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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
by 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 agoNearly 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 agoThe "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 agoWasn'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 agoI'd classify humans hiding it as an additional human error.
- noah_buddy 3y agoIt makes you wonder how many flights take off with several errors and mistakes every day.
- ranger207 3y agoProbably most. Complex systems run in degraded mode as a matter of course. https://how.complexsystems.fail/ https://how.complexsystems.fail/
- gcoakes 3y agoLooks at dmesg... "Heh, how is this thing still running?"
- WalterBright 3y agoI have no direct knowledge of this, but I'm sure it happens all the time. It's just that there's a lot of redundancy in all aspects of flight operations. For example, there are two pilots. One pushes the buttons, the other crosschecks it.
- KyleSanderson 3y agoIf you fly Air Canada, they'll have you believe that a single light in one of the three the restrooms is a critical safety concern, and that's the reason for your 6 hour delay without compensation.
- WalterBright 3y agoIf it's the smoke detector light, that is a critical safety concern.
- ineedasername 3y agoIt reminds me of the Swiss Cheese theory regarding the failure of any system: https://en.m.wikipedia.org/wiki/Swiss_cheese_model https://en.m.wikipedia.org/wiki/Swiss_cheese_model