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A Matter of Millimeters: The story of Qantas flight 32

admiralcloudberg.medium.com

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Re: A Matter of Millimeters: The story of Qantas flight 32

#111

Post by EdwardDiego »

Gare wrote: post #70
crabmusket wrote: post #60

Earlier quoted context omitted.

> To be able to zero in on what turned out to be a single faulty part and then trace the entire provenance and environment that led to that defective part entering service speaks to the robustness of the industry. And to be able to reconstruct the chain of events after the components in question have exploded and been scattered throughout south-east Asia is incredible.

My impressiom was that the defective part was still inside the engine when it landed.

Probably a reference to other incidents. Shout out to the NTSB for fighting off alligators while investigating this crash... https://en.wikipedia.org/wiki/ValuJet_Flight_592

Re: A Matter of Millimeters: The story of Qantas flight 32

#112

Post by cedivad »

WalterBright wrote: post #65
modernpacifist wrote: post #40

I don't know about others, but I can't help but smile when I read the detailed series of events in aviation postmortems. To be able to zero in on what turned out to be a single faulty part and then trace the entire provenance and environment that led to that defective part entering service speaks to the robustness of the industry. I say that sincerely since mistakes are going to happen and in my view robustness has l…

As a former Boeing engineer, other industries can learn a great deal from how airplanes are designed. The Fukushima and Deepwater Horizon disasters were both "zipper" failures that showed little thought was given to "when X fails, then what?" Note I wrote when X fails, not if X fails. It's a different way of thinking.

> When my AoA sensor fails, then what?

crickets, let's just randomise which sensor we use during boot, that ought to do it!

Re: A Matter of Millimeters: The story of Qantas flight 32

#113

Post by EdwardDiego »

nextos wrote: post #58
modernpacifist wrote: post #40

I don't know about others, but I can't help but smile when I read the detailed series of events in aviation postmortems. To be able to zero in on what turned out to be a single faulty part and then trace the entire provenance and environment that led to that defective part entering service speaks to the robustness of the industry. I say that sincerely since mistakes are going to happen and in my view robustness has l…

Aviation is great because the industry learns so much after incidents and accidents. There is a culture of trying to improve, rather than merely seeking culprits. However, I have been told by an insider that supply chain integrity is an underappreciated issue. Someone has been caught selling fake plane parts through an elaborate scheme, and there are other suspicious suppliers, which is a bit unsettling: "Safran conf…

Admiral Cloudberg has covered a case where counterfeit or EOL-but-with-new-paperworks components were involved in a crash.

https://admiralcloudberg.medium.com/riven-by-deceit-the-cras...

Re: A Matter of Millimeters: The story of Qantas flight 32

#114

Post by matwood »

ghaff wrote: post #95
gumby wrote: post #36

Earlier quoted context omitted.

Wow. I was (long ago!) in an engine fire emergency landing situation and though I did take a connecting flight to get home I didn’t fly for a while afterwards. Psychologically, your choice was probably the smarter one.

I've been in a couple situations. - The main one was that I had a flight from Vancouver to Victoria and the weather was too bad for the helicopter to fly. So we took a prop. On takeoff, some cross-wind hit the plane and we tipped over. My colleague and I who were sitting across from each other thought that was it. - The other one was my plane was reported crashed when I was visiting my parents for some holiday or oth…

> On takeoff, some cross-wind hit the plane and we tipped over.

I had a near tip-over coming out of a DIA years ago. DIA gets very windy. We were nearing speed to lift off and a gust of cross wind hit the plane. Looking out the window I thought for sure the wing was going to hit the ground, but in that moment the pilot seemed to shift from a standard take off to something that felt much more vertical. Once we were airborne the flight attendant came by who looked a little shaken and offered me a free drink.

Re: A Matter of Millimeters: The story of Qantas flight 32

#115

Post by abrookewood »

gumby wrote: post #34

30 years ago I was in an emergency landing due to engine failure situation (flight attendants take away your shoes, practice crash position, rearrange the passengers etc) and the thing that stuck out the most for me was that everybody did as they were told. No self righteous people; it was clear to everyone why there are flight attendants aboard and that they were key to your survival. The evacuation was orderly, tho…

Honestly, each and every one of those people should either be charged with reckless endangerments, put on an no-fly list or both. It really pisses me off when I see that. F**ing entitled idiots.

Re: A Matter of Millimeters: The story of Qantas flight 32

#116

Post by genewitch »

Stratoscope wrote: post #29

It may be a cliché to call someone a "national treasure", but I would take it a step further for Admiral Cloudberg: she is a world treasure. Kyra has written so many great articles under her nom de cloud . Trust me, just pick any of them and you will learn something. https://news.ycombinator.com/from?site=admiralcloudberg.medi...

there's a video podcast, too, which they should put on TV instead of whatever is on there now, overdramatized claptrap

Re: A Matter of Millimeters: The story of Qantas flight 32

#117

Post by brutusborn »

tgbugs wrote: post #110

My internal alarm bells started going off as soon as I read about datum AA and datum M. Shouldn't it be possible if not standard practice for the design software to issue a giant warning if you have a part that is defined by two datums that are almost but not quite the same? If they aren't the exact same datum then something like this will inevitably happen.

It’s definitely possible, but the checking system was probably built under the implicit assumption that the sources of truth for the checks (datums, dimensions) were correct.

2 datums might need to be very similar but not quite the same, so checking for it might present a lot of hard to handle false positives and make the system very complex.

Re: A Matter of Millimeters: The story of Qantas flight 32

#118

Post by brutusborn »

camkego wrote: post #27

This article highlights the dangers from fake/illegitimate/non-oem aircraft replacement parts that are being used to repair aircraft. https://www.reuters.com/business/aerospace-defense/engine-ma... Doesn't make me feel comfortable about flying.

It doesn’t really specify the risk though, the parts may not be critical. I would hope regulations require independent certification for critical parts, but I’m scared to look.

Re: A Matter of Millimeters: The story of Qantas flight 32

#119

Post by dabiged »

grecy wrote: post #44
aunty_helen wrote: post #35

My first job was working at a mro that overhauled engines a bit smaller than the Trent 900s but same principles apply. I built qa software to digitize the forms and signature process like what’s mentioned in the article as having not correctly been signed off on. I ate lunch with repair engineers that had dark wells of knowledge about the engines they worked on. They could talk so deep on a subject that lunch break w…

> As for Qantas, near the end it mentions the plane was repaired at great cost Indeed. Qantas has been ranked the safest airline int he world almost every year since forever [1] I clearly remember when QF32 happened and everyone was utterly shocked. That simply DOES NOT happen to Qantas. [1] https://www.forbes.com/sites/laurabegleybloom/2023/01/03/ran...

QANTAS has, for the last 10+, had a CEO who was not part of this culture and did everything he could to drive costs down. He laid off huge swaths of engineers, outsourced key maintenance contracts to the lowest bidder and left the airline with an aging fleet that needs billions spent to replenish. He was recently fired by the board for essentially destroying the reputation of the airline within Australia, with their practice of cancelling flights at short notice, illegally sacking thousands of staff during COVID and taking 100's of millions of dollars from the Australian government to keep staff employed during the airline's grounding during COVID and handing it all to shareholders.

It is a situation very similar to the downfall of Boeing.

Re: A Matter of Millimeters: The story of Qantas flight 32

#120

Post by f1shy »

WalterBright wrote: post #65
modernpacifist wrote: post #40

I don't know about others, but I can't help but smile when I read the detailed series of events in aviation postmortems. To be able to zero in on what turned out to be a single faulty part and then trace the entire provenance and environment that led to that defective part entering service speaks to the robustness of the industry. I say that sincerely since mistakes are going to happen and in my view robustness has l…

As a former Boeing engineer, other industries can learn a great deal from how airplanes are designed. The Fukushima and Deepwater Horizon disasters were both "zipper" failures that showed little thought was given to "when X fails, then what?" Note I wrote when X fails, not if X fails. It's a different way of thinking.

As an engineer I think a lot about tradeoffs of cost vs other criteria. There is little I can learn from nuclear or aviation industry, as the cost structure ist so completely different. I’m very happy that the costs of safety in aviation are very good accepted, but I understand that few people are willing to pay similar costs for other things like, say, cars.
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