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

admiralcloudberg.medium.com

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

#81

Post by FpUser »

I remember for a while they were trying to make Robert Piche into a scapegoat. What I see here is:

1) Design error. Ok I am a total nobody in this area but still fuel leak detection not being included seems like a major design fault. I mean something that measures difference between whatever fuel injectors deliver into the engine and whatever leaves the tank is quite possible I think.

2) How many times have we read when a fucking management pushed for event happen / to be on time no matter what and the following disaster. Challenger, Columbia etc. etc.

3) Service procedures, manuals etc. I guess those are combinations of (1) and (2)

4) Errors by service and flight crews. I can imagine that the person who bent the line had enough reason to raise concern. The rest can't really be blamed.

As for Robert Piche - he is a hero in my book

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

#82

Post by bambax »

dsfyu404ed wrote: post #77
kqr wrote: 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…

> But maintenance people in aviation aren't really ever exercising those creative problem solving skills

This is the opposite of what happened. The engineers were confronted with a novel and unexpected problem, and instead of following procedure (which they lacked access to) they applied "creative problem solving skills". From TFA:

> Although it was possible to install the post-SB fuel lines and hydraulic pump with a pre-SB hydraulic tube, the tube would rest against one of the fuel lines at a point where it rounded a 90-degree bend close to the pump. Aware that the plane could not be dispatched unless there was clearance between the tubes, the technicians torqued a nut on the end of the hydraulic tube until it rose approximately 0.635 mm off the face of the fuel line.

Torquing a nut so that the hydraulic tube isn't technically rubbing against the fuel line is pretty creative and seems to solve the problem. But it didn't take into account pressure and vibration while in flight, and almost caused the death of 306 people.

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

#83

Post by sokoloff »

bambax wrote: post #40

For some reason I'm a little obsessed with airline incidents and crashes. Admiral Cloudberg produces outstanding write-ups, and of course the videos of Mentour Pilot on YT are also excellent. While this is in no way scientific, it seems that what most catastrophes have in common are bad CRM (crew intra-communication) and lower-than-average airmanship. In most cases, for a catastrophe to occur there must be an initial…

> most catastrophes have...lower-than-average airmanship

I wonder how many (significantly) lower than average airmanship days happen everyday without incident. I suspect it’s a lot, and the overall system catches/corrects many and is resilient to the effects of many others.

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

#84

Post by iso1631 »

phire wrote: post #74
iso1631 wrote: post #70

Earlier quoted context omitted.

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

Looking at FR24's tracks (which are suplemented by satellite updates now), they do seem to fly further south, presumably to benefit from winds

Well into the 24 hour polar night/day period though (depending on time of year)

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

#86

Post by somewhereoutth »

bambax wrote: post #40

For some reason I'm a little obsessed with airline incidents and crashes. Admiral Cloudberg produces outstanding write-ups, and of course the videos of Mentour Pilot on YT are also excellent. While this is in no way scientific, it seems that what most catastrophes have in common are bad CRM (crew intra-communication) and lower-than-average airmanship. In most cases, for a catastrophe to occur there must be an initial…

Some of the most upsetting disasters (in the sense of how avoidable they should have been) have been caused by failures of the human-machine interface, particularly with automation.

For example https://en.wikipedia.org/wiki/Emirates_Flight_521 - a go around was commanded by the pilots to abort a landing, but they weren't aware that the automated go around system - specifically the auto-throttles - would not engage if the wheels had touched the ground (if only briefly). Thus engine power remained at idle/landing speed, and the plane fell out of the sky.

The pilots should have checked the throttles of course, but they would not necessarily have been aware that the wheels had touched down, may not have known/remembered that the automatic go around system would not function in that case, and they were concentrating on flying the plane in presumably unusual circumstances that led to the go around in the first place - they assumed the automation would function as it usually does.

A better human-machine interface (e.g. with a warning that go around automation was disabled) would have prevented the crash. I think anyone designing human-machine interfaces, especially safety critical systems, should read up on these cases.

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

#87

Post by bambax »

sokoloff wrote: post #83
bambax wrote: post #40

For some reason I'm a little obsessed with airline incidents and crashes. Admiral Cloudberg produces outstanding write-ups, and of course the videos of Mentour Pilot on YT are also excellent. While this is in no way scientific, it seems that what most catastrophes have in common are bad CRM (crew intra-communication) and lower-than-average airmanship. In most cases, for a catastrophe to occur there must be an initial…

> most catastrophes have...lower-than-average airmanship I wonder how many (significantly) lower than average airmanship days happen everyday without incident. I suspect it’s a lot, and the overall system catches/corrects many and is resilient to the effects of many others.

It's a very good question. But the argument isn't against machines; it's in favor of excellent airmanship. The slippery slope is when good machines appear to make good craftsmanship redundant. They don't.

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

#88

Post by avidphantasm »

I think it’s unreasonable to pin the mistake on the pilots for not running all the checklists. This is where a flight engineer would come into play in my lay opinion. The pilots were tactically focused; they were trying to keep the plane in the air. You need someone on the flight deck who is looking at the bigger picture, doing the fuel calculations (even if the automated systems aren’t warning about certain fuel-related variables), running the checklists, etc. Perhaps a flight engineer role (perhaps filled by a spare pilot) should be required for all ETOPS flights?

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

#89

Post by hef19898 »

silvestrov wrote: post #72
kqr wrote: 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.

Which it is, tech pubs are huge part of the after market activities of every aerospace manufacturer. That those are not up to date, or not available when or where needed, is a major finding during audits or investigations.

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

#90

Post by Gasp0de »

avidphantasm wrote: post #88

I think it’s unreasonable to pin the mistake on the pilots for not running all the checklists. This is where a flight engineer would come into play in my lay opinion. The pilots were tactically focused; they were trying to keep the plane in the air. You need someone on the flight deck who is looking at the bigger picture, doing the fuel calculations (even if the automated systems aren’t warning about certain fuel-rel…

They did contact the engineering department. Maybe it would have sufficed to have a telemetry uplink back to the engineering department. Should be doable with Starlink etc. soon enough.
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