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Frog in a pot phenomenon

mgiles — Mon, 02 Nov 2009 06:45:32 +0000

Frog in pot

There is a saying that if one slowly heats a pot of water with a live frog in it the frog will go to sleep and not get out and so get cooked whereas if he is dropped into a hot pot he will leap out. So it is in many situations in life. We have it in aviation where slowly evolving situations get way past a point where some action should be taken because each development is incremental and not so different from the last situation. So it is with Airbus pitots and standby instruments and now with Flight 188 overflying its destination I think we have the same thing. It does not really matter if they went to sleep or lost track of time there was considerable potential for trouble. Much has been made of the poor match of the human physiology and performance and yet steadily the man is being taken out of the loop in flying so that such things can happen. An extraordinary number of RPT flights pass uneventfully but where a trend emerges it should be addressed. Ground control is now possible and studies should be made, discussed and decisions taken. Pilots do not have to leave the cockpit. It is just another logical progression. The Helios tragedy where apparently a cabin crew member was walking about with a portable O2 system but unable to enter the cockpit is another situation where ground control could have saved hundreds. The reasons why this has not happened are many and various and to do with how aviation has evolved a rigid and inflexible regulatory process. Vested interests are many but it is mainly a sort of general inertia and no one has had the courage really to say come on guys wake up or more to the point, hear those who have been saying such. As usual there will be wails of technical difficulty and cost but it seems clear that it is going to be a small cost in the long-term and long over due for considerations. Maybe the risk of different sort of hostile take over is behind the resistance but we seem to find ways to trust our fellow men in many other situations. Why not?

911 Impact

In this last episode apparently, the pilots were so engrossed in conversation while checking their laptops that they lost contact with ground controllers for about 90 minutes.
The two pilots involved have had their licenses revoked, the Federal Aviation Administration reported.
The Wall Street Journal described the episode that occurred last week as illustrating two of the biggest problems in commercial aviation: cockpit discipline and pilot complacency. Surely, said airline experts, they must have fallen asleep. Apparently not. According to interview notes from the National Transportation Safety Board: – Both pilots are experienced and have never had an accident, incident or violation.
- Neither reported medical conditions. Both said they were not sleepy or fatigued. They had just had a 19-hour layover before the flight from San Diego to Minneapolis. Yet, from 6:46 p.m. Central Time until 8:14 p.m., the pilots did not communicate, reported The New York Times. More than a dozen controllers in three radar rooms tried to contact the pilots. Was the plane hijacked? Were the pilots in a medical crisis? Four fighter jets were on runway alert in case they were needed. What happened?
In short, the pilots radioed to controllers that there was “cockpit distraction” and “dealing with company issues.” It appears the pilots were discussing a new workplace schedule system following the merger of Northwest and Delta Air Lines, The Wall Street Journal reported. In the meantime, they failed to switch radio frequencies for a different set of air traffic controllers. Besides this inexcusable (? I’ll bet they dont ever do this again so why terminate thier careers?) example of incompetence, this points out several areas needing correction. Are cockpits too cozy? So much piloting is done automatically, in dark cockpits, that it’s easy to nod off or become inattentive. Airlines need to take steps to put the pilots at work doing something useful during that “down time” in the air. Some Boeing aircraft are equipped with warnings when pilots fail to adjust controls, The Wall Street Journal reported. Are voice recorders adequate?
The box recording the cockpit discussions only had the last 30 minutes available, leaving no record of the earlier distracted time. Every box should record every minute of every flight.
And what about video cameras? They should be used in every cockpit. This is not a privacy issue for the pilots, it’s a safety issue. When so many lives are at stake – 144 passengers, two pilots and three attendants – every reasonable means should be taken to protect them.
The good example of being prepared has been well documented, when Chester “Sully” Sullenberger safely landed an aircraft in the Hudson River with only a few minutes from warning to landing. As for the Northwest Airline pilots, every possible lesson should be learned from this strange incident. It would be appropriate for Congress to hold hearings – not to sensationalize this particular incident – but to probe for issues it has revealed. from http://jacksonville.com/opinion/editorials/2009-10-30/story/aircraft_safety_incredible_failure

Frog in pot

Death by Computer

mgiles — Mon, 07 Sep 2009 02:15:55 +0000

There has been a deafening silence in the general press about the AF 447 tragedy of recent times. What with drones running round in various places bombing baddies with the occasional bit of collateral damage generally agreed to be regrettable by the responsible (what a way to use the word) parties and regular suicide bombings not to mention ferries turning over and NSW Cabinet Ministers being laid low by spurned lovers it does not take long for even such a monumental tragedy to fade into the background but those of us who fly are worried and will not rest until some sense can be made of it.
At present the official position is that we do not know the cause but suspect a perfect storm of events starting with a sensor failure led to a loss of control. The more time passes the more this seems pretty thin. If this could be the case then thousands are daily in danger. I expect that behind the scenes this is being taken very seriously and I also suspect that given the propensity for litigation currently prevailing loose lips sink financial ships is guiding the dissemination of information i.e. what you don’t know wont hurt you (or more accurately in some cases wont hurt the company).
It seems we have reached the point predicted frequently by experts where systems too complicated to be completely analyzed have been created and are in daily world wide service.
In the design philosophy of the Airbus et al a very serious effort has been made to build in protection by redundancy but as reports come in more and more evidence of startling failures emerges of the type which warrant drastic action.
I have collected reports of a total of 52 incidents in which malfunctions of automated flight systems with computers at their core have created situations where there was a serious risk of the loss of an aircraft and all aboard. As my research has not been exhaustive likely ther are many more. Two of these situations did lead to the loss of aircraft. In one case, the crash of a B2, the crew were able to eject but the bomber worth about $250 mil was lost while in the other case – AF 447, the aircraft and all on board were lost.
Why are we continuing to fly them? In the case of the Air force and B2s the failure was diagnosed and corrected but in the case of the AF447 it is clear that in actual fact the risks are regarded as acceptable in the face of the cost of the only rational action which is to stop using these aircraft till we understand what is going on. Or am I just just being alarmist?

Governments and Industry Ignored Warning Signs
Letter from John T Halliday
To: The Honorable Robert A. Sturgell, Acting FAA Administrator
Copy: European Aviation Safety Agency
Subject: NTSB Safety Recommendation
Date: July 22, 2008
On January 25, 2008, a United Airlines A320 lost three of six cockpit electronic flight displays after takeoff from Newark as the plane headed for downtown New York. The landing gear would not retract, all radios died, the overhead systems panel went blank. The emergency attitude indicator failed. The copilot testified, “If Newark had fog, and my attitude indicator had not recovered, we could have crashed.” Airbus reports 49 similar incidents — 17 when five or six displays blanked. 7 planes lost all flight displays. The UK Air Accidents Branch examined 14 display-blanking incidents. The NTSB believes these multiple losses create challenging situations. The United pilots reported multiple scrolling failure messages with corrective actions the computer removed so quickly, they were unable to interpret them. Blanking of flight displays coupled with systems failures is a significant safety risk because of increased pilot workload. Airlines have not informed their pilots, nor provided training. Crew attempts to troubleshoot these unusual problems may even lead to loss of aircraft control.
And as the London Times wrote on July 1 of this year:
The European Aviation Safety Agency is likely to be asked why it had never taken action to remedy the trouble well known within the Airbus 330 and 340 series. ‘EASA has a legal and moral obligation to get to the bottom of this problem. If there is a defective system and the aircraft is unsafe then it should be grounded,’ said James Healy- Pratt of Stewarts Law in London. Suspicion over the air data systems on the Airbus 330 and 340 series has increased after disclosure the aircraft experienced 36 episodes similar to the one that brought Flight 447 down. We mourn the loss of these souls. Our hearts go out to their famlies. We share their sorrow and we hope the tragic loss of their loved ones sparks long-overdue change.
There were snakes on this Airbus — snakes that left no trace evidence. Can pitot tube moisture turn computers rogue, leave pilots helpless to override, and crash a plane? The Air Force gets it. The pilots of this
$1.4 billion dollar B-2 couldn’t override their rogue computer:
Stars and Stripes Report Faults Computer in Guam B-2 Crash. The crash was caused by bad data sent to flight computers from three tiny wing sensors. General Floyd Carpenter: ‘The B-2 was on takeoff when the computer falsely told pilots it was moving along the runway at 140 knots, fast enough to fly. The computer then sensed the aircraft was going into a nosedive just as pilots tried to lift the craft off the ground. The (rogue) computer then ordered the B-2’s nose to pitch up to 30 degrees. The pilots desperately tried to override the computer, but it took the aircraft into a fatal stall. The aircraft performed as designed; all systems were functioning normally.’ Replacing Airbus pitot heaters is a good shot in the dark, but they have little to do with this tragedy. Maybe the heaters did it. Maybe a software bug did it. Maybe a rogue computer. Maybe a virus. Maybe the Tooth Fairy did it. Maybe the captain and copilot decided to commit mass murder, so flew into a thunderstorm. Maybe it was Colonel Mustard in the kitchen with the knife. But if it waddles like a computer, quacks like a computer and crashes like a computer . . . We may never know what happened without those missing black boxes, but need to pay attention to the computer-generated elephant sitting on our chests. The captain that horrid night was the Little Dutch Boy, trying to jam his fingers into the leaking dike of crashing computers amid their scary screams. Only he couldn’t plug holes as fast as the computers drilled more and more. He couldn’t keep up with the runaway holes, then ran out of fingers. And the sea rushed in and consumed them — murder by computer. His computers should have been fail-safe. They were fail-deadly — more interested in saving themselves than human beings. Bottom line? Designers have built machines humans can’t control. Replacing the pitot heaters plugs just one of the dike holes that killed 228. At some point, you have to build a new dike. Dr. Jordan Grafman, Chief of Neuroscience at the National Institute of Neurological Disorders, explains: “One of the big problems about multitasking is it’s impossible to gain a depth of knowledge of any task you’re doing; you only get surface-level knowledge.” Replacing those pitot heaters amounts to giving a cancer patient aspirin. The heaters are mere symptoms of the underlying fever. Air France 447 was a massive, beyond-human-control, China Syndome, chain-reaction computer system failure that rivals the Hindenberg tragedy that marked the end of hydrogen-filled airships. The question is: what about this computer system’s design allowed it to pinball out-of-control and why wasn’t there a way for the pilots to stop it?
Dr. Lisanne Bainbridge, Engineering Psychologist at the University College London, helps us understand in her “Ironies of Automation”: The classic aim of automation is to replace human manual control, planning and problem solving by automatic devices and computers. The automation designers’ view is that the pilot is unreliable and inefficient, so should be eliminated. The irony is that designer errors can be a major source of operational errors. Designers computerize the easy parts of the pilot’s job and make the hardest jobs even harder, leaving pilots the toughest tasks that designers can’t think how to computerize. Designers put computers in planes because computers remember more and make quicker decisions than humans. There is, therefore, no way pilots can check in real-time if the computer is following its rules correctly. Pilots have no way to check on if what the smarter machine is doing is acceptable. So if the computer is there because human judgement and intuitive reasoning are not adequate to keep up, which decisions is the human to accept? The pilot has been given an impossible task. See http://www.huffingtonpost.com/john-t-halliday/government-and-industry-i_b_276367.html

Dallas dudes dodge decompression death

mgiles — Thu, 16 Jul 2009 02:48:04 +0000

Southwest 737 hull failure

Southwest Airlines inspected Nearly 200 Boeing 737 belonging to Southwest airline had to be inspected after a hole in the aft fuselage of one of their aircraft forced an emergency landing.

Federal safety officials at Dallas are investigating how a foot-long hole opened in the top of the jet, forcing the emergency landing in Charleston, W. Va.

The Boeing 737 jet lost pressure in the cabin, but no one was injured on Monday’s Nashville-to-Baltimore flight that carried 126 passengers and five crew members.

The plane was built in 1994, and government records indicated that an inspection in January turned up eight cracks in the frame that required repairs.

Southwest said Tuesday that it inspected all 181 of its identical Boeing 737-300-series jets overnight before putting them back in the sky. Passenger Michael Cunningham told NBC’s “Today” show Tuesday that he had dozed off in his seat in mid-cabin when he was awakened by “the loudest roar I’d ever heard,” and saw the hole above his seat.

Cunningham said people stayed calm and put on oxygen masks that dropped from the ceiling. “After we landed in Charleston, the pilot came out and looked up through the hole, and everybody applauded, shook his hand, a couple of people gave him hugs,” he said.
Passengers in the front rows didn’t know the full extent of the hole — that it went right through to the sky, said Charles Overby, CEO of the Freedom Forum, a free-press foundation that runs the Newseum in Washington. “I was just as happy not to know that,” he told The Associated Press. “It was pretty harrowing, but I’ve been through worse landings during turbulence.”

Southwest said it was unclear what caused the hole, which ripped open just in front of the vertical tail fin as the plane cruised at 30,000 feet. The jet flew on for nearly half an hour to Charleston.

Federal Aviation Administration records show that during the plane’s 14-year checkup in January, eight cracks were found in the fuselage frame and repaired.

Damage from wear and tear is not unusual in planes of that age, and the FAA requires special inspections for cracks. In March, Southwest agreed to pay $7.5 million to settle charges that it operated planes that had missed those required inspections.

FAA spokesman Lynn Lunsford said an initial review indicated that inspection orders for the Boeing 737-300 didn’t include inspecting the area of the body where the tear appeared on Monday’s flight.
The FAA and the National Transportation Safety Board sent investigators to the scene to interview the crew and examine maintenance and inspection records, but could take months to find a cause, said agency spokesman Keith Holloway.
Southwest spokeswoman Marilee McInnis said workers conducted “a walk-around visual inspection” of the airline’s other 737-300s and discovered no cracks. During periodic maintenance overhauls, workers use equipment designed to detect cracks that aren’t visible.

The 137-seat 737-300 makes up about one-third of Southwest’s fleet. All its 544 jets are various models of the Boeing 737. Southwest operated a normal schedule of flights — about 3,300 per day — with no cancelations or delays through midday, McInnis said. Experts said the tear could have been caused by damage from a dent or ding, or the plane’s skin could have suffered from age-related fatigue. Jet cabins are pressurized and depressurized with every flight, which can cause tiny cracks over time. The Southwest jet was built in 1994.
Bill Voss, president of the Flight Safety Foundation in Alexandria, Va., said a finding of fatigue would be more frightening. If that were the cause, it could force the FAA to consider more rigorous inspections for older aircraft, he said.

Alten “Skip” Grandt, an aeronautics professor at Purdue University who specializes in structural analysis, said that the fuselage of the Boeing jet performed as designed by preventing a sudden and catastrophic loss of pressure, and stopping the hole from expanding.

The cabin depressurized, he said, “but whatever caused that hole, it didn’t cause the whole airplane to blow up.”

In 1988, cracks caused part of the roof of an Aloha Airlines Boeing 737 to peel open while the jet flew from Hilo to Honolulu. A flight attendant was blown out of the plane and plunged to her death, and dozens of passengers were injured. The incident led to tougher rules for inspecting fuselages.

In March, Southwest agreed to pay a $7.5 million civil penalty imposed by the Federal Aviation Administration for operating nearly 60,000 flights in 2007 on planes that had not undergone required inspections for cracks in the fuselage.
About 1,450 flights took place after the FAA had notified Southwest of the missed inspections.

Dallas-based Southwest Airlines Co. carries more than 100 million U.S. passengers a year, more than any other airline.
Original article at http://www.fox4kc.com/sns-ap-us-emergency-landing,0,2481185.story

Drugs Alcohol and Aviation

mgiles — Mon, 15 Jun 2009 06:37:43 +0000

Here in Oz we have recently introduced compulsory drug testing for people involved in aviation.
At first sight this might seem like a good thing and a sort of Motherhood matter. Who could object to it?
On second thought I am not so sure.
Firstly what is the rationale for it? Do we really think people are flying and working in aviation under the influence? Where is the evidence?
If there are individuals so irresponsible and I do fear there are would anyone so irresponsible be liable to change their behaviour in the face of possibly being confronted with a blow in the bag or lick the stick man?

I rather suspect not.
How much does all this cost and where is the cost benefit analysis?
Having observed Aviation for quite a long time I have a very uneasy feeling that the reality here is that this is a feel good exercise for box tickers which will as is becoming usual lead to much of the effort and a large slab of the cost being handed on to the aviation community so bureaucrats can be seen to be doing good stuff.
Aviation is, perhaps inevitably, highly regulated but recently I have noticed increasing mountains of paper all in the name of compliance and safety with entities such as the SMS (Safety Management system) becoming required and yet in practice becoming more like a distracting burden. There is only so much time people can give to such things before they actually subtract from the time and attention available to Aviate safely.
Maybe there should be a requirement for a regulation to be removed before another can be applied?
I would be very intersted in the views of others on this.