O reported no recent
changes or difficulties in personal relationships.
It was concluded there was no evidence that either pilot was experiencing difficulties in
any personal relationships.
2.14.2 First Officer (F/O)
The investigation into the F/O's personal and professional history revealed no unusual
issues. No records of incidents or unusual events were found, and no career setbacks or
difficulties were experienced. Financial records showed no evidence of financial
problems. Interviews with family, close friends and relations seem to indicate that the
F/O was a well-balanced and well-adjusted person, and keen on his job, and planning to
advance his a flying career. There were no reports on recent changes in his behavior.
2.14.3 Pilot-in-Command (PIC)
The investigation into the personal and professional career revealed that the PIC was
considered to have been a good pilot, making his transition from a military pilot to
commercial pilot smoothly. His career at SilkAir showed that he was well accepted and
given higher responsibilities. He was considered to be a leader among the Singaporean
pilot community in SilkAir.
N-50
During his professional career at SilkAir, he was involved in a few work-related events,
which were in general considered minor operational incidents by the management.
However in one particular event, for non-technical reasons the PIC infringed a standard
operating procedure, i.e. with the intention to preserve a conversation between the PIC
and his copilot, the PIC pulled out the CVR circuit breaker, but the PIC reset the circuit
breaker in its original position before the flight. This was considered a serious incident
by the management, and the PIC was relieved of his LIP appointment. The PIC was
known to have tried through existing company procedures to reverse the management
decision. Although there were some indications of the PIC being upset by the outcome of
the events, the magnitude of the psychological impact on the PIC could not be
determined.
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本文链接地址：
NTSC Aircraft Accident Report SILKAIR FLIGHT MI 185 BOEING B(72)
