7 ms·

> What's more, over the course of his 55 years in the profession, he [lawyer Marc Moller] [has] learned that every plane crash can be traced back to a single, s

by FabHK 7y ago

> What's more, over the course of his 55 years in the profession, he [lawyer Marc Moller] [has] learned that every plane crash can be traced back to a single, simple cause. I don't know, that strikes me as nonsense. It's precisely the interplay of many factors that lead to an accident - and if any one of them had been different, the outcome might have been different. See Reason's "swiss cheese" model of accidents - all the holes have to line up [1]. How you can go and designate one of these holes the hole, the "single, simple cause" is beyond me. This doesn't do the complexity of engineering justice. Might help to win cases with juries, but I don't see how it could help to make flying safer. [1] https://en.wikipedia.org/wiki/Swiss_cheese_model https://en.wikipedia.org/wiki/Swiss_cheese_model

notfashion 7y ago
The journalist writing the article may have distorted what he said. Is their a dogma of accident investigation that says there is always a root cause, or is it just a conventional way of working? There are certainly domains in which root cause analysis is inappropriate—psychiatry, for example. https://en.wikipedia.org/wiki/Root_cause_analysis https://en.wikipedia.org/wiki/Root_cause_analysis
nness 7y ago
I think, as a lawyer, he's using the phase a "simple cause" to mean "a singular responsibility, culpability, and liability."
- FabHK 7y ago
  Probably. Goes to show that the lawyer representing the victims and the safety folks (NTSB etc.) trying to make sure an accident does not repeat have very different goals, incentives, ways of thinking, etc.
  - mieseratte 7y ago
    Given how vague the language is, I don't know that we can necessarily draw a conclusion. That "single item" might be the component-failure, that which fell through the aligned holes in the swiss-cheese, or it could be "the single layer of the system that was left out" that would have mitigated or otherwise precluding the class of failure. One could castigate Boeing for not having a more redundant use of sensors the MAX case, or one could say "Why don't you have 'hackers' as a part of your process, whose job it is to find these classes of problems and raise all hell when they do." Then again based on the phrasing "single, simple cause" I'm more inclined to say you're on the money. That the lawyer is looking at the component-failure rather than "avoiding non-redundant systems" as a class of problem to solve.
    - salawat 7y ago
      The single simple cause he may be alluding to is greed. Lawyers aren't interested in the technical minutiae except in as much as it can be useful in communicating intent to the jury. "Why did you decide to only use one sensor to feed such a critical system?" "Why did it not occur to anyone to reevaluate the safety rating when the software was changed?" "Was there any pressure to not do as thorough an analysis as possible?" What I would do as an attorney is cross examine everyone involved to establish that there was a clear and present intent to put the completion of the product on time ahead of completing the project in total compliance with federal regulations. It's proving intent to the jury that matters. Not arguing over the finer points of aircraft design. In fact, I'd be surprised if anyone with an aviation background would even make it passed voir dire unchallenged.
      - TheOtherHobbes 7y ago
        Yes. He's certainly not going to approach this like an engineer going bug hunting. The goal will be to establish that the problem was cultural and political. An avoidable cascade of engineering failures and regulatory misrepresentations was the result, not the cause.
    - magduf 7y ago
      Yeah, I think the language used there just isn't being that precise, by engineering standards, that's all. When you're assigning blame for something like an aircraft crash, what you want to single out is errors which were preventable. So, for instance, icing on critical sensors probably isn't preventable 100%, so that's why we do things like have redundant sensors, algorithms about how to use that sensor data to avoid letting a bad sensor reading cause a big problem, etc. Another thing that isn't preventable is weather, of course, so we engineer things to handle that. But preventable errors, especially ones which we've already learned how to handle in the past, are generally considered unforgivable and worthy of assigning blame. A crash caused by a Russian AA missile isn't really avoidable for a passenger jet, so we don't blame the pilot or the aircraft maker or airline. A crash caused by using a single sensor that's known to ice up and is used for a system that's only there because someone thought it'd be a great idea to slap some oversize engines on an obsolete airframe from the 60s in the wrong position, however, is clearly a preventable error.
  - SilasX 7y ago
    "It's difficult to get a man to understand something when his salary depends on his not understanding it."
meristem 7y ago
For decades accident analysis stopped at the component part. Nowadays it may extend to organizational issues. Even more recent safety paradigms stretch to complex links between product, organizational, business, governmental contexts. Depending on how Moller has worked in the past he could mean a lawyer's language of culpability or an outdated view of safety.
the_duke 7y ago
I also wanted to mention this after reading the paragraph, but it is a pretty unimportant side note in the article. The framing here is obviously from a lawyers perspective. A lawyer that has been very successful at extracting money from companies. Making the issue appear simple and traceable to a single problem seems like a great way to convince a jury.
- pjmorris 7y ago
  > Making the issue appear simple and traceable to a single problem seems like a great way to convince a jury. Or, an electorate. Maybe oversimplification is the path to popularity.
  - aaronbrethorst 7y ago
    Telling a good story. Sometimes that means oversimplifying.
AnimalMuppet 7y ago
Forgive me a great deal of cynicism here. I suspect that a more accurate statement is "he learned that it works well for him to argue that every plane crash can be traced back to a single, simple cause." We don't ask lawyers to do surgery. We don't ask them to design bridges. And we don't ask them to do root cause analysis. We leave all of those things to those who actually know what they're doing in those areas.
- SilasX 7y ago
  Yeah, but the work of lawyers has often forced industries to do things differently, even when the best science says they shouldn't do it that way. For example, lawsuits over botched baby deliveries that argued "you should have c[aesarean]-sectioned" resulted in extreme overuse of the procedure in the US, with higher resultant risks. So ... I wish it worked like you described.
  - TheSpiceIsLife 7y ago
    I suspect the reasons for increased c-sections are manifold. When we medicalise pregnancy and childbirth, then fill hospitals with profit driven policy, and surgeons who fear malpractice accusations, is it any wonder c-sections can become over used? Fear of malpractice alone can’t explain it all, as it some other lawyer could demonstrate c-sections are over used and lead to complications.
    - jfnixon 7y ago
      I don't think the parent is arguing malpractice fear explains it all. But clearly, that fear is a significant element in many decisions.
- amelius 7y ago
  You don't need to be able to analyze causes in order to count them.
  - AnimalMuppet 7y ago
cmpolis 7y ago
The quote from Marc Moller seems counter to what I have seen as the prevailing thought regarding aviation accidents, which is: accidents are the result of a "chain" of failures; if any link in the chain does not occur the accident can be avoided. It is easy to say "software bug" or some single thing caused this failure, but there are many other factors that need to be considered: a/c certification requirements, training requirements (sim time, transitioning to new variants of an a/c), design philosophy for the Max, etc... (Not an expert, but private pilot, have read many NTSB accident reports).
- dredmorbius 7y ago
  A lawyer's job is to win the case. A forensic engineer's job is to prevent the next accident. Cases are won on clear, persuasive argument. A simple, single-cause narrative works. Accidents are avoided by removing or mitigating contributing factors, based on significance and costs. Put another way: truth and science are not rhetorical activities. Politics and business are.
- salawat 7y ago
  Note that the aviation industry (as you are likely aware) operates on a blameless basis in the interest of preventing a repeat of the same tragedy. That part has come and gone. The cooperation has happened. The investigation has been conducted, the physical, objective nature of the issue; it's implementation, and the physical chain of events that led to the crashes is established. Boeing survived that. What they haven't survived is the full process of peeling back the layers of paperwork, and subsequent investigation into what enabled the physical foundation of these crashes to come about. Considering there was apparently a whistleblower willing to testify that decisions material to enabling the crash were made specifically to meet deadlines by dodging regulator scrutiny, I have the feeling Boeing will have a rough time of it.
karmelapple 7y ago
In the world of avionics, the concept of a “single point failure” is widely known and greatly focused on eliminating. The failures that take down aircraft will likely involve multiple things going wrong, because the engineers (mechanical, aeronautical, system, software, etc) work hard to ensure a single thing going awry won’t down a plane.
DuskStar 7y ago
I mean, if the crashes were due to a single cause, that cause should probably be either the failure of the last backstop, or the failure that started the chain. IMO the start of the chain would be the AOA sensor failure, and the last backstop would be the pilots running through the stab trim runaway checklist... That doesn't get him settlement money, though.
WalterBright 7y ago
> that strikes me as nonsense It is nonsense. It takes multiple failures to bring down an airliner, and the NTSB accident reports recommend fixing all of them. It's why airliners are so safe today. The 737MAX issue is no different.
- jacquesm 7y ago
  It's different in that it starts to look as though there was a fairly concerted effort to keep the planes flying even though it was known to have a pretty big flaw.
  - kjar 7y ago
    the flawed product was rushed to market to "beat" Airbus there, but hey it's only ~350 people killed, and weeks of delay to ground the fleet. Sorry Boeing, you messed up hard. Personally I don't care to fly, but I sure as F am not getting on your planes. Fish rot from the head down, and I see that in this tragic case.
    - WalterBright 7y ago
      I guess you won't fly Airbus either, as they were recently slapped with an AD to address pitch instability problems. "The FAA is adopting a new airworthiness directive (AD) for all Airbus SAS Model A321-251N, A321-252N, A321-253N, A321-271N, A321-272N, A321-251NX, A321-252NX, A321-253NX, A321-271NX, and A321-272NX airplanes. This AD was prompted by analysis of the behavior of the elevator aileron computer (ELAC) L102 that revealed that excessive pitch attitude can occur in certain conditions and during specific maneuvers. This AD requires revising the airplane flight manual (AFM) to incorporate updated procedures and operational limitations, as specified in a European Union Aviation Safety Agency (EASA) AD, which is incorporated by reference. The FAA is issuing this AD to address the unsafe condition on these products." http://rgl.faa.gov/Regulatory_and_Guidance_Library/rgad.nsf/0/6aeb8ae4513720768625845e00444321/$FILE/2019-15-02.pdf http://rgl.faa.gov/Regulatory_and_Guidance_Library/rgad.nsf/...
- salawat 7y ago
cptskippy 7y ago
What if every accident shares one common hole among all the holes that aligned, and had that hole been eliminate then none of the accidents would have occurred?
tus88 7y ago
Well the probability of having two or more independent, crash resulting faults occur at the same time is remarkably low.
- Gibbon1 7y ago
  > independent That assumption and the birthday paradox is what leaves people walking funny.
deleted 7y ago
[deleted]

by FabHK 7y ago

notfashion 7y ago

The journalist writing the article may have distorted what he said. Is their a dogma of accident investigation that says there is always a root cause, or is it just a conventional way of working? There are certainly domains in which root cause analysis is inappropriate—psychiatry, for example. https://en.wikipedia.org/wiki/Root_cause_analysis https://en.wikipedia.org/wiki/Root_cause_analysis

nness 7y ago

I think, as a lawyer, he's using the phase a "simple cause" to mean "a singular responsibility, culpability, and liability."

FabHK 7y ago
Probably. Goes to show that the lawyer representing the victims and the safety folks (NTSB etc.) trying to make sure an accident does not repeat have very different goals, incentives, ways of thinking, etc.
- mieseratte 7y ago
  Given how vague the language is, I don't know that we can necessarily draw a conclusion. That "single item" might be the component-failure, that which fell through the aligned holes in the swiss-cheese, or it could be "the single layer of the system that was left out" that would have mitigated or otherwise precluding the class of failure. One could castigate Boeing for not having a more redundant use of sensors the MAX case, or one could say "Why don't you have 'hackers' as a part of your process, whose job it is to find these classes of problems and raise all hell when they do." Then again based on the phrasing "single, simple cause" I'm more inclined to say you're on the money. That the lawyer is looking at the component-failure rather than "avoiding non-redundant systems" as a class of problem to solve.
  - salawat 7y ago
    The single simple cause he may be alluding to is greed. Lawyers aren't interested in the technical minutiae except in as much as it can be useful in communicating intent to the jury. "Why did you decide to only use one sensor to feed such a critical system?" "Why did it not occur to anyone to reevaluate the safety rating when the software was changed?" "Was there any pressure to not do as thorough an analysis as possible?" What I would do as an attorney is cross examine everyone involved to establish that there was a clear and present intent to put the completion of the product on time ahead of completing the project in total compliance with federal regulations. It's proving intent to the jury that matters. Not arguing over the finer points of aircraft design. In fact, I'd be surprised if anyone with an aviation background would even make it passed voir dire unchallenged.
    - TheOtherHobbes 7y ago
      Yes. He's certainly not going to approach this like an engineer going bug hunting. The goal will be to establish that the problem was cultural and political. An avoidable cascade of engineering failures and regulatory misrepresentations was the result, not the cause.
  - magduf 7y ago
    Yeah, I think the language used there just isn't being that precise, by engineering standards, that's all. When you're assigning blame for something like an aircraft crash, what you want to single out is errors which were preventable. So, for instance, icing on critical sensors probably isn't preventable 100%, so that's why we do things like have redundant sensors, algorithms about how to use that sensor data to avoid letting a bad sensor reading cause a big problem, etc. Another thing that isn't preventable is weather, of course, so we engineer things to handle that. But preventable errors, especially ones which we've already learned how to handle in the past, are generally considered unforgivable and worthy of assigning blame. A crash caused by a Russian AA missile isn't really avoidable for a passenger jet, so we don't blame the pilot or the aircraft maker or airline. A crash caused by using a single sensor that's known to ice up and is used for a system that's only there because someone thought it'd be a great idea to slap some oversize engines on an obsolete airframe from the 60s in the wrong position, however, is clearly a preventable error.
- SilasX 7y ago
  "It's difficult to get a man to understand something when his salary depends on his not understanding it."

meristem 7y ago

For decades accident analysis stopped at the component part. Nowadays it may extend to organizational issues. Even more recent safety paradigms stretch to complex links between product, organizational, business, governmental contexts. Depending on how Moller has worked in the past he could mean a lawyer's language of culpability or an outdated view of safety.

the_duke 7y ago

I also wanted to mention this after reading the paragraph, but it is a pretty unimportant side note in the article. The framing here is obviously from a lawyers perspective. A lawyer that has been very successful at extracting money from companies. Making the issue appear simple and traceable to a single problem seems like a great way to convince a jury.

pjmorris 7y ago
> Making the issue appear simple and traceable to a single problem seems like a great way to convince a jury. Or, an electorate. Maybe oversimplification is the path to popularity.
- aaronbrethorst 7y ago
  Telling a good story. Sometimes that means oversimplifying.

AnimalMuppet 7y ago

Forgive me a great deal of cynicism here. I suspect that a more accurate statement is "he learned that it works well for him to argue that every plane crash can be traced back to a single, simple cause." We don't ask lawyers to do surgery. We don't ask them to design bridges. And we don't ask them to do root cause analysis. We leave all of those things to those who actually know what they're doing in those areas.

SilasX 7y ago
Yeah, but the work of lawyers has often forced industries to do things differently, even when the best science says they shouldn't do it that way. For example, lawsuits over botched baby deliveries that argued "you should have c[aesarean]-sectioned" resulted in extreme overuse of the procedure in the US, with higher resultant risks. So ... I wish it worked like you described.
- TheSpiceIsLife 7y ago
  I suspect the reasons for increased c-sections are manifold. When we medicalise pregnancy and childbirth, then fill hospitals with profit driven policy, and surgeons who fear malpractice accusations, is it any wonder c-sections can become over used? Fear of malpractice alone can’t explain it all, as it some other lawyer could demonstrate c-sections are over used and lead to complications.
  - jfnixon 7y ago
    I don't think the parent is arguing malpractice fear explains it all. But clearly, that fear is a significant element in many decisions.
amelius 7y ago
You don't need to be able to analyze causes in order to count them.
- AnimalMuppet 7y ago

cmpolis 7y ago

The quote from Marc Moller seems counter to what I have seen as the prevailing thought regarding aviation accidents, which is: accidents are the result of a "chain" of failures; if any link in the chain does not occur the accident can be avoided. It is easy to say "software bug" or some single thing caused this failure, but there are many other factors that need to be considered: a/c certification requirements, training requirements (sim time, transitioning to new variants of an a/c), design philosophy for the Max, etc... (Not an expert, but private pilot, have read many NTSB accident reports).

dredmorbius 7y ago
A lawyer's job is to win the case. A forensic engineer's job is to prevent the next accident. Cases are won on clear, persuasive argument. A simple, single-cause narrative works. Accidents are avoided by removing or mitigating contributing factors, based on significance and costs. Put another way: truth and science are not rhetorical activities. Politics and business are.
salawat 7y ago
Note that the aviation industry (as you are likely aware) operates on a blameless basis in the interest of preventing a repeat of the same tragedy. That part has come and gone. The cooperation has happened. The investigation has been conducted, the physical, objective nature of the issue; it's implementation, and the physical chain of events that led to the crashes is established. Boeing survived that. What they haven't survived is the full process of peeling back the layers of paperwork, and subsequent investigation into what enabled the physical foundation of these crashes to come about. Considering there was apparently a whistleblower willing to testify that decisions material to enabling the crash were made specifically to meet deadlines by dodging regulator scrutiny, I have the feeling Boeing will have a rough time of it.

karmelapple 7y ago

In the world of avionics, the concept of a “single point failure” is widely known and greatly focused on eliminating. The failures that take down aircraft will likely involve multiple things going wrong, because the engineers (mechanical, aeronautical, system, software, etc) work hard to ensure a single thing going awry won’t down a plane.

DuskStar 7y ago

I mean, if the crashes were due to a single cause, that cause should probably be either the failure of the last backstop, or the failure that started the chain. IMO the start of the chain would be the AOA sensor failure, and the last backstop would be the pilots running through the stab trim runaway checklist... That doesn't get him settlement money, though.

WalterBright 7y ago

> that strikes me as nonsense It is nonsense. It takes multiple failures to bring down an airliner, and the NTSB accident reports recommend fixing all of them. It's why airliners are so safe today. The 737MAX issue is no different.

jacquesm 7y ago
It's different in that it starts to look as though there was a fairly concerted effort to keep the planes flying even though it was known to have a pretty big flaw.
- kjar 7y ago
  the flawed product was rushed to market to "beat" Airbus there, but hey it's only ~350 people killed, and weeks of delay to ground the fleet. Sorry Boeing, you messed up hard. Personally I don't care to fly, but I sure as F am not getting on your planes. Fish rot from the head down, and I see that in this tragic case.
  - WalterBright 7y ago
    I guess you won't fly Airbus either, as they were recently slapped with an AD to address pitch instability problems. "The FAA is adopting a new airworthiness directive (AD) for all Airbus SAS Model A321-251N, A321-252N, A321-253N, A321-271N, A321-272N, A321-251NX, A321-252NX, A321-253NX, A321-271NX, and A321-272NX airplanes. This AD was prompted by analysis of the behavior of the elevator aileron computer (ELAC) L102 that revealed that excessive pitch attitude can occur in certain conditions and during specific maneuvers. This AD requires revising the airplane flight manual (AFM) to incorporate updated procedures and operational limitations, as specified in a European Union Aviation Safety Agency (EASA) AD, which is incorporated by reference. The FAA is issuing this AD to address the unsafe condition on these products." http://rgl.faa.gov/Regulatory_and_Guidance_Library/rgad.nsf/0/6aeb8ae4513720768625845e00444321/$FILE/2019-15-02.pdf http://rgl.faa.gov/Regulatory_and_Guidance_Library/rgad.nsf/...
salawat 7y ago

cptskippy 7y ago

What if every accident shares one common hole among all the holes that aligned, and had that hole been eliminate then none of the accidents would have occurred?

tus88 7y ago

Well the probability of having two or more independent, crash resulting faults occur at the same time is remarkably low.

Gibbon1 7y ago
> independent That assumption and the birthday paradox is what leaves people walking funny.

deleted 7y ago

[deleted]