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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

#101

Post by ttcbj »

voxadam wrote: post #49
quickthrower2 wrote: post #42

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…

I just discovered cloudberg a few months ago, on HN. I agree the writeups are amazing.

What I enjoy most is that frequently, the crash appears to have a clear “culprit” early on, then cloud berg points out 5-7 other factors, any one of which might have prevented the accident. If the series had a theme, I think it would be that airplane crashes are less about human failings than systemic ones.

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

#102

Post by btrettel »

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…

That's a pet peeve of mine too. Here's a relevant HN comment I wrote about my experience as a patent examiner that applies more broadly:

https://news.ycombinator.com/item?id=31315234

> There are way too many jobs where management doesn't give the front-line worker an appropriate amount of time and/or resources, and when things inevitably go wrong, the front-line worker is blamed, and the problem is studied as if the only factor was the front-line worker.

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

#103

Post by mannykannot »

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…

In this case, there is no evidence here of any ontoward pressure on the maintenance crew, and there is not even any evidence that anyone in the chain of command outside of those involved in the task had any inkling that this might develop into a schedule disruption.

On the contrary, the evidence strongly suggests that the maintenance crew did not feel they were under any special pressure: in their minds, they had found the correct solution, one which would allow them to complete the job on time, so any risk of flights being delayed or canceled had been solved.

You do not even have to work in the airline industry to see that unscheduled maintenance risks creating delays, and that is less than optimal for everyone involved - no-one has to be told it. If that knowledge creates too much stress and conflict of interest to be safe, commercial aviation would simply be untenable.

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

#104

Post by sidewndr46 »

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…

Management cannot be at fault because they are not responsible for safely flying the aircraft or safely maintaining the aircraft. That is the job of the employees, not management.

Now if management had for example knowingly procured inferior replacement parts or hired non-certified personnel to work on the aircraft, they would be at fault.

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

#105

Post by [deleted] »

sidewndr46 wrote: post #104
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…

Management cannot be at fault because they are not responsible for safely flying the aircraft or safely maintaining the aircraft. That is the job of the employees, not management. Now if management had for example knowingly procured inferior replacement parts or hired non-certified personnel to work on the aircraft, they would be at fault.

[deleted]

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

#106

Post by mrguyorama »

iso1631 wrote: post #93
bambax wrote: post #82

Earlier quoted context omitted.

> 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…

I'm amazed they can measure the distance between two real non-fixed components down to a few micrometers (they wrote 0.635mm, implying somewhere between 630um and 640um) If 0.635mm (an odd number itself which happens to be exactly 1/40th of an inch, or "25 thous" in American sizes) and they let it go that sounds really odd. That's literally the size of a grain of sand. If the concern is rubbing, sure that implies it…

Plane maintenance involves a lot of precise and specially designed tools.

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

#107

Post by mrguyorama »

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…

"Follow the process" is because this is like the tenth example of engineers and maintenance personnel trying to ignore the instruction booklet and nearly getting hundreds of people killed.

"Read and follow the directions exactly" is a rule that is written in blood.

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

#108

Post by gambiting »

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.

The article says the service bulletin was actually available on site through a different publication, but the mechanic wasn't aware of this(and yet did the right thing of contacting dedicated support, who didn't advise him correctly):

" The Rolls Royce SBs were also listed in the Trent Illustrated Parts Catalogue, accessible from any computer at the facility, but he was apparently unaware of this, so he instead switched to plan B and called the Air Transat Maintenance Control Center for help."

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

#109

Post by t0mas88 »

midasuni wrote: post #16
robga wrote: post #9

Interesting that they call Lajes a “military airfield”. On the Azorean island of Terceira, Lajes (TER) is a mixed use airfield that is the commercial landing strip of the island since the 1930s, as well as having a multi-national military base on the other side since the 1940s. There is a picture in the story. The NTSB report called it a military airbase, and other reports say “Military air traffic controllers guided…

To cross the Atlantic between NA and Europe you need to be able to travel 138 minutes from an airport, although for almost the entire area it’s 120 minutes. This is accomplished by having air strips which can take massive planes like A350s at remote places which can’t justify planes of that size normally like Newfoundland, Greenland and the Azores While these are mainly there for military and temporary emergency use,…

The maximum time you can be away from a suitable landing spot depends on the ETOPS certification (or 60 minutes if you don't have one). The certification is specific to the type of plane and operator.

A modern 777 at most airlines for example has an ETOPS rating of 180 minutes.

That's 180 minutes of flying with a failed engine. So you have to take into account whether you can maintain altitude on 1 engine. Most of the time you can't, you'll be flying lower. Which means slower speed, so the calculation is 180 minutes at that speed.

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

#110

Post by t0mas88 »

Gasp0de wrote: post #90
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.

No need for Starlink, sat com voice and data links have been a standard things for oceanic flights for years before Starlink.
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