13 ms·

Crisis over The Atlantic: The near crash of Air Transat flight 236

234 points by Overtonwindow 4y ago

xrayarx 4y ago
About a near crash in 2001, you might have heard, the longest glide by commercial aircraft after fuel runs out. 32 min read for the whole story.
- Overtonwindow 4y ago
  What I also loved was that the Captain had once been arrested for marijuana trafficking with his airplane. Total bad ass.
  - holler 4y ago
    Was visualizing the cabin during that last 360 circle, followed by the "slew" maneuver, must have been surreal.
    - doctor_eval 4y ago
      Me too, despite knowing the rule “aviate, navigate, communicate”, I was hoping that the captain was explaining what was going on to the passengers but then I remembered: no power, no PA
- Simon_O_Rourke 4y ago
  What is it about Canadian commercial jets having to glide to a landing after running out of fuel? https://en.wikipedia.org/wiki/Gimli_Glider https://en.wikipedia.org/wiki/Gimli_Glider
  - cperciva 4y ago
    Canada doesn't have the best aircraft pilots, but we definitely have the world's best glider pilots.
noduerme 4y ago
Against my own inclination to never watch YouTube, I've become a bit obsessed with this one fellow who does excellent reconstructions and analyses of aviation incidents. He covers this one here: https://www.youtube.com/watch?v=9becqrhsedE https://www.youtube.com/watch?v=9becqrhsedE
- jerrya 4y ago
  What's good about Mentour Pilot is he reads and interprets the NTSB reports and the reports from other relevant agencies, and also adds what his own experience as a 737 pilot tells him. I've often found that means his reports conflict in various ways regarding either what happened, or what caused what happened, with what is found in so many other reconstructions, many of which seem to goes as deep as a Wikipedia article and not a whole lot further. I find he provides a ton of insight then...
- ricardobayes 4y ago
  Seems a bit weird to say "never watch youtube". It's like never reading a book anymore because someone gave you a bad one. It's up to you to filter out content you dislike, just like with everything else.
  - robin_reala 4y ago
    I assume OP’s position is more like never buying a book from a publisher they perceive as being problematic.
    - deanCommie 4y ago
      YouTube is much closer to a "medium" than an a publisher.
      - kqr 4y ago
        That's also a reason to avoid it, to be honest... any time a publisher becomes closer to a medium than a publisher we're in trouble!
robga 4y ago
Interesting that they call Lajes a “military airfield”. On the Azorean island of Terceira, Lajes (TER) is a mixed use airfield that is the commercial landing strip of the island since the 1930s, as well as having a multi-national military base on the other side since the 1940s. There is a picture in the story. The NTSB report called it a military airbase, and other reports say “Military air traffic controllers guided the aircraft”. Civilian aircraft can use the military side with a permit. Plenty more info on the air field at https://military-history.fandom.com/wiki/Lajes_Field https://military-history.fandom.com/wiki/Lajes_Field Lajes’s other claim to fame is that Bush and Blair met there just days before the Iraq invasion to hammer out whatever deal they thought had to be dealt. The tale of the stricken aircraft was fascinating. I’ve always wondered, over the decades as I’ve flown slight doglegs over Earth’s oceans, if the strategy to route over remote airfields in case of emergency has ever had a “cost” estimated. How many hours and gallons of fuel has been spent for this safety blanket? The infrastructural insurance spent to prevent lives lost in air travel appears to be much higher than lives on road travel. Could it be that the insurance is for the aircraft, not the lives? Hmm. The island, and the others of the Azores, are a wonderful place to visit by the way.
- midasuni 4y ago
  To cross the Atlantic between NA and Europe you need to be able to travel 138 minutes from an airport, although for almost the entire area it’s 120 minutes. This is accomplished by having air strips which can take massive planes like A350s at remote places which can’t justify planes of that size normally like Newfoundland, Greenland and the Azores While these are mainly there for military and temporary emergency use, in 2001 they were used far more - with dozens of planes landing at tiny towns like Gander and St. John’s in Newfoundland, places which only really expect a single large plane to land and refuel rather than 30 with passengers to accommodate for days.
  - cjrp 4y ago
    To cross the Atlantic with a twin-engined plane has that requirement (ETOPS).
Reason077 4y ago
See also: the “Gimli glider” incident from the 1980s.
marze 4y ago
I think if you asked the engineers who designed the airbus in question, could you create a "leak" warning, using just the existing sensor suite, they'd say "sure". You know the fuel level in each tank, and have a good estimate or actual flow data on engine fuel usage. Simple math says "leak" or "no leak". If that would work, it is surprising it isn't in the software.
- Dalewyn 4y ago
  If I recall, one of the duties of the pilots (usually the first officer's) is to keep track of fuel levels and consumption throughout the flight so any anomalies in the engine or fuel system can hopefully be found sooner. If a human can do it, I would imagine a computer could automate the process. Likely wouldn't remove the need for the pilots to do it anyway, though; redundancy and reliability and all that.
  - quickthrower2 4y ago
    They did it according to the article, but 200kg was seen as insignificant. I bet it is hard: imagine driving 100 miles and them trying to gauge from the fuel used if there is a leak that lost you 200ml.
  - markdown 4y ago
    > usually the Pilot Monitoring FTFY. It's a common misconception in the general population that the Captain always flies the plane and the FO supports them. There's always a pilot flying, and pilot monitoring. The roles are usually decided before the flight by the Captain and have nothing to do with who is Captain and who is First Officer.
- relix 4y ago
  Make it broader - before take-off, pilots enter the expected destination (or expected distance). During cruising, computers keep track of how much fuel is being used (lost) per unit of time, and projects forward to see if they can still make their expected destination or not. If the number does not reach within expected margins, then show an error. This protects against leaks, but also miscalculation of fuel needed by the pilots, misfueling, or efficiency loss somehow.
NKosmatos 4y ago
Nice read, almost like a movie and full of interesting facts. I won't spoil it, go ahead and read it :-)
- deleted 4y ago
  [deleted]
bambax 4y ago
For some reason I'm a little obsessed with airline incidents and crashes. Admiral Cloudberg produces outstanding write-ups, and of course the videos of Mentour Pilot on YT are also excellent. While this is in no way scientific, it seems that what most catastrophes have in common are bad CRM (crew intra-communication) and lower-than-average airmanship. In most cases, for a catastrophe to occur there must be an initial problem, sometimes very small, that is made worse and worse by bad communication and a series of misunderstandings. And ultimately, in some cases, pilots fail to fly the plane. For poor airmanship, AF 447 comes to mind (very minor initial incident, plane working perfectly fine, disaster caused by incompetence), as well as a comparable problem on AirAsia 8501 (the captain decided to reboot the computers in flight (!) and the first officer was unable to fly the plane properly without autopilot). Disasters caused by poor CRM include the Tenerife Airport disaster (deadliest accident in aviation history). But I find incidents that don't result in a catastrophe often more interesting. Incidents and problems are impossible to avoid when using machines as complex as modern airplanes; what's fascinating is how humans, working together and using all of their skill, are able to save the day. This is the case here. The problem was caused by the maintenance team who didn't use the proper hydraulic tube when replacing an engine, because they didn't have immediate access to the text of the service bulletin that described the procedure, and they thought they could do without. (The wrong hydraulic tube didn't have the proper clearance; when under pressure, it wore away at the fuel line beneath it, until it cracked and leaked.) The actions of the pilots in flight compounded the problem but this was completely excusable given the information and training they had, and the checklists as they were written. Ultimately, disaster was averted by excellent airmanship. There were other events like that. The most famous one is of course US Airways 1549 ("miracle on the Hudson"), but a less well-known, very similar, and possibly more impressive one, happened in 1988. On TACA Flight 110, the pilot landed the plane on a patch of grass with no engines, with no injuries to the passengers or damage to the plane. That pilot, Carlos Dardano, had only one eye, having been shot in the face while landing in El Salvador a few years prior and being caught in a cross fire. He had started flying when he was a toddler, on the knees of his father. At the time of the incident, he was 29 but he had already amassed 13,410 flight hours, with almost 11,000 of these as pilot in command. Another amazing story is the Air Astana flight 1388, in 2018. A heavy maintenance operation had resulted in the inversion of the aileron cables, but not the spoilers, making the plane utterly impossible to control. This problem escaped detection until the plane was in flight. The pilots, after calmly discussing how to ditch the plane in the sea to minimize the number of victims on the ground (it was a test flight with only 6 people on board, all pilots or engineers), managed to regain a semblance of control and landed safely, after 90 minutes of the wildest roller coaster imaginable. It looks like Kazakhs can fly. It seems the modern world doesn't hold skills in high esteem (what used to be called tradecraft before the word became associated with espionnage); the MBA culture essentially regards workers as interchangeable; and of course we have all these machines! But the opposite is true. What will save your life is not the machine, it's the experience, professionalism and competence of the people using the machine.
quickthrower2 4y ago
I really love the straightforward but gripping style of writing here. I read every word! Which is rare for anything submitted to HN (or elsewhere for that matter)
- voxadam 4y ago
  I've been reading Admiral Cloudberg's write-ups for a few years since discovering them over on Reddit's r/CatastrophicFailure,[0] they're all truly excellent. I really enjoy his clear, no nonsense writing style. What us failure analysis nerds need, what we deserve, is a 90s era Discovery Channel show written by Cloudberg. Either that or a a United States Chemical Safety Board[1] style series. [0] https://www.reddit.com/r/CatastrophicFailure https://www.reddit.com/r/CatastrophicFailure [1] https://www.youtube.com/@USCSB https://www.youtube.com/@USCSB
  - LadyCailin 4y ago
    Not sure if you’ve heard about the podcast Cautionary Tales. It’s wonderful, especially if you like these kinds of things.
    - voxadam 4y ago
      This is my first time hearing about it. Thanks for the tip, I'll give it a listen.
    - kyleee 4y ago
      Who is the host? There are apparently a few podcasts with this title and I am confused
      - FabHK 4y ago
        Not GP, but pretty sure they’re referring to Cautionary Tales with Tim Harford (the “Undercover Economist”), which is gripping, informative, and entertaining. https://www.pushkin.fm/podcasts/cautionary-tales https://www.pushkin.fm/podcasts/cautionary-tales
kqr 4y ago
The actual report: http://www.fss.aero/accident-reports/dvdfiles/PT/2001-08-24-PT.pdf http://www.fss.aero/accident-reports/dvdfiles/PT/2001-08-24-... One of my pet peeves: the first 7 "causes and contributing factors" effectively blames the engine technicians for taking shortcuts. Nowhere does it say anything about the scheduling pressure from management that made the technicians consider shortcuts in the first place. If you have hiring and firing power and you tell someone they need to get the plane back in the air a few days later, they will do things to get the plane back in the air a few days later. This is considered simply a "risk" by the report, and not a direct cause. As a consequence, the actual actions taken basically all belong to the category of "fix the engineers", "fix the flight crew", or "fix the plane". Not a single "fix the stressful maintenance environment".
- Shank 4y ago
  It really underscores the importance of using a framework like HFACS [0] in a situation like this, because you end up exhausting all possible sources of problems and ensuring that you reach the correct root cause. It seems abundantly clear that the forcing-function was getting the aircraft back into service as fast as possible, not as safely as possible or as carefully as possible. A well-designed organization would have said that any unexpected contingencies during the maintenance process would have led to a full re-evaluation of the situation to understand it. The moment the engine didn't match their understanding, they should have scheduled a replacement plane or cancelled the upcoming flight, and reset expectations about how fast the plane could be back in-service. [0]: https://en.wikipedia.org/wiki/Human_Factors_Analysis_and_Classification_System https://en.wikipedia.org/wiki/Human_Factors_Analysis_and_Cla...
- silvestrov 4y ago
  Also lack of access to documentation: the technician attempted to access the Rolls-Royce EIPC and the SB’s through the computer network, but was also denied access. This should be a major point for a maintenance shop. Documentation should always be available, both online and in offline versions.
  - hef19898 4y ago
unlog 4y ago
I'm left wondering if the feed data from planes is broadcasted to pilots on the ground to figure out possible problems. Like the actual instrumentation data, as the article says, there was an oversight from their part.
- Shank 4y ago
  Airbus advertises a product called Skywise [0] now, which appears to offer realtime data streaming back home. In a documentary on Qantas Flight 32, they mention that Qantas had realtime data access to ECAM at least. I believe this is more-standard now, but obviously in 2001 it would've been a different ballgame. [0]: https://aircraft.airbus.com/en/services/enhance/skywise/skywise-solutions/skywise-health-monitoring https://aircraft.airbus.com/en/services/enhance/skywise/skyw...
ajeet_dhaliwal 4y ago
Great read. Interesting parallels to software engineering failures. Time, pressure, quality control, operator error, documentation, training... a human challenge.
manxman 4y ago
This seems to be a Canadian thing. They did it here as well. https://en.m.wikipedia.org/wiki/Gimli_Glider https://en.m.wikipedia.org/wiki/Gimli_Glider
ErikVandeWater 4y ago
> Investigators felt that quality control experts, had they been present, might have been more skeptical, but none were on site, because Air Transat’s quality control personnel only worked Monday to Friday.
FpUser 4y ago
I remember for a while they were trying to make Robert Piche into a scapegoat. What I see here is: 1) Design error. Ok I am a total nobody in this area but still fuel leak detection not being included seems like a major design fault. I mean something that measures difference between whatever fuel injectors deliver into the engine and whatever leaves the tank is quite possible I think. 2) How many times have we read when a fucking management pushed for event happen / to be on time no matter what and the following disaster. Challenger, Columbia etc. etc. 3) Service procedures, manuals etc. I guess those are combinations of (1) and (2) 4) Errors by service and flight crews. I can imagine that the person who bent the line had enough reason to raise concern. The rest can't really be blamed. As for Robert Piche - he is a hero in my book
avidphantasm 4y ago
I think it’s unreasonable to pin the mistake on the pilots for not running all the checklists. This is where a flight engineer would come into play in my lay opinion. The pilots were tactically focused; they were trying to keep the plane in the air. You need someone on the flight deck who is looking at the bigger picture, doing the fuel calculations (even if the automated systems aren’t warning about certain fuel-related variables), running the checklists, etc. Perhaps a flight engineer role (perhaps filled by a spare pilot) should be required for all ETOPS flights?
- Gasp0de 4y ago
  They did contact the engineering department. Maybe it would have sufficed to have a telemetry uplink back to the engineering department. Should be doable with Starlink etc. soon enough.
  - t0mas88 4y ago
    No need for Starlink, sat com voice and data links have been a standard things for oceanic flights for years before Starlink.
  - kayodelycaon 4y ago
    Aircraft already have telemetry uplinks via satellite. See ACARS. https://en.wikipedia.org/wiki/ACARS https://en.wikipedia.org/wiki/ACARS
- kayodelycaon 4y ago
  There isn’t a need for a flight engineer. The non-flying pilot (pilot monitoring)’s entire job is to be looking at the big picture. If something goes wrong, they are the ones managing the checklist. In any case, the automation handles the vast majority of flight engineer duties. And fuel leak warnings have been added now.
- mannykannot 4y ago
  It is an objective fact that if they had run the checklists they would have arrived with fuel remaining, and also that they had plenty of time to do so. If we can't say this, how can we learn anything from the investigation?
smdyc1 4y ago
In my time as an avionics tech on C-130s, it was drilled incessantly into us to never perform maintenance from memory. Always consult each step in the relevant publication and have it with you. We weren't immune, we also had ASORs (Aircraft Safety Occurrences, but nowhere near this level of seriousness) where mistakes were made because the techo did not consult the publication. We had tuffbooks that were loaded with all publications and STIs (Special Technical Instructions, similar to SBs) that should have always been carried to the aircraft and consulted during maintenance. If the SB in this case was unavailable, maintenance should have ceased until it became available. When you sign off on maintenance, you are signing off on it being completed in accordance with the publications referencing the specific section of the publication (at least, that's what we did in the Air Force). On the driver side, my immediate thought was: How did a fuel leak in one engine cause a total loss of fuel? I would hope that there are now checklists that prioritise shutting off the cross-feed valve if a leak is suspected. Weight and balance are subordinate to the risk of running out of fuel and starving both engines. On a side note, we would have regular "Safety Days" where incidents of ours, and major incidents like these that have happened to other aircraft were presented to the squadron (both aircrew and maintenance) in detail and discussed. Having the potential consequences in your mind at all times really helped fortify the necessity of following the correct procedures during the regular conduct of your work.
- jacquesm 4y ago
  This sort of thing is why I am a huge fan of 'Risks digest' and spend a lot of my free time reading there. How things can go wrong is a wealth of important knowledge. Unfortunately a lot of it is very hard won and written in blood and to see how little it can sometimes take to cause a major accident possibly with loss of life is a great reminder of your responsibility when designing technology.

234 points by Overtonwindow 4y ago

About a near crash in 2001, you might have heard, the longest glide by commercial aircraft after fuel runs out. 32 min read for the whole story.

Overtonwindow 4y ago
What I also loved was that the Captain had once been arrested for marijuana trafficking with his airplane. Total bad ass.
- holler 4y ago
  Was visualizing the cabin during that last 360 circle, followed by the "slew" maneuver, must have been surreal.
  - doctor_eval 4y ago
    Me too, despite knowing the rule “aviate, navigate, communicate”, I was hoping that the captain was explaining what was going on to the passengers but then I remembered: no power, no PA
Simon_O_Rourke 4y ago
What is it about Canadian commercial jets having to glide to a landing after running out of fuel? https://en.wikipedia.org/wiki/Gimli_Glider https://en.wikipedia.org/wiki/Gimli_Glider
- cperciva 4y ago
  Canada doesn't have the best aircraft pilots, but we definitely have the world's best glider pilots.

noduerme 4y ago

Against my own inclination to never watch YouTube, I've become a bit obsessed with this one fellow who does excellent reconstructions and analyses of aviation incidents. He covers this one here: https://www.youtube.com/watch?v=9becqrhsedE https://www.youtube.com/watch?v=9becqrhsedE

jerrya 4y ago
What's good about Mentour Pilot is he reads and interprets the NTSB reports and the reports from other relevant agencies, and also adds what his own experience as a 737 pilot tells him. I've often found that means his reports conflict in various ways regarding either what happened, or what caused what happened, with what is found in so many other reconstructions, many of which seem to goes as deep as a Wikipedia article and not a whole lot further. I find he provides a ton of insight then...
ricardobayes 4y ago
Seems a bit weird to say "never watch youtube". It's like never reading a book anymore because someone gave you a bad one. It's up to you to filter out content you dislike, just like with everything else.
- robin_reala 4y ago
  I assume OP’s position is more like never buying a book from a publisher they perceive as being problematic.
  - deanCommie 4y ago
    YouTube is much closer to a "medium" than an a publisher.
    - kqr 4y ago
      That's also a reason to avoid it, to be honest... any time a publisher becomes closer to a medium than a publisher we're in trouble!

robga 4y ago

Interesting that they call Lajes a “military airfield”. On the Azorean island of Terceira, Lajes (TER) is a mixed use airfield that is the commercial landing strip of the island since the 1930s, as well as having a multi-national military base on the other side since the 1940s. There is a picture in the story. The NTSB report called it a military airbase, and other reports say “Military air traffic controllers guided the aircraft”. Civilian aircraft can use the military side with a permit. Plenty more info on the air field at https://military-history.fandom.com/wiki/Lajes_Field https://military-history.fandom.com/wiki/Lajes_Field Lajes’s other claim to fame is that Bush and Blair met there just days before the Iraq invasion to hammer out whatever deal they thought had to be dealt. The tale of the stricken aircraft was fascinating. I’ve always wondered, over the decades as I’ve flown slight doglegs over Earth’s oceans, if the strategy to route over remote airfields in case of emergency has ever had a “cost” estimated. How many hours and gallons of fuel has been spent for this safety blanket? The infrastructural insurance spent to prevent lives lost in air travel appears to be much higher than lives on road travel. Could it be that the insurance is for the aircraft, not the lives? Hmm. The island, and the others of the Azores, are a wonderful place to visit by the way.

midasuni 4y ago
To cross the Atlantic between NA and Europe you need to be able to travel 138 minutes from an airport, although for almost the entire area it’s 120 minutes. This is accomplished by having air strips which can take massive planes like A350s at remote places which can’t justify planes of that size normally like Newfoundland, Greenland and the Azores While these are mainly there for military and temporary emergency use, in 2001 they were used far more - with dozens of planes landing at tiny towns like Gander and St. John’s in Newfoundland, places which only really expect a single large plane to land and refuel rather than 30 with passengers to accommodate for days.
- cjrp 4y ago
  To cross the Atlantic with a twin-engined plane has that requirement (ETOPS).

Reason077 4y ago

See also: the “Gimli glider” incident from the 1980s.

marze 4y ago

I think if you asked the engineers who designed the airbus in question, could you create a "leak" warning, using just the existing sensor suite, they'd say "sure". You know the fuel level in each tank, and have a good estimate or actual flow data on engine fuel usage. Simple math says "leak" or "no leak". If that would work, it is surprising it isn't in the software.

Dalewyn 4y ago
If I recall, one of the duties of the pilots (usually the first officer's) is to keep track of fuel levels and consumption throughout the flight so any anomalies in the engine or fuel system can hopefully be found sooner. If a human can do it, I would imagine a computer could automate the process. Likely wouldn't remove the need for the pilots to do it anyway, though; redundancy and reliability and all that.
- quickthrower2 4y ago
  They did it according to the article, but 200kg was seen as insignificant. I bet it is hard: imagine driving 100 miles and them trying to gauge from the fuel used if there is a leak that lost you 200ml.
- markdown 4y ago
  > usually the Pilot Monitoring FTFY. It's a common misconception in the general population that the Captain always flies the plane and the FO supports them. There's always a pilot flying, and pilot monitoring. The roles are usually decided before the flight by the Captain and have nothing to do with who is Captain and who is First Officer.
relix 4y ago
Make it broader - before take-off, pilots enter the expected destination (or expected distance). During cruising, computers keep track of how much fuel is being used (lost) per unit of time, and projects forward to see if they can still make their expected destination or not. If the number does not reach within expected margins, then show an error. This protects against leaks, but also miscalculation of fuel needed by the pilots, misfueling, or efficiency loss somehow.

NKosmatos 4y ago

Nice read, almost like a movie and full of interesting facts. I won't spoil it, go ahead and read it :-)

deleted 4y ago
[deleted]

bambax 4y ago

For some reason I'm a little obsessed with airline incidents and crashes. Admiral Cloudberg produces outstanding write-ups, and of course the videos of Mentour Pilot on YT are also excellent. While this is in no way scientific, it seems that what most catastrophes have in common are bad CRM (crew intra-communication) and lower-than-average airmanship. In most cases, for a catastrophe to occur there must be an initial problem, sometimes very small, that is made worse and worse by bad communication and a series of misunderstandings. And ultimately, in some cases, pilots fail to fly the plane. For poor airmanship, AF 447 comes to mind (very minor initial incident, plane working perfectly fine, disaster caused by incompetence), as well as a comparable problem on AirAsia 8501 (the captain decided to reboot the computers in flight (!) and the first officer was unable to fly the plane properly without autopilot). Disasters caused by poor CRM include the Tenerife Airport disaster (deadliest accident in aviation history). But I find incidents that don't result in a catastrophe often more interesting. Incidents and problems are impossible to avoid when using machines as complex as modern airplanes; what's fascinating is how humans, working together and using all of their skill, are able to save the day. This is the case here. The problem was caused by the maintenance team who didn't use the proper hydraulic tube when replacing an engine, because they didn't have immediate access to the text of the service bulletin that described the procedure, and they thought they could do without. (The wrong hydraulic tube didn't have the proper clearance; when under pressure, it wore away at the fuel line beneath it, until it cracked and leaked.) The actions of the pilots in flight compounded the problem but this was completely excusable given the information and training they had, and the checklists as they were written. Ultimately, disaster was averted by excellent airmanship. There were other events like that. The most famous one is of course US Airways 1549 ("miracle on the Hudson"), but a less well-known, very similar, and possibly more impressive one, happened in 1988. On TACA Flight 110, the pilot landed the plane on a patch of grass with no engines, with no injuries to the passengers or damage to the plane. That pilot, Carlos Dardano, had only one eye, having been shot in the face while landing in El Salvador a few years prior and being caught in a cross fire. He had started flying when he was a toddler, on the knees of his father. At the time of the incident, he was 29 but he had already amassed 13,410 flight hours, with almost 11,000 of these as pilot in command. Another amazing story is the Air Astana flight 1388, in 2018. A heavy maintenance operation had resulted in the inversion of the aileron cables, but not the spoilers, making the plane utterly impossible to control. This problem escaped detection until the plane was in flight. The pilots, after calmly discussing how to ditch the plane in the sea to minimize the number of victims on the ground (it was a test flight with only 6 people on board, all pilots or engineers), managed to regain a semblance of control and landed safely, after 90 minutes of the wildest roller coaster imaginable. It looks like Kazakhs can fly. It seems the modern world doesn't hold skills in high esteem (what used to be called tradecraft before the word became associated with espionnage); the MBA culture essentially regards workers as interchangeable; and of course we have all these machines! But the opposite is true. What will save your life is not the machine, it's the experience, professionalism and competence of the people using the machine.

quickthrower2 4y ago

I really love the straightforward but gripping style of writing here. I read every word! Which is rare for anything submitted to HN (or elsewhere for that matter)

voxadam 4y ago
I've been reading Admiral Cloudberg's write-ups for a few years since discovering them over on Reddit's r/CatastrophicFailure,[0] they're all truly excellent. I really enjoy his clear, no nonsense writing style. What us failure analysis nerds need, what we deserve, is a 90s era Discovery Channel show written by Cloudberg. Either that or a a United States Chemical Safety Board[1] style series. [0] https://www.reddit.com/r/CatastrophicFailure https://www.reddit.com/r/CatastrophicFailure [1] https://www.youtube.com/@USCSB https://www.youtube.com/@USCSB
- LadyCailin 4y ago
  Not sure if you’ve heard about the podcast Cautionary Tales. It’s wonderful, especially if you like these kinds of things.
  - voxadam 4y ago
    This is my first time hearing about it. Thanks for the tip, I'll give it a listen.
  - kyleee 4y ago
    Who is the host? There are apparently a few podcasts with this title and I am confused
    - FabHK 4y ago
      Not GP, but pretty sure they’re referring to Cautionary Tales with Tim Harford (the “Undercover Economist”), which is gripping, informative, and entertaining. https://www.pushkin.fm/podcasts/cautionary-tales https://www.pushkin.fm/podcasts/cautionary-tales

kqr 4y ago

The actual report: http://www.fss.aero/accident-reports/dvdfiles/PT/2001-08-24-PT.pdf http://www.fss.aero/accident-reports/dvdfiles/PT/2001-08-24-... One of my pet peeves: the first 7 "causes and contributing factors" effectively blames the engine technicians for taking shortcuts. Nowhere does it say anything about the scheduling pressure from management that made the technicians consider shortcuts in the first place. If you have hiring and firing power and you tell someone they need to get the plane back in the air a few days later, they will do things to get the plane back in the air a few days later. This is considered simply a "risk" by the report, and not a direct cause. As a consequence, the actual actions taken basically all belong to the category of "fix the engineers", "fix the flight crew", or "fix the plane". Not a single "fix the stressful maintenance environment".

Shank 4y ago
It really underscores the importance of using a framework like HFACS [0] in a situation like this, because you end up exhausting all possible sources of problems and ensuring that you reach the correct root cause. It seems abundantly clear that the forcing-function was getting the aircraft back into service as fast as possible, not as safely as possible or as carefully as possible. A well-designed organization would have said that any unexpected contingencies during the maintenance process would have led to a full re-evaluation of the situation to understand it. The moment the engine didn't match their understanding, they should have scheduled a replacement plane or cancelled the upcoming flight, and reset expectations about how fast the plane could be back in-service. [0]: https://en.wikipedia.org/wiki/Human_Factors_Analysis_and_Classification_System https://en.wikipedia.org/wiki/Human_Factors_Analysis_and_Cla...
silvestrov 4y ago
Also lack of access to documentation: the technician attempted to access the Rolls-Royce EIPC and the SB’s through the computer network, but was also denied access. This should be a major point for a maintenance shop. Documentation should always be available, both online and in offline versions.
- hef19898 4y ago

unlog 4y ago

I'm left wondering if the feed data from planes is broadcasted to pilots on the ground to figure out possible problems. Like the actual instrumentation data, as the article says, there was an oversight from their part.

Shank 4y ago
Airbus advertises a product called Skywise [0] now, which appears to offer realtime data streaming back home. In a documentary on Qantas Flight 32, they mention that Qantas had realtime data access to ECAM at least. I believe this is more-standard now, but obviously in 2001 it would've been a different ballgame. [0]: https://aircraft.airbus.com/en/services/enhance/skywise/skywise-solutions/skywise-health-monitoring https://aircraft.airbus.com/en/services/enhance/skywise/skyw...

ajeet_dhaliwal 4y ago

Great read. Interesting parallels to software engineering failures. Time, pressure, quality control, operator error, documentation, training... a human challenge.

manxman 4y ago

This seems to be a Canadian thing. They did it here as well. https://en.m.wikipedia.org/wiki/Gimli_Glider https://en.m.wikipedia.org/wiki/Gimli_Glider

ErikVandeWater 4y ago

> Investigators felt that quality control experts, had they been present, might have been more skeptical, but none were on site, because Air Transat’s quality control personnel only worked Monday to Friday.

FpUser 4y ago

I remember for a while they were trying to make Robert Piche into a scapegoat. What I see here is: 1) Design error. Ok I am a total nobody in this area but still fuel leak detection not being included seems like a major design fault. I mean something that measures difference between whatever fuel injectors deliver into the engine and whatever leaves the tank is quite possible I think. 2) How many times have we read when a fucking management pushed for event happen / to be on time no matter what and the following disaster. Challenger, Columbia etc. etc. 3) Service procedures, manuals etc. I guess those are combinations of (1) and (2) 4) Errors by service and flight crews. I can imagine that the person who bent the line had enough reason to raise concern. The rest can't really be blamed. As for Robert Piche - he is a hero in my book

avidphantasm 4y ago

I think it’s unreasonable to pin the mistake on the pilots for not running all the checklists. This is where a flight engineer would come into play in my lay opinion. The pilots were tactically focused; they were trying to keep the plane in the air. You need someone on the flight deck who is looking at the bigger picture, doing the fuel calculations (even if the automated systems aren’t warning about certain fuel-related variables), running the checklists, etc. Perhaps a flight engineer role (perhaps filled by a spare pilot) should be required for all ETOPS flights?

Gasp0de 4y ago
They did contact the engineering department. Maybe it would have sufficed to have a telemetry uplink back to the engineering department. Should be doable with Starlink etc. soon enough.
- t0mas88 4y ago
  No need for Starlink, sat com voice and data links have been a standard things for oceanic flights for years before Starlink.
- kayodelycaon 4y ago
  Aircraft already have telemetry uplinks via satellite. See ACARS. https://en.wikipedia.org/wiki/ACARS https://en.wikipedia.org/wiki/ACARS
kayodelycaon 4y ago
There isn’t a need for a flight engineer. The non-flying pilot (pilot monitoring)’s entire job is to be looking at the big picture. If something goes wrong, they are the ones managing the checklist. In any case, the automation handles the vast majority of flight engineer duties. And fuel leak warnings have been added now.
mannykannot 4y ago
It is an objective fact that if they had run the checklists they would have arrived with fuel remaining, and also that they had plenty of time to do so. If we can't say this, how can we learn anything from the investigation?

smdyc1 4y ago

In my time as an avionics tech on C-130s, it was drilled incessantly into us to never perform maintenance from memory. Always consult each step in the relevant publication and have it with you. We weren't immune, we also had ASORs (Aircraft Safety Occurrences, but nowhere near this level of seriousness) where mistakes were made because the techo did not consult the publication. We had tuffbooks that were loaded with all publications and STIs (Special Technical Instructions, similar to SBs) that should have always been carried to the aircraft and consulted during maintenance. If the SB in this case was unavailable, maintenance should have ceased until it became available. When you sign off on maintenance, you are signing off on it being completed in accordance with the publications referencing the specific section of the publication (at least, that's what we did in the Air Force). On the driver side, my immediate thought was: How did a fuel leak in one engine cause a total loss of fuel? I would hope that there are now checklists that prioritise shutting off the cross-feed valve if a leak is suspected. Weight and balance are subordinate to the risk of running out of fuel and starving both engines. On a side note, we would have regular "Safety Days" where incidents of ours, and major incidents like these that have happened to other aircraft were presented to the squadron (both aircrew and maintenance) in detail and discussed. Having the potential consequences in your mind at all times really helped fortify the necessity of following the correct procedures during the regular conduct of your work.

jacquesm 4y ago
This sort of thing is why I am a huge fan of 'Risks digest' and spend a lot of my free time reading there. How things can go wrong is a wealth of important knowledge. Unfortunately a lot of it is very hard won and written in blood and to see how little it can sometimes take to cause a major accident possibly with loss of life is a great reminder of your responsibility when designing technology.