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USS McCain collision ultimately caused by UI confusion

arstechnica.co.uk

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Re: USS McCain collision ultimately caused by UI confusion

#61

Post by cyberferret »

inferiorhuman wrote: post #52
JshWright wrote: post #46

Earlier quoted context omitted.

Decent odds you've flown on an airplane with a similar UX for primary flight controls. Airbus uses two "side stick" controllers that are on opposite sides of the cockpit. This was a contributing factor in the Air France 447 crash.

> > Amazing that someone would design in multiple steering wheels, only one of which is active, and no big indicator to make it super-obvious which one it is. > Decent odds you've flown on an airplane with a similar UX for primary flight controls. Ah, well Airbus does a few things. 1.) A "dual input" warning is issued if there is an attempt at using both controls simultaneously. 2.) There are lights to indicate when…

I believe the warning can change depending on which of the 3 flight modes the aircraft is in at the time. Big contribution to AF447's demise was that the aircraft was in 'alternate flight' mode and the crew assumed it was still in 'normal flight' mode and made a lot of their judgement calls accordingly.

For an industry that is so safety conscious, I believe this is a huge flaw in disaster control. To put it in context that most readers here can understand - lets say your everyday computer uses OS X as its operating system, but one day, with deadlines to meet, you have a huge crash, and the OS reverts to Windows, and you have to find the problem and remember the appropriate commands under intense pressure...

Re: USS McCain collision ultimately caused by UI confusion

#62

Post by mjlee »

csours wrote: post #24
jordanb wrote: post #17

The real cause of the collision was poor seamanship and failure to follow the COLREGS on the part of the bridge crew of the destroyer. Most specifically they were seriously in violation of Rule 6: the Safe Speed Rule http://navruleshandbook.com/Rule6.html Every vessel shall at all times proceed at a safe speed so that she can take proper and effective action to avoid collision and be stopped within a distance appropr…

The path to a disaster has been compared to a tunnel [0]. You can escape from the tunnel at many points, but you may not realize it. Trying to find the 'real cause' is a fool's errand, because there are many places and ways to avoid the outcome. I do take your meaning, reducing speed and following well established rules would have almost certainly have saved them. 0. PDF: http://www.leonardo-in-flight.nl/PDF/FieldGui…

I prefer the swiss cheese model.

https://en.wikipedia.org/wiki/Swiss_cheese_model

"In the Swiss Cheese model, an organisation's defenses against failure are modeled as a series of barriers, represented as slices of cheese. The holes in the slices represent weaknesses in individual parts of the system and are continually varying in size and position across the slices. The system produces failures when a hole in each slice momentarily aligns, permitting (in Reason's words) "a trajectory of accident opportunity", so that a hazard passes through holes in all of the slices, leading to a failure."

A series of minor failures that combine for a serious crisis seems very relatable.

Re: USS McCain collision ultimately caused by UI confusion

#63

Post by rdl »

Everyone in the chain of command in 7th fleet (from ADM Smith on down through the captains and those standing watch) should have been separated and potentially prosecuted for negligence. UI confusion would be an excuse for an untrained civilian being put on the bridge and told to run the ship, but not for professionals, and obviously many systems failed for this to happen. When the military runs well, it runs on accountability -- there's been a serious shortage of that, especially above O-6, for a long time.

"Retiring" without losing rank doesn't cut it.

Re: USS McCain collision ultimately caused by UI confusion

#64

Post by kevinburke »

rdl wrote: post #63

Everyone in the chain of command in 7th fleet (from ADM Smith on down through the captains and those standing watch) should have been separated and potentially prosecuted for negligence. UI confusion would be an excuse for an untrained civilian being put on the bridge and told to run the ship, but not for professionals, and obviously many systems failed for this to happen. When the military runs well, it runs on acco…

> UI confusion would be an excuse for an untrained civilian being put on the bridge and told to run the ship, but not for professionals

There are plenty of examples of "UI confusion" causing professionals to make mistakes in all sorts of industries. I'd suggest taking a look at the book "Behind Human Error," for example.

http://www.usabilityfirst.com/glossary/mode-error/index.html https://www.amazon.com/Behind-Human-Error-David-Woods/dp/075...

Re: USS McCain collision ultimately caused by UI confusion

#65

Post by foldr »

mikeash wrote: post #55
foldr wrote: post #36

Earlier quoted context omitted.

That is an article in popular mechanics that contains a few excerpts from the transcript selected in order to make a particular point. The accident report gives a detailed description of the behavior of both pilots before the copilot entered (2.1.2.3). One possible misconception here is that the copilot would have had his hands on the stick. It isn't normal for both pilots to have their hands on the stick. Only the p…

I believe this is the official transcript: https://www.bea.aero/uploads/tx_elyextendttnews/annexe.01_04... I see that the first link I posted doesn't contain everything, but I don't see any major omissions either. At 2:11:37.5, Robert takes control of the plane. According to the report, he pushed the stick to the left twice. Bonin then took back control. Figure 69 on page 96 of the report you linked shows Bonin's pit…

Figure 69 shows Bonin's stick inputs before Robert took control (and a few seconds after). As explained on p. 182 of the report, Robert pressed the override switch at this point and took control, so Bonin's stick inputs would have been ignored. Bonin then took back control by himself pressing the override switch. In effect, then, at this late stage, the pilots were fighting over the stick. If it had been a physical fight via linked control columns, the outcome would most likely have been the same. What can you do if the pilot and co-pilot just don't agree on the correct input, and neither is willing to yield to the other?

For context, all of this is happening at a relatively late stage. Recovery may still have been possible, but the problem developed when the PF was unambiguously in control and the PNF would not have been holding the stick.

Re: USS McCain collision ultimately caused by UI confusion

#66

Post by mjlee »

Zak wrote: post #21

Aside from the lack of clarity about which station has control over what, which should be made really obvious, with additional warnings when someone sets a control input on an inactive station, this seems bizarre to me: While the Ship's Control Console has a wheel for manual steering, both steering and throttle can be controlled with trackballs, with the adjustments showing up on the screens for each station. I've ne…

I have been on the bridge of a ship, as an Officer of the Watch in the Royal Navy.

Ships have both open loop and closed loop control systems. Closed loop is the normal mode of operation, but there are open loop systems to fall back to. The procedure tends to involve sending someone down to the rudder to communicate back the actual angle of the rudder.

The difference between a warship and a most other vehicles is that you can't simply stop a warship and get out. You need to be able to fight even if you've lost the feedback loop from the bridge to the rudder. For the comparison to the blackhawk, in a ship you can at least do something about mechanical failures in control systems.

Re: USS McCain collision ultimately caused by UI confusion

#67

Post by civilian »

mjlee wrote: post #62
csours wrote: post #24

Earlier quoted context omitted.

The path to a disaster has been compared to a tunnel [0]. You can escape from the tunnel at many points, but you may not realize it. Trying to find the 'real cause' is a fool's errand, because there are many places and ways to avoid the outcome. I do take your meaning, reducing speed and following well established rules would have almost certainly have saved them. 0. PDF: http://www.leonardo-in-flight.nl/PDF/FieldGui…

I prefer the swiss cheese model. https://en.wikipedia.org/wiki/Swiss_cheese_model "In the Swiss Cheese model, an organisation's defenses against failure are modeled as a series of barriers, represented as slices of cheese. The holes in the slices represent weaknesses in individual parts of the system and are continually varying in size and position across the slices. The system produces failures when a hole in each s…

Yup! My cousin & cousin-in-law work to maintain human health at some nuclear power plants in Canada. They use the swiss-cheese model, and whenever they notice that one layer missed something, they do a re-evaulation of that safety layer.

Re: USS McCain collision ultimately caused by UI confusion

#68

Post by trhway »

>At this point, everyone on the bridge thought there had been a loss of steering. In the commotion that ensued, the commanding officer and bridge crew lost track of what was going on around them.

now add to that picture (according to your historical preferences) a salvo of the 10 inch battery from an enemy battlecruiser 10 miles away or 2 Moskits rushing at 2.5x Mach ... blaming UI is just so childish and lame. Like our Sun executives blaming market conditions back then 10 years ago when everybody else had already been enjoying the boom for a few years.

Re: USS McCain collision ultimately caused by UI confusion

#69

Post by JshWright »

inferiorhuman wrote: post #52
JshWright wrote: post #46

Earlier quoted context omitted.

Decent odds you've flown on an airplane with a similar UX for primary flight controls. Airbus uses two "side stick" controllers that are on opposite sides of the cockpit. This was a contributing factor in the Air France 447 crash.

> > Amazing that someone would design in multiple steering wheels, only one of which is active, and no big indicator to make it super-obvious which one it is. > Decent odds you've flown on an airplane with a similar UX for primary flight controls. Ah, well Airbus does a few things. 1.) A "dual input" warning is issued if there is an attempt at using both controls simultaneously. 2.) There are lights to indicate when…

And as the Air France 447 cockpit voice recordings demonstrated, those are not sufficiently obvious in all circumstances (particularly in high stress situations when you're already several steps down the path to disaster).

Re: USS McCain collision ultimately caused by UI confusion

#70

Post by drdrey »

csours wrote: post #24
jordanb wrote: post #17

The real cause of the collision was poor seamanship and failure to follow the COLREGS on the part of the bridge crew of the destroyer. Most specifically they were seriously in violation of Rule 6: the Safe Speed Rule http://navruleshandbook.com/Rule6.html Every vessel shall at all times proceed at a safe speed so that she can take proper and effective action to avoid collision and be stopped within a distance appropr…

The path to a disaster has been compared to a tunnel [0]. You can escape from the tunnel at many points, but you may not realize it. Trying to find the 'real cause' is a fool's errand, because there are many places and ways to avoid the outcome. I do take your meaning, reducing speed and following well established rules would have almost certainly have saved them. 0. PDF: http://www.leonardo-in-flight.nl/PDF/FieldGui…

Are you recommending the 2nd edition specifically? There is a 3rd edition available: https://www.amazon.com/Field-Guide-Understanding-Human-Error...
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