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Crisis over The Atlantic: The near crash of Air Transat flight 236

admiralcloudberg.medium.com

71–80 of 151 posts

Re: Crisis over The Atlantic: The near crash of Air Transat flight 236

#72
post #47

The actual report: http://www.fss.aero/accident-reports/dvdfiles/PT/2001-08-24-... One of my pet peeves: the first 7 "causes and contributing factors" effectively blames the engine technicians for taking shortcuts. Nowhere does it say anything about the scheduling pressure from management that made the technicians consider shortcuts in the first place. If you have hiring and firing power and you tell someone they nee…

Also lack of access to documentation: the technician attempted to access the Rolls-Royce EIPC and the SB’s through the computer network, but was also denied access.

This should be a major point for a maintenance shop. Documentation should always be available, both online and in offline versions.

Re: Crisis over The Atlantic: The near crash of Air Transat flight 236

#73

Earlier quoted context omitted.

Not that uncommon. The Czech motorway D1 can be converted to a military airstrip here: https://www.google.com/maps/@49.3870307,15.9211894,289m/data... See where the grass divider ends, and gets replaced by a jersey barrier for 2 km? That part is the runway - it would require some hours of preparation before it would be usable, it's not quite "declare mayday and dump the plane there."

ah, that's very cool. Makes me think of all kinds of NATO-level shit that's strewn around the world waiting to be uncovered ;) The thing with the road in Uruguay is that as you're driving, there's basically a yellow sign with a picture of an airplane and an arrow pointing up, and you're like "what the fuck did that mean?" And then suddenly you understand exactly what it meant because you're driving on a fucking runwa…

The Czech one is more of a Warsaw-Pact-level shit. :-) Here is a (originally secret) documentary video about MiG-21 exercise on the highway (in Czech, obviously): https://www.youtube.com/watch?v=FDoZGoaG9_w

Re: Crisis over The Atlantic: The near crash of Air Transat flight 236

#74
post #70
post #64

Earlier quoted context omitted.

Even then, it didn't take the actual great circle route because Russia. The Japan to Europe flights are even worse. The great circle route cuts west, straight across Russia [0]. These days, they fly east to the Bering Strait then more or less directly over the north pole [1] (though probably easier to see on great-circle: [2]) [0] http://www.gcmap.com/mapui?P=HND-FRA [1] https://flightaware.com/live/flight/DLH717/his…

The direct route from FRA (Frankfurt Airport) to KUTAL (a navigational beacon on the Baring Sea in American airspace) passes within just 51 miles of the North Pole Back in the Soviet era when USSR airspace was closed to most Western flights, planes couldn't do that route non stop from Europe, so had to stop over in Anchorage for refueling. http://www.gcmap.com/mapui?P=BINP%2CFRA-KUTAL%0D%0A&MS=wls&D... Need to find a…

That's pretty close.

Playing around, a theoretical NUE (Nuremberg) to KUTAL flight comes within 1 mile of the North Pole

Re: Crisis over The Atlantic: The near crash of Air Transat flight 236

#75
post #49

I really love the straightforward but gripping style of writing here. I read every word! Which is rare for anything submitted to HN (or elsewhere for that matter)

I've been reading Admiral Cloudberg's write-ups for a few years since discovering them over on Reddit's r/CatastrophicFailure,[0] they're all truly excellent. I really enjoy his clear, no nonsense writing style. What us failure analysis nerds need, what we deserve, is a 90s era Discovery Channel show written by Cloudberg. Either that or a a United States Chemical Safety Board[1] style series. [0] https://www.reddit.c…

Not sure if you’ve heard about the podcast Cautionary Tales. It’s wonderful, especially if you like these kinds of things.

Re: Crisis over The Atlantic: The near crash of Air Transat flight 236

#76
post #49

Earlier quoted context omitted.

I've been reading Admiral Cloudberg's write-ups for a few years since discovering them over on Reddit's r/CatastrophicFailure,[0] they're all truly excellent. I really enjoy his clear, no nonsense writing style. What us failure analysis nerds need, what we deserve, is a 90s era Discovery Channel show written by Cloudberg. Either that or a a United States Chemical Safety Board[1] style series. [0] https://www.reddit.c…

Not sure if you’ve heard about the podcast Cautionary Tales. It’s wonderful, especially if you like these kinds of things.

This is my first time hearing about it. Thanks for the tip, I'll give it a listen.

Re: Crisis over The Atlantic: The near crash of Air Transat flight 236

#77
post #47

The actual report: http://www.fss.aero/accident-reports/dvdfiles/PT/2001-08-24-... One of my pet peeves: the first 7 "causes and contributing factors" effectively blames the engine technicians for taking shortcuts. Nowhere does it say anything about the scheduling pressure from management that made the technicians consider shortcuts in the first place. If you have hiring and firing power and you tell someone they nee…

What shortcuts? Spec said no touchy between tubes. Tubes no touchy when aircraft left the hanger? Seems good to me.

These are the kinds of failures you get when you try to proceduralize everything with foolproof procedures, checklists, run-books, processes, etc. The maintenance people didn't even know they were making a judgement call.

Had the technicians sleeved the offending tubes with appropriate chafing gear and secured them to reduce movement as would be common place in more earthly situations instead of trying to get it "technically in spec" without thinking about the implications of what they were actually doing this problem may very well have been averted. But maintenance people in aviation aren't really ever exercising those creative problem solving skills since it's such a book driven workflow they're always dealing with so of course they missed the forest for the trees (not that they would have been allowed to implement a one-off fix like that).

Re: Crisis over The Atlantic: The near crash of Air Transat flight 236

#78
post #47

The actual report: http://www.fss.aero/accident-reports/dvdfiles/PT/2001-08-24-... One of my pet peeves: the first 7 "causes and contributing factors" effectively blames the engine technicians for taking shortcuts. Nowhere does it say anything about the scheduling pressure from management that made the technicians consider shortcuts in the first place. If you have hiring and firing power and you tell someone they nee…

What shortcuts? Spec said no touchy between tubes. Tubes no touchy when aircraft left the hanger? Seems good to me. These are the kinds of failures you get when you try to proceduralize everything with foolproof procedures, checklists, run-books, processes, etc. The maintenance people didn't even know they were making a judgement call. Had the technicians sleeved the offending tubes with appropriate chafing gear and…

I don't think this is true at all

> These are the kinds of failures you get when you try to proceduralize everything with foolproof procedures

> Had the technicians

The report makes it clear that the problem was their lack of access to the relevant details, not that the process was defective. If they had seen the need to replace the hydraulic hose, they would have presumably changed it or flagged the problem to someone higher up.

> The maintenance people didn't even know they were making a judgement call.

It seems like they did. If you replace a part and something is touching, you are not trusted in aviation to try and make some space with a bit of fiddling for exactly this reason. They did make a judgment call. If they had relied on the process, again, they could have queried why the new pump was touching when the old one wasn't.

Re: Crisis over The Atlantic: The near crash of Air Transat flight 236

#79

I really love the straightforward but gripping style of writing here. I read every word! Which is rare for anything submitted to HN (or elsewhere for that matter)

I find a similar pace in the Air Crash Investigations series. Despite the low-budgeet filming and the actors who are clearly not allowed to speak, it goes into enough detail to be interesting without labouring the point.

Re: Crisis over The Atlantic: The near crash of Air Transat flight 236

#80
post #21

I think if you asked the engineers who designed the airbus in question, could you create a "leak" warning, using just the existing sensor suite, they'd say "sure". You know the fuel level in each tank, and have a good estimate or actual flow data on engine fuel usage. Simple math says "leak" or "no leak". If that would work, it is surprising it isn't in the software.

It's not very surprising. The computers are relatively basic by desktop standards and the time taken to develop a system securely means that many "obvious" things as seen from the armchair don't exist irl.

Also, like most engineers, you don't necessarily add systems for every conceivable thing that could go wrong. If you think about how many times this has happened against the millions of plane-miles travelled, you can see why it wouldn't necessarily have been high on the list.

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