[HN Gopher] Dark Waters of Self-Delusion: The crash of Transair ...
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Dark Waters of Self-Delusion: The crash of Transair flight 810
Author : rwmj
Score : 83 points
Date : 2023-07-04 18:32 UTC (4 hours ago)
(HTM) web link (admiralcloudberg.medium.com)
(TXT) w3m dump (admiralcloudberg.medium.com)
| kortilla wrote:
| Warning: the author makes significant conclusions that are not
| corroborated by the NTSB. All of the commentary on the violation
| of the sterile cockpit rule and argument before departure are
| irrelevant to the actual cause, despite the author stating
| otherwise.
|
| There are some great lessons to learn from this (better flight
| control handovers during emergency, double checking which engine
| failed, applying thrust to both engines when nothing else works).
| The violation of the sterile cockpit rule and the asshole nature
| of the captain were not factors here as determined by the NTSB.
|
| The first officer gave him bad info and he accepted it. That is
| not a failure mode caused by being obstinate nor a "team player".
| BoxFour wrote:
| The author explicitly points out the nonappearance of the
| captains rant within the NTSB report.
|
| The author points out that NTSB report does allude to the
| captain's many instances of dubious judgment during the
| emergency.
|
| The author also highlights the protracted diatribe spanning
| thirty minutes, transpiring even during the hallowed period of
| the "sterile cockpit," implying a discernible lack of
| concentration on the imminent mission.
|
| The captain's unclear headspace became evident by his
| protracted tirade. He was likely mentally unfit for the task of
| captaining that day, and the rant was evidence of it.
| cat_plus_plus wrote:
| That's some major scapegoating of flight crew, when their airline
| clearly has not maintained the plane properly and caused engine
| failure in the first place and airport failed to provide adequate
| ground control support. Easy to be a backsit driver/pilot when
| you are not flying a damaged plane over the ocean with nobody
| acknowledging that you have an emergency. Ideally sure, pilot and
| first office would have done everything by the book and maybe
| landed at airport safely. But life is never ideal, and I wonder
| if Transair offered a lot of paid time on simulator to
| periodically review every likely emergency scenario. Copilot
| saved captain's life by directing rescue crew to leave him alone
| in the water and focus on captain first, so I don't think they
| are horrible human beings.
| krisoft wrote:
| > so I don't think they are horrible human beings
|
| I don't think anybody thinks that they are horrible human
| beings. The article is certainly not implying that in any way
| about the copilot. The captain clearly has failings, as
| described by the article, but it is not implied in any way that
| he is a terrible human being.
|
| > some major scapegoating of flight crew
|
| I disagree. They had a perfectly flyable airplane and crashed
| it almost killing themselves. That is not good airmanship.
|
| Yes, all of those other things were also factors. I totaly
| understand that. The point of hearing stories like this is to
| understand what went wrong and how we can learn from them to
| not commit the same mistakes. Zero scapegoating.
| mschuster91 wrote:
| For me, the biggest takeaway is "never fly under stress" - which
| can be dangerous even when flying small drones!
|
| The problem is when corporate culture, and be it because of
| understaffing or penalizing people for calling out,
| disincentivizes people from following that basic principle.
|
| A side note: The fact that such absurd crew confusion is still
| possible in 2021 doesn't exactly warm me up to the thought of
| twin-jets crossing over the Atlantic and Pacific oceans.
| jacquesm wrote:
| You can extend that rule to the operation of any vehicle.
| icegreentea2 wrote:
| If by confusion you mean getting the failed engine wrong, there
| are already technical mitigations that exist (as noted by the
| article). They just haven't been retrofitted to ancient 737s.
| woliveirajr wrote:
| > "Of course, the reason was because First Officer Ryan had set
| both thrust levers to idle, and because of the control handover,
| no one pushed them back up again."
|
| > "In fact, with both engines at idle, the asymmetric thrust had
| disappeared, and it was trivial to keep the plane straight and
| level."
|
| > "First Officer Ryan even seemingly forgot that the left engine
| was at idle power because he put it there himself not even two
| minutes earlier."
|
| And here we have the primary cause of all the confusion. It was
| not trivial to keep the plane at level, if engines had no power.
| The "sexism", the "given their earlier conversation, he surely
| knew where arguing with Okai would get him (which was nowhere)"
| aren't the cause here.
| lisasays wrote:
| The article clearly identifies _stress_ (and potential power
| /trust issues between the pilots), not sexism per se as a
| potential causative factor.
|
| As per other comments in this thread, e.g.
| https://news.ycombinator.com/item?id=36591776
| foobarbecue wrote:
| No, sexism didn't cause the accident, but I'm glad the article
| brought it up. Those comments excusing men who murder their
| annoying wives were horrifying and frankly I think anyone who
| says stuff like that in the workplace (in this case, violating
| sterile cockpit) deserves to be exposed publicly (especially a
| divorce lawyer).
|
| And, it is relevant context, given the kerffufle about whether
| to follow the checklist and how flustered Okai became.
| pessimizer wrote:
| It's bizarre to fantasize about cancelling a [not dead] pilot
| and trying to get his wife to divorce him.
| [deleted]
| foobarbecue wrote:
| That would indeed be bizarre if somebody did that.
| (History: This originally said "dead", another comment
| corrected it and it was changed and subsequently that other
| comment was deleted. My comment above was also confused, I
| was thinking Okai was a divorce lawyer, but actually that
| was Ryan.)
| rycomb wrote:
| Ryan --not Okai-- is the one with a legal practice.
| foobarbecue wrote:
| Ah, my bad, thanks for the correction. I had them mixed up.
| Well, that's a small relief.
| kortilla wrote:
| > And, it is relevant context, given the kerffufle about
| whether to follow the checklist and how flustered Okai
| became.
|
| No it's not. The call to not follow the checklist came from
| the first officer (focusing on flying the plane was higher
| priority). The captain didn't challenge him on it because he
| agreed with the call. There was no "kerffufle" or even
| disagreement.
| foobarbecue wrote:
| I called it a kerfuffle because they started the engine
| shutdown checklist and then abandoned it after a couple of
| items, which seems pretty kerfuffly to me.
|
| I thought the discussion with Moore was relevant because
| that argument had been about Okai not doing procedures by
| the book, and because Okai has been previously reprimanded
| for failing to follow an engine shutdown checklist.
| WesolyKubeczek wrote:
| I'm inclined to cite not so much "sexism" as "32-minute rant".
| For all I care, it could be tabs vs spaces, with the same
| outcome.
| JJMcJ wrote:
| An atmosphere of confusion and hostility.
| blamazon wrote:
| > As First Officer Ryan listened, interjecting only
| occasionally to affirm his captain
|
| So, I think the sexism is important to the explanatory
| narrative because it demonstrates the scale of the power
| imbalance between the captain and the first officer - the
| captain sat there and blabbed for 32 minutes including
| something _so_ objectionable as musing about how if annoying
| women get murdered, it 's their fault. Quoth the article:
|
| > "These are the kind of women you don't wanna get married
| to," he said. "You know, some men, they lose their temper and
| the next thing you know, the wife is dead, you know... they
| start punching them and kicking them, and they lost their
| minds, you know... they kill the woman... it's the woman who
| can drive you to do crazy stuff, you know?"
|
| But the first officer was not empowered to object to that -
| not empowered to object for sexism and murder, not for tabs
| vs spaces, not for anything. There was, therefore, possibly
| _nothing_ the captain could have said in that 32 minutes that
| the first officer would have objected to.
| wpietri wrote:
| > So, I think the sexism is important to the explanatory
| narrative because it demonstrates the scale of the power
| imbalance between the captain and the first officer
|
| Exactly. Patriarchy isn't just a system where all men have
| power over all women. It's also about hierarchies of men. A
| good example is the FLDS [1], which Jon Krakauer wrote
| about in Under the Banner of Heaven. [2] There, the
| highest-status men are supported by other men who are
| rewarded with dominance over other lower-down people. That
| produces a bunch of surplus young men who are eventually
| driven off.
|
| This sort of continually enforced dominance hierarchy,
| whatever you think of it morally, is poisonous to the kind
| of mindset and relationships you need to keep up our
| (extraordinarily good) airline safety record.
|
| And let me also add a plug for Dekker's "The Field Guide to
| Understanding 'Human Error'", which is on the surface about
| understanding airplane crashes, but does a great job of
| conveying why important technological systems require a
| very different way of thinking about things to succeed. One
| of my top books of all time, especially for anybody in tech
| who cares about uptime.
|
| [1] https://en.wikipedia.org/wiki/Fundamentalist_Church_of_
| Jesus_Christ_of_Latter-Day_Saints
|
| [2]
| https://en.wikipedia.org/wiki/Under_the_Banner_of_Heaven
| kortilla wrote:
| Or the first officer just didn't care. He didn't call it up
| in the post interviews as something that he felt
| uncomfortable about. Sexism is shockingly rampant.
| eastbound wrote:
| Can sexism be used as a sign of lack of social
| adaptation? I personally despise women, having been
| surrounded by horrible ones during formative years and
| beyind, and I think a word should be said about men being
| humans even when they aren't dutifully providing service
| to society; but the moment you start saying it in public,
| it's a sign of unhappiness, a sign that one is going
| overboard, and a sign that one should not be driving 300
| souls.
|
| (Yes, seize the irony).
| foobarbecue wrote:
| Dang, that really sucks about your formative experiences.
| I'm sorry for you and hope you don't have to spend the
| rest of your life harboring a secret hatred for half of
| all humans. I'm guessing that at some level you realize
| women are people and it's not healthy or sensible to
| despise them as a group, but it's not an opinion you can
| just "fix". Have you tried counselling for this?
|
| And frankly, yeah, it's disqualifying. Having read this
| comment, I wouldn't consider hiring you for any position
| or voluntarily working with you at all until I had some
| assurance that you're able to transcend this issue. (n.b.
| I'm a straight, cis, white, man)
| jacquesm wrote:
| > I personally despise women
|
| At some point you have to deal with the fact that your
| formative years are not an excuse for holding a life-long
| grudge against such a large group of people. This makes
| no sense at all.
| cat_plus_plus wrote:
| You don't think women might trade tirades about men when
| having off the record conversation with just two of them
| in the cockpit? People vent, it doesn't mean much by
| itself. If he had a fight with a male copilot, he may
| have had a different tirade.
| foobarbecue wrote:
| Agreed. Women can be certainly be sexist and should be
| held to the same standard as men. If a woman crewmember
| said women can't be blamed for murdering annoying
| husbands while taxiing a 737, that would absolutely be
| inappropriate. And, the main point here wasn't that there
| was fight followed by sexist reflections on said fight,
| but that there was a fight.
| WesolyKubeczek wrote:
| That reminds me of this incident
| https://nypost.com/2017/02/12/crazed-pilot-rants-about-
| polit...
| foobarbecue wrote:
| Excellent article. Taught me about the "sterile cockpit rule,"
| which I think might be really useful at my work. Sometimes people
| start chatting at critical moments during operations and I think
| I might introduce the concept of "sterile cockpit" during those
| moments to get people's focus back.
| zgluck wrote:
| Haven't been involved in realtime shit-hits-the-fan ops for
| some time now (phew).
|
| Are devops/SRE/etc people using voice comms these days during
| high impact incidents or is text (irc/slack/etc) still
| preferred?
| foobarbecue wrote:
| Dunno. I'm talking about working Curiosity and Ingenuity ops
| (Mars).
| zgluck wrote:
| :-) Cool.
|
| I guess I assumed you were deploying overly complicated
| glorified CRUD apps like (most of) the rest of us.
|
| So what do you use for comms during high impact incidents?
| Are you all in the same room?
| foobarbecue wrote:
| Better link:
| https://doi.org/10.1109/AERO50100.2021.9438370
| foobarbecue wrote:
| https://dataverse.jpl.nasa.gov/file.xhtml?fileId=74511&ve
| rsi... is still pretty accurate. Uplink is still mostly
| work from home for Curiosity and Ingenuity.
|
| And as it happens... I do CRUD web apps too, offically
| about 20% of my time. Including that one. And for those
| we use text.
| zgluck wrote:
| It would be really interesting to learn how you value
| text vs voice comms, for instance.
| foobarbecue wrote:
| We rely on both, and I think we've got the mix about
| right. Text for relatively simple things, when numbers
| and other identifiers need to be transmitted accurately,
| voice / video for complex discussions that require screen
| sharing and / or when there are multiple opinions that
| might need to be reconciled.
| dylan604 wrote:
| I'm surprised that's not already an thing in that ops
| center. Maybe being an outsider I've built up an
| unrealistic aura of awe around NASA/JPL type environments
| where those places would be quiet as a church unless
| something like landing or some other epic accomplishment
| where everyone was cheering. Otherwise, I'd expect everyone
| to know that when the shit hits the fan, everyone is
| hunkered down doing what needs to be done. Does the long
| lag between issuing commands kind of break that?
| foobarbecue wrote:
| There's a well-choreographed dance of meetings (with
| polls, e.g. go / no go) and head-down sequence writing.
| Meetings have a pretty rigid structure and there are zero
| off-topic comments. But the time for getting the actual
| sequencing done often has chatter with varying amounts of
| on-topic-ness. Generally, people are really great at not
| distracting each other-- I've only occasionally had an
| issue and when I bring it up, chatter ends. It's just
| that having a term for it would make it easier to bring
| up.
|
| "Socialize with your colleagues" is actually an item on
| one of our checklists!
| [deleted]
| dylan604 wrote:
| Do you feel that something as long running as Curiosity
| that things become a little more lax as everyone gets to
| a level of complacency? I could see where that might
| happen, but at the same time the concept of I'm
| controlling something on the surface of another planet is
| hard to forget. Basically, super curious about the day to
| day of a job I'm very jealous of in a very respectful way
| foobarbecue wrote:
| Interesting question about complacency. Hard for me to
| speak objectively on this since I'm too close to it to be
| unbiased, but I'll try. I actually think the level of
| acceptable risk is gradually dropping. Each time
| something goes wrong, we add procedures. It's much easier
| to add rules than to remove them.
|
| I do think the risk tolerance of individuals on the
| project does tend to gradually increase with experience,
| but we have fairly high turnover. It's common for MSL
| roles to have a year or more of training before
| certification during which you spend a lot of time
| focusing on what can go wrong, so new people definitely
| trend cautious.
| dylan604 wrote:
| That makes sense. Thanks for taking the time to answer my
| curiosity about your Curiosity
| Animats wrote:
| Shutting off the good engine after an engine failure is an error
| that has caused at least three previous crashes.[1][2][3] It can
| be surprisingly difficult to tell which engine failed.
|
| [1] https://www.airforcetimes.com/news/your-air-
| force/2021/01/21...
|
| [2] https://en.wikipedia.org/wiki/Kegworth_air_disaster
|
| [3] https://aerossurance.com/safety-management/bua-
| bac11-g-asjj-...
| Animats wrote:
| Of those,
|
| 1) was a USAF aircraft, a 2-engine Bombardier aircraft. Despite
| the name, this is a small civilian jetliner. "Loud bang" and
| engine failure in cruise. _" Because the warning signal did not
| immediately light up for the catastrophically damaged left
| engine -- it took several seconds for its RPMs to drop below
| the point that would have triggered the signal -- the crew
| didn't immediately know which engine had blown. The pilots
| thought the right engine had experienced the emergency, leading
| them to shut it down instead of the left one. The shutdown
| meant the plane now had no engines operating, and happened
| relatively quickly, about 24 seconds after the fan blade
| broke."_ A restart of the wrong engine was attempted while the
| good engine was kept shut down.
|
| 2) is a well known disaster. _" The aircraft was on a scheduled
| flight from London Heathrow Airport to Belfast International
| Airport when a fan blade broke in the left engine, disrupting
| the air conditioning and filling the cabin with smoke. The
| pilots believed this indicated a fault in the right engine,
| since earlier models of the 737 ventilated the cabin from the
| right, and they were unaware that the 737-400 used a different
| system. The pilots mistakenly shut down the functioning engine.
| They selected full thrust from the malfunctioning one and this
| increased its fuel supply, causing it to catch fire. Of the 126
| people aboard, 47 died and 74 sustained serious injuries."_
|
| 3) is from 1969, and is something of a period piece. This plane
| had _three_ pilots; two in seats with controls, and a third one
| as "pilot in command" supervising but with no access to the
| controls. His comment, afterward, was _"It is perhaps not quite
| correct to be ultimately responsible for the safe handling of
| an aircraft in an emergency unless occupying a seat from where
| this can be done. I feel, somehow, that had I been occupying
| either of the pilot's seats I might have reacted differently;
| on the other hand, it is possible that had I not been present
| the two pilots might also have reacted differently."_ That
| strange setup may have been a holdover from the British early
| WWII "aircraft commander" concept. This was borrowed from
| naval practice, where the officer of the deck tells the junior
| people who are actually driving the ship what to do. It turned
| out to be a terrible idea in the air, where things happened
| faster. But somehow British United Airways was doing it in
| 1969. Nobody questioned the pilot in command deciding, wrongly,
| which engine had failed.
| geocrasher wrote:
| Although he hasn't yet covered _this_ incident, lovers of these
| kinds of breakdowns may enjoy Mentour Pilot.
|
| https://www.youtube.com/@MentourPilot/videos
|
| His accident breakdowns are fantastic, as are those by Juan
| Brown:
|
| https://www.youtube.com/@blancolirio/videos
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(page generated 2023-07-04 23:00 UTC)