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A Matter of Millimeters: The story of Qantas flight 32

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

#141

Post by bambax »

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…

The Checklist Manifesto (2009) is a great short book that shows how using simple checklists would help immensely in many different industries, esp. in medical (the author is a surgeon).

Checklists of course are not the same as detailed post-mortems but they belong to the same way of thinking. And they would cost pretty much nothing to implement.

Also CRM: it's very important to have a culture where underlings feel they can speak up when something doesn't look right -- or when a checklist item is overlooked, for that matter.

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

#142

Post by woutr_be »

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…

I’ve always wondered what happens after an emergency landing. Do you just kinda sit there and wait for bags and personal belongings to be offloaded? And then wait for another flight out?

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

#143

Post by woutr_be »

abrookewood wrote: post #115
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.

I remember there was this video of a plane in Russia that was on fire, multiple people died. And you see people walking away with their luggage, can’t help it think people would still be alive if it wasn’t for those who so urgently needed their suitcases.

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

#144

Post by rytis »

cedivad wrote: post #112
WalterBright wrote: post #65

Earlier quoted context omitted.

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!

"AoA sensor" - Angle of Attack sensor.

And the reference is presumably to 737 MAX accident. https://www.afacwa.org/the_inside_story_of_mcas_seattle_time...

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

#145

Post by laydn »

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.

What's fascinating about airplane design for me is not the huge technical complexity, but rather, the way it is designed such that a lot of its subsystems are serviceable by technicians so quickly and reliably, not just in a fully controlled environment like a maintenance hangar, but right on the tarmac, waiting for takeoff.

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

#146

Post by bboygravity »

uselpa wrote: post #126
f1shy wrote: post #120

Earlier quoted context omitted.

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.

Cars might not be the best example, since human lives are at stake, as in aviation. Unless you work on Teslas autopilot, it seems. But yes, backups and restores are often good enough.

Any substantiation for "Unless you work on Teslas autopilot, it seems"?

I mean you're implying that there are more accidents with autopilot than without it, right? Seems like quite the claim...

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

#147

Post by uselpa »

bboygravity wrote: post #146
uselpa wrote: post #126

Earlier quoted context omitted.

Cars might not be the best example, since human lives are at stake, as in aviation. Unless you work on Teslas autopilot, it seems. But yes, backups and restores are often good enough.

Any substantiation for "Unless you work on Teslas autopilot, it seems"? I mean you're implying that there are more accidents with autopilot than without it, right? Seems like quite the claim...

No, I'm implying that the autopilot code has not been as thoroughly tested as it should have been.

Example: https://www.theguardian.com/technology/2023/nov/22/tesla-aut...

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

#148

Post by conradev »

girvo wrote: post #64
Horffupolde wrote: post #62

Earlier quoted context omitted.

If 200 people died after a db instance crashed, software would be equal in that regard.

To prove this, software that deals with medical stuff is somewhat more like aviation.

Yep. Insulin pumps can kill their owner and the software updates need to be FDA approved:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4773959/

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

#149

Post by krisoft »

jstanley wrote: post #137
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…

> robustness has less to do with the number of mistakes but how one responds to them It must have something to do with the number of mistakes, otherwise it's all a waste of time! It's all well and good responding to mistakes as thoroughly as possible, but if it's not reducing the number of mistakes, what's it all for?

> It must have something to do with the number of mistakes, otherwise it's all a waste of time!

Not really. Imagine two systems with the same amount of mistakes. (Here the mistakes can be either bugs, or operator mistakes.)

One is designed such that every mistake brings the whole system down for a day with millions of dollars of lost revenue each time.

The other is designed such that when a mistake happens it is caught early, and when it is not caught it only impacts some limited parts of the system and recovering from the mistake is fast and reliable.

They both have the same amount of mistakes, yet one of these two systems is wastly more reliable.

> if it's not reducing the number of mistakes, what's it all for

For reducing their impact.

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

#150

Post by arendtio »

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.

In the context of disasters that happened due to software failures (e.g. Ariane 5 [1]), one of my professors used to tell us, that software doesn't break somewhen but is broken from the beginning.

I like the idea of thinking 'when' instead of 'if', but the verdict should be even harder when it comes to software engineering because it has this rare material at its disposal, which doesn't degrade over time.

[1] https://en.wikipedia.org/wiki/Ariane_5#Notable_launches

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