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A Matter of Millimeters: The story of Qantas flight 32

admiralcloudberg.medium.com

291–300 of 307 posts

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

#291

Earlier quoted context omitted.

You don’t need any such incompetence in this case, as explained in the article, though it does help and that specific facility had several issues. The tube was built to spec, it’s the specs that were not what they should have been. The failures were more with the whole process (like the reference points with different tolerances and the inadequate paperwork) rather than machinist incompetence. They are just the guys…

The engineer documents did not match the design documents. Incompetence number one. The machinist would have seen with the naked eye very easily that the hole was not close to center, an old salt would have raised it up. Incompetence number 2. The machinist not being aware that moving the jig was ruining the setpoint. Incompetence number 3. There were clearly incompetent individuals working at the facility. I get wha…

> The engineer documents did not match the design documents. Incompetence number one.

There was no correcting mechanism and nothing to catch the issue. This is a system failure. The person who set the second datum for a different operation did nothing wrong: a new reference was needed for production reasons and that new reference did not need the same tight tolerance. They were not responsible for what happened later. Then, as the author mentions in the article, the software should have flagged the tolerance mismatch when that datum was used for something else.

> The machinist would have seen with the naked eye very easily that the hole was not close to center, an old salt would have raised it up.

No machinist is ever going to eyeball tolerance violations by a fraction of a millimetre on all the measures of every piece they build. That’s science fiction. Checking should have been in the manufacturing check list. Again, a system failure.

> The machinist not being aware that moving the jig was ruining the setpoint. Incompetence number 3.

Moving it was more or less required for another operation, which is the reason why there were different reference points for seemingly the same thing. Again, that is not the problem. The fundamental problem was that the second datum was used instead of the first.

Besides, if a machinist being aware that a bit of metal must not move at all is required to keep aircrafts flying, the real failure is not to specify that. I don’t know where you live, but in most of the world humans do what they can but are not perfect. That’s why there are checks and procedures to correct mistakes. No single decision or action should result in a crashed aircraft. Otherwise the whole system is just creating death traps.

> There were clearly incompetent individuals working at the facility.

You call them incompetent without seemingly understanding the actual problems, even though they were explained in detail in the article. There will always be out-of-specs pieces and random issues everywhere. If your system depends on humans being perfect, then your system is the problem.

Even great people are bound to make a mistake sometimes. You need to reduce it, sure, and I hope that this specific failure never happens again, but we need to take a broader view.

The article mentioned some of these tubes being rejected, and yet this one made it through.

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

#292
post #76

I am addicted to a fault to Mentour Pilot's studies of flight incidents. Again, here, he goes into greater depth: https://www.youtube.com/watch?v=JSMe1wAdMdg

I was going to mention him! I found his channel in the last year and have loved watching his coverage, especially from the point of view of a pilot. If you like this article you’ll also likely like the show Air Disasters too (also known as Air Crash Investigations and Mayday, depending on where you are). It goes into a lot of detail based on crash reports without sensationalizing things too, though not quite as far a…

Another great channel is "Green Dot Aviation". I think he's the best in class, personally. Him and Admiral Cloudberg are the best aviation content out there.

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

#294

Earlier quoted context omitted.

The planes are still in service and need new engines and even existing engines require spare parts. What I heard was that there was quite a scramble to buy up all existing supply and also talk some alternate manufacturers into continuing production at a low rate. B777 was introduced in 1995. Having an engine controller that is obsolete and not available any more at the moment it is launched, seems a bit shortsighted…

> B777 was introduced in 1995. Having an engine controller that is obsolete and not available any more at the moment it is launched, seems a bit shortsighted to me. First, in 1995 Motorola stopped development of the ISA, that says nothing about chip manufacturing which is what RR or airlines would care for. Ti launched the 68k-powered 89 three years later , and only switched away with the N-Spire CAS in 2007. Pilots…

All sorts of ancient architecture chips are still being made. 6502, z80, 8081, 386

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

#295
post #288

Earlier quoted context omitted.

Everything I wrote is true. The LA crew restored normal trim 25 times, but never thought to turn off the stab trim system. The trim cutoff switch is right there on the center console within easy reach for just that purpose. The EA crew oversped the airplane (you can hear the overspeed warning horn on the CVR) and did nothing to correct it. This made things worse. They were also given an Emergency Airworthiness Direct…

Everything you said might well be true, and indeed as far as I know it is, but aircraft should not have fail-deadly systems which require lightning reflexes and up-to-the-second training to diagnose and disable fast enough before they crash the freaking plane in the first place. Yes, the pilots of the affected flights might have been able to save the aircraft if their training had been just that little bit better. We…

It did not require lightning reflexes or up-to-the-second training. The first LA crash came after the crew dealt with it for 11 minutes, and restored trim 25 times. The EA crew restored normal trim a couple times, and crashed after 3 minutes if I recall correctly.

As for training, turning off the stab trim system to stop runaway trim is a "memory item", which means the pilots must know it without needing to consult a checklist. Additionally, after the first crash, all MAX crews received an EMERGENCY AIRWORTHINESS DIRECTIVE with a two-step procedure:

1. restore normal trim with the electric trim switches

2. turn off the trim system

I expect a MAX pilot to read, understand, and remember an EMERGENCY AIRWORTHINESS DIRECTIVE, especially as it contains instructions on how not to crash like the previous crew. Don't you?

> might have been able to save the aircraft

It's a certainty. Remember the first LA MAX incident, the airplane did not crash because after restoring normal trim a couple times, the crew turned off the trim system, and continued the flight normally. They apparently didn't even think it was a big deal, as the aircraft was handed over to the next crew, who crashed.

> a bit of extra training

They are already required to know all "memory items".

> Coming up with this narrative about how it's the crew's fault because they failed to disable Boeing's quietly introduced little self-destruct system fast enough to save their own lives was a particularly despicable move from their PR department

AFAIK Boeing never did say it was the crew's fault. The "have to respond within 5 seconds" is a fantasy invented by the media. It is not factual.

Both Boeing and the crews share responsibility for the crashes.

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

#296

there are some crazy talented pilots out there who are able to perform under massive amounts of pressure, United Flight 232 is a more extreme version of this article https://en.wikipedia.org/wiki/United_Airlines_Flight_232 >Despite the fatalities, the accident is considered a good example of successful crew resource management. A majority of those aboard survived; experienced test pilots in simulators were unable to…

I’m only aware of one other incident of an aircraft landing after loss of hydraulics.

https://en.m.wikipedia.org/wiki/2003_Baghdad_DHL_attempted_s...

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

#297
post #229

Earlier quoted context omitted.

At this point the secret sauce is that the EAA isn’t tolerating the same degree of certification fucking and laxity from airbus, and that they generally seem to have their act together. Like what’s the secret sauce of nvidia vs radeon or AMD vs intel? Reliable execution, seemingly - and this is an environment where failures are supposed to be contained to very specific rates at given levels of severity. The FAA has g…

It's actually safer for new airplane types to have flying characteristics like the previous types. There have been many accidents where a situation happened and the pilot did the right thing for the previous airplane he flew, but was the wrong thing for the one he was currently flying. Most of what was written about the MAX crashes in the mass media is utter garbage and misinformation. No surprise there, as journalis…

>Both crashes could have been easily averted if the crews had followed well-known procedures.

I thought that the majority of the problems was that Boeing wanted the same type-rating, so that airlines could avoid paying for training. This resulted in crews not getting proper training and so not knowing the proper procedures ... which was by decision.

Both the airlines and Boeing should take the blame; I don't really see how it would be the pilots fault, if you lie and say "it's the same plane, it flies the same, you don't need conversion training".

I am not in aviation, most of this is from YouTube sources, so y'know ...

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

#298
post #152

Earlier quoted context omitted.

When I worked in an industrial context, some coding tasks would seem trivial to today's Joe Random software dev, but we had to be constantly thinking about failure modes: from degraded modes that would keep a plant 100% operative 100% of the time in spite of some component being down, to driving a 10m high oven has the opportunity to break airborne water molecules from mere ambient humidity into hydrogen whose buildu…

> we had to be constantly thinking about failure modes This to me is the biggest difference between writing code for the software industry vs. an industrial industry. Software is all about the happy path ("move fast and break things") because the consequences typically range from a minor inconvenience to a major financial loss. Industrial control is all about sad paths ("what happens if someone drives a forklift into…

You do /not/ want to make it on the USCSB YouTube channel.

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

#300

Many things failed, at least: (1) failure to identify safety-critical parts for review (2) failure in design drawings made without regard for fabrication (3) failure to make reference to original design goals when altering part designs (4) bad machining plan altering work-holding during the machining (5) failure to inspect finished parts

(5) was particularly bad: an off center hole should have been visible to the naked eye of any trained machinist, and at least one person should have inspected all safety critical parts. This would have been the final fail-safe to catch the combination of all prior errors. It was not made.

There's actually another failure - (6) - which is the failure to perform visual inspection of the assembling mechanic which should have generated a query or note at the very least. While at this point the mechanic is probably given specific points to check, and an aggressive timeline for assembly, and has little motivation to extend critical thinking beyond the assembly task as they cannot possibly intuit all of the design intent for every part and subassembly, a better run assembly process with a culture of observation would have had this flagged for verification with designers.

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