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responding to flight control inputs from the cockpit.”
Human Factors
• Both pilots were properly trained, licensed, and qualified to conduct the flight.
• There was no evidence found to indicate that the performance of either pilot was
adversely affected by any medical or physiological condition.
• Interviews with respective superiors, colleagues, friends and family revealed no
evidence that both the flight crew members had changed their normal behaviour
prior to the accident.
This conclusion is not representative of the findings of the HPG investigation.
Although consistent with the HPG’s conclusion (in HPG report Version 6.0, July 30,
1999) regarding the first officer, the conclusion in the draft report is inconsistent
with the HPG’s conclusion regarding the captain. The HPG report states, "There
were some indications that the captain’s behavior or lifestyle changed prior to the
accident." It is suggested that this conclusion be separated to accurately describe
the captain’s and first officer’s behavior.
N-55
• There was no evidence found to indicate that there were any difficulties in the
relationship between the two pilots either during or before the accident flight; or had
been experiencing noteworthy difficulties in any personal relationships (family and
friends).
• Until the stoppage of the CVR, the pilots conducted the flight in a normal manner
and conformed to all requirements and standard operating procedures.
• Although a flight attendant had been in the cockpit previously, after the last meal
service and until the stoppage of the CVR there was no indication that anyone else
was in the cockpit other than the two pilots.
• In the final seconds of the CVR recording the PIC voiced his intention to leave the
flight deck, however there were no indications or evidence that he had left.
• Interviews and records showed that in 1997 the PIC had experienced a number of
flight operations related events, one of which resulted in his being relieved of his LIP
position.
In its evaluation of the data collected, the HPG made a more definitive
conclusion regarding the captain’s career in the 6 months prior to the accident. The
HPG conclusion, "During 1997 the PIC experienced multiple work-related
difficulties, particularly during the last 6 months" should be used to modify the
existing conclusion.
• The PIC was involved in stock-trading activities, but no conclusions could be made
indicating that these activities had influenced his personal behavior.
The first part of this conclusion, “The PIC was involved in stock-trading
activities” is a statement of fact and does not provide the basis for a conclusion.
Further, the factual report substantiates that at the time of the accident, the PIC
had been requested to pay a significant amount of money for outstanding debts and
did not have liquid assets from which to pay these debts. This latter information
forms the basis for a conclusion regarding the captain’s financial stressors. In the
HPG report, the conclusion was made that "At the time of the accident the PIC was
experiencing significant financial difficulties." Also, this information was presented
in the NTSC’s interim report issued August 1999. Therefore, it is suggested that the
NTSC revise this conclusion to be consistent with information cited in the AAIC
HPG report and that was disseminated to the public in 1999.
• From the data available to the NTSC there was no evidence found to indicate if the
mortgage policy taken out by the PIC in connection with his housing loan has any
relevance to the accident.
N-56
Finally, the NTSC’s conclusions do not address the crash of the three
training aircraft from the captain’s squadron while he was serving in the military.
As discussed in the comments to section 1.18.3.1, the HPG examined the effect this
event may have had on the captain but could not determine the extent to which he
may have been affected. It is strongly suggested that the NTSC’s draft Final Report
include the conclusion from the AAIC HPG report that states, “The accident [in
Palembang] occurred on the same date as the 1979 RSAF crash in the Philippines;
the extent to which the PIC was affected by this event could not be determined.”
3.2 Final Remarks
• The NTSC investigation into the MI 185 accident was a very extensive, exhaustive
and complex investigation to find out what happened, how it happened, and why it
happened. It was an extremely difficult investigation due to the degree of destruction
of the aircraft resulting in highly fragmented wreckage, the difficulties presented by
　
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