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Here is a better article about Flight 143 from the brilliant admiralcloudberg crash analysis blog: https://admiralcloudberg.medium.com/a-mathematical-miracle-t

Here is a better article about Flight 143 from the brilliant admiralcloudberg crash analysis blog: https://admiralcloudberg.medium.com/a-mathematical-miracle-the-story-of-air-canada-flight-143-or-the-gimli-glider-9e99545d9b3d https://admiralcloudberg.medium.com/a-mathematical-miracle-t... The linked article is not bad but reads a bit too much like a Dan Brown novelization for me taste… “ The mustachioed Captain Pearson pulled out the trusty Boeing handbook, his fingers dashing through the pages…”

fwlr 3y ago
The Admiral Cloudberg article is much better, particularly in its explanation of how the plane came to be flown with blank fuel gauges. The first technician noticed an issue with the fuel gauges being blank a few flights earlier and applied a fix he happened to know: disabling one of the two channels, which restored the gauges. This was an acceptable fix - the plane was certified to fly with only one of the two channels active, as long as the lost redundancy was regained with manual checks. It was flown twice in this state (working gauges, single channel, manual backup fuel check). When this captain handed the plane over to the captain of the incident flight, there was a misunderstanding in the conversation that led to the incoming captain believing the prior captain had been flying with blank fuel gauges and only manual fuel checks. In an unfortunate coincidence, the second technician who was checking the plane at this time disabled both channels to try and troubleshoot the issue again, but failed to return the system to the “one channel” functioning state (apparently because he was interrupted by a request to help with the manual fuel check, ironically). The second technician’s mistake would have been noticed by the pilots, except that due to the misunderstanding, they were expecting to see blank gauges. Those were the initial conditions that allowed the “pounds, not kilograms” mistake to threaten the flight.
- libraryofbabel 3y ago
  Definitely. What makes Admiral Cloudberg so good is the intense focus on details: both details of technical systems, and details of how humans (mis-)communicate with each other. Those details are where the reasons for failure reside, and so they are the place to focus if you’re interested in these stories from an incident analysis perspective. With flight 143, the sheer brilliance of the flying after the fuel ran out - plus the too-neat story of “it was all caused by metric / imperial conversion” can easily distract from the real lynchpin of the whole incident, which was as you say why the plane was flown with non-functional fuel gauges when that was contrary to the Minimum Equipment List for the aircraft. Taking off with blank fuel gauges was the core safety rule that was violated: the mistake with the unit conversions was necessary to make that violation dangerous but it wasn’t really the core of the accident.
  - WalterBright 3y ago
    Nearly all airliner crashes are due to an unexpected confluence of multiple errors. If any one of the errors had gone right, nothing bad would have happened.
    - pfdietz 3y ago
      The "swiss cheese" model of accidents. When all the holes line up...
    - dctoedt 3y ago
      > If any one of the errors had gone right, nothing bad would have happened. IIRC, a cascade of human errors is also what happened at Three Mile Island and Chernobyl.
      - gcoakes 3y ago
        Wasn't there active attempts to hide the extent of the issue with Chernobyl which significantly worsened the damage? If so, that seems like saying there were cascading human errors in a murder-suicide. You're technically right on some level, but I wouldn't so much call that human error.
        IIsi50MHz 3y ago
        I'd classify humans hiding it as an additional human error.
    - noah_buddy 3y ago
      It makes you wonder how many flights take off with several errors and mistakes every day.
      - ranger207 3y ago
        Probably most. Complex systems run in degraded mode as a matter of course. https://how.complexsystems.fail/ https://how.complexsystems.fail/
tailspin2019 3y ago
That was a gripping read!
mewse-hn 3y ago
[flagged]
- q845712 3y ago
  in my experience it is how both real and imaginary Canadians talk
  - nvy 3y ago
    Usually when people parody Canadians they get the "eh" completely wrong.
- DamnInteresting 3y ago
  Author of the linked article here. If you're implying that I manufactured the "eh"s, you are mistaken, they were in the transcript of the cockpit voice recorder. If you are implying that I intentionally left them in for comedic value, I cannot argue with that.
  - cf100clunk 3y ago
    Indeed, thank you for your attention to that detail. I would expect that cockpit recordings from Yanks would have plenty of sentences ending in "Huh?", as in "Ya remembered ta turn that switch off, huh?"
- wintogreen74 3y ago
  Sorry eh, but that's actually how we talk ya hoser.
  - dredmorbius 3y ago
    Somewhat less prevalent in BC, or Quebec (francophones), but yes. It's often challenged my capacity to keep a straight face when it reaches self-parodying levels.
  - WalterBright 3y ago
    I'll be honest with you, like, totally, gag me with a spoon, know whut I mean?
bc_programming 3y ago
The thing that gets me in the originally posted link is that the author decided since this was Air Canada, every single person involved must end their sentences with 'eh'.
joezydeco 3y ago
Cloudberg is the best but....wait a minute. This aircraft took back off again after refueling and repair?
mortenjorck 3y ago
I'd almost say the two make good companion pieces. DI's is a masterclass in nonfiction storytelling, while Cloudberg's is equally adept in its detailed, high-stakes procedural drama. It's an incredible enough event that it's worth reading both!
gcoakes 3y ago
I, for one, quite enjoyed the novelization of it. Especially the part about the space-irony continuum. My sleeping wife did not appreciate being woken up by laughter though.
RheingoldRiver 3y ago
That was a great article. It seems ridiculous to me that the pilots were punished for this given very specifically the unclear delegation of responsibility when automation was introduced. And if ignoring the MEL was a company culture issue, then it was a company culture issue, and you won't make the company safer by encouraging people not to reveal violations.
r00f 3y ago
There is one part in that article that I cant understand. It says: > ...when flight attendants opened the rear emergency exits, they found that the tail was so high in the air that the slides didn’t touch the ground. Sliding down them was less like schoolyard fun and more like jumping off the second or third floor of a building But then it proceeds showing a photo of deployed rear exit slides, and judging by human standing there they almost touched the ground, the difference is like half that human at most. Now, while I agree that jumping from 1 meter may be too much for some people, comparing it with 3rd floor jump is totally out of place. What am I missing here?
- rattus_rattus 3y ago
  I am guessing that the slides would swing backwards into a more vertical position if someone were to try to use it, because the bottom wasn’t touching the ground and thus preventing the swinging movement. This would then cause the slide to then be an essentially vertical drop instead.

fwlr 3y ago

The Admiral Cloudberg article is much better, particularly in its explanation of how the plane came to be flown with blank fuel gauges. The first technician noticed an issue with the fuel gauges being blank a few flights earlier and applied a fix he happened to know: disabling one of the two channels, which restored the gauges. This was an acceptable fix - the plane was certified to fly with only one of the two channels active, as long as the lost redundancy was regained with manual checks. It was flown twice in this state (working gauges, single channel, manual backup fuel check). When this captain handed the plane over to the captain of the incident flight, there was a misunderstanding in the conversation that led to the incoming captain believing the prior captain had been flying with blank fuel gauges and only manual fuel checks. In an unfortunate coincidence, the second technician who was checking the plane at this time disabled both channels to try and troubleshoot the issue again, but failed to return the system to the “one channel” functioning state (apparently because he was interrupted by a request to help with the manual fuel check, ironically). The second technician’s mistake would have been noticed by the pilots, except that due to the misunderstanding, they were expecting to see blank gauges. Those were the initial conditions that allowed the “pounds, not kilograms” mistake to threaten the flight.

libraryofbabel 3y ago
Definitely. What makes Admiral Cloudberg so good is the intense focus on details: both details of technical systems, and details of how humans (mis-)communicate with each other. Those details are where the reasons for failure reside, and so they are the place to focus if you’re interested in these stories from an incident analysis perspective. With flight 143, the sheer brilliance of the flying after the fuel ran out - plus the too-neat story of “it was all caused by metric / imperial conversion” can easily distract from the real lynchpin of the whole incident, which was as you say why the plane was flown with non-functional fuel gauges when that was contrary to the Minimum Equipment List for the aircraft. Taking off with blank fuel gauges was the core safety rule that was violated: the mistake with the unit conversions was necessary to make that violation dangerous but it wasn’t really the core of the accident.
- WalterBright 3y ago
  Nearly all airliner crashes are due to an unexpected confluence of multiple errors. If any one of the errors had gone right, nothing bad would have happened.
  - pfdietz 3y ago
    The "swiss cheese" model of accidents. When all the holes line up...
  - dctoedt 3y ago
    > If any one of the errors had gone right, nothing bad would have happened. IIRC, a cascade of human errors is also what happened at Three Mile Island and Chernobyl.
    - gcoakes 3y ago
      Wasn't there active attempts to hide the extent of the issue with Chernobyl which significantly worsened the damage? If so, that seems like saying there were cascading human errors in a murder-suicide. You're technically right on some level, but I wouldn't so much call that human error.
      - IIsi50MHz 3y ago
        I'd classify humans hiding it as an additional human error.
  - noah_buddy 3y ago
    It makes you wonder how many flights take off with several errors and mistakes every day.
    - ranger207 3y ago
      Probably most. Complex systems run in degraded mode as a matter of course. https://how.complexsystems.fail/ https://how.complexsystems.fail/

tailspin2019 3y ago

That was a gripping read!

mewse-hn 3y ago

[flagged]

q845712 3y ago
in my experience it is how both real and imaginary Canadians talk
- nvy 3y ago
  Usually when people parody Canadians they get the "eh" completely wrong.
DamnInteresting 3y ago
Author of the linked article here. If you're implying that I manufactured the "eh"s, you are mistaken, they were in the transcript of the cockpit voice recorder. If you are implying that I intentionally left them in for comedic value, I cannot argue with that.
- cf100clunk 3y ago
  Indeed, thank you for your attention to that detail. I would expect that cockpit recordings from Yanks would have plenty of sentences ending in "Huh?", as in "Ya remembered ta turn that switch off, huh?"
wintogreen74 3y ago
Sorry eh, but that's actually how we talk ya hoser.
- dredmorbius 3y ago
  Somewhat less prevalent in BC, or Quebec (francophones), but yes. It's often challenged my capacity to keep a straight face when it reaches self-parodying levels.
- WalterBright 3y ago
  I'll be honest with you, like, totally, gag me with a spoon, know whut I mean?

bc_programming 3y ago

The thing that gets me in the originally posted link is that the author decided since this was Air Canada, every single person involved must end their sentences with 'eh'.

joezydeco 3y ago

Cloudberg is the best but....wait a minute. This aircraft took back off again after refueling and repair?

mortenjorck 3y ago

I'd almost say the two make good companion pieces. DI's is a masterclass in nonfiction storytelling, while Cloudberg's is equally adept in its detailed, high-stakes procedural drama. It's an incredible enough event that it's worth reading both!

gcoakes 3y ago

I, for one, quite enjoyed the novelization of it. Especially the part about the space-irony continuum. My sleeping wife did not appreciate being woken up by laughter though.

RheingoldRiver 3y ago

That was a great article. It seems ridiculous to me that the pilots were punished for this given very specifically the unclear delegation of responsibility when automation was introduced. And if ignoring the MEL was a company culture issue, then it was a company culture issue, and you won't make the company safer by encouraging people not to reveal violations.

r00f 3y ago

There is one part in that article that I cant understand. It says: > ...when flight attendants opened the rear emergency exits, they found that the tail was so high in the air that the slides didn’t touch the ground. Sliding down them was less like schoolyard fun and more like jumping off the second or third floor of a building But then it proceeds showing a photo of deployed rear exit slides, and judging by human standing there they almost touched the ground, the difference is like half that human at most. Now, while I agree that jumping from 1 meter may be too much for some people, comparing it with 3rd floor jump is totally out of place. What am I missing here?

rattus_rattus 3y ago
I am guessing that the slides would swing backwards into a more vertical position if someone were to try to use it, because the bottom wasn’t touching the ground and thus preventing the swinging movement. This would then cause the slide to then be an essentially vertical drop instead.