Thursday, April 30, 2009

Fast Finger Freddy strikes again

Wrong computer numbers caused Emirates jet to almost crash at Melbourne Airport

Tail Strike -A6-ERG, Airbus A340-500, Melbourne Airport, VIC, 20 March 2009

I didn't initially realise just how serious this incident was. According to the preliminary report the aircraft didn't actually start climbing until 300 metres past the end of the runway, taking out a strobe light and two radio transmitters along the way.

Friday, April 17, 2009

Systems failure, not people failure

Triple-0 sarcasm a 'disease'

This is a tragic case, and I don't presume to know all of the technical details, but I can see a parallel with many tragic aviation incidents. There were many factors that lead to the death of David Ireland, but I am of the opinion that the attitude of the 000 operators was just a link in the chain of events, rather than the root cause.

Firstly, the majority of 000 calls are dealt with professionally and effectively - these calls were not. Why?

I would hazard a guess that the prank or hoax calls that 000 receives must make the operators cynical whenever they receive a call which is out of the ordinary and for which details are scant, which is certainly the case here. The caller was on a mobile, in the middle of nowhere, not knowing where he was, cutting off calls abruptly when his signal dropped out, shouting to make himself heard - all behaviours which might make an operator think 'prank.'

The operators are city based, and in an urban setting it is easy to forget that out in the bush, services, streets, all sorts of 'normal' facilities simply don't exist. I fly into many country airports where there is no pay phone, no internet, no radio or phone reception, no nothing. The city based air traffic controllers can be a little sarcastic when you try and lodge a flight plan in the air or get some met info, simply because they forget that some places still exist without curb guttering and coffee shopes every ten feet.

Judging for the article the operators follow a script of sorts, inputting information into a computer system which allows them to communicate the relevant details to the emergency services. Where the system fell down was where they had received a call where none of the information matched that allowable by the computer system. As far as it was concerned there was no emergency. Furthermore the information they collected did not get to the search parties quickly enough, because there is an unspecified impediment to emailing it, it had to be printed and presumably delivered to where it wss needed by hand.

He agreed the behaviour of three operators was worthy of an internal investigation and possible action. Two operators had been "counselled" about their behaviour.

This is dodging the issue. I can only imagine the guilt these operators feel, admonishing them is unlikely to fix the problem now or in the future. All blaming the operators is likely to do is make the guy at the top look like he is taking action. Until the inherent failings in the system are acknowledged and corrected all that will do is delay the inevitable - history repeating itself.

Monday, April 13, 2009

The Easter Bunny meets an unfortunate end.

I have some bad news, kids. The Easter Bunny went to visit Santa Claus and, uh, well...

Wednesday, April 08, 2009

Pilot found guilty, all other parties try to look innocent

Despair as Garuda pilot gets two years

I'm not a lawyer, so I'm not going to get into the appropriateness of the sentence or anything else, but I'm personally of the opinion that justice was not fully served and that aviation in Indonesia is not substantially any safer than before the Garuda incident.

My reasoning is that aviation accidents rarely, if ever, have a sole cause. This incident is no different. The poor decision making of the pilot was merely one link in the chain of events, one more hole in a slice of swiss cheese that resulted in the deaths of 21 people.

Where, for example, were the aerodrome operators, the airline executives, the regulators who were, in some way, also culpable for the incident?

AE-2007-015: Boeing 737-497, PK-GZC; Adi Sucipto Airport, Yogyakarta, Indonesia; 7 March 2007

The aircraft exceeded its speed limit of 250 knots below 10,000 feet, air traffic control either had no way of identifying this, or chose to do nothing.

The 1st officer did not appear to have been given the required simulator checks by the airline.

The regulator, the DGCA, had only conducted two safety audits of the airline during the previous ten year period. Most general aviation flying schools in Australia get audited more regularly than that, usually once a year.

The fire-fighting units were dispatched to to the crash site, only to find themselves trapped behind an airport perimeter fence 130 metres away. The fire-fighting units themselves did not comply with ICAO recommendations, and even if they had been able to get past the fence, were ill-equipped to perform the task required of them.

Garuda took 33 hours to provide the cargo manifest to authorities - so long, in fact, that it negated the whole point of providing it in the first place.

The runway itself did not meet ICAO standards, and the DGCA had failed to notify the ICAO of this difference.

The flight data recorder did not record all of the parameters it was required to record, as the unit was a digital unit, and unable to record the analogue input.

Pilot guilty, but is flying in Indonesia any safer?

The answer appears to be a little, but not much. The EU has still banned Indonesian airlines from flying in EU airspace, a step Australia appears unwilling to take, probably due to political considerations.

The conclusion that I draw from all of this is; until a blame culture is overcome, until there is a willingness to acknowledge inadequacies, the system cannot be substantially improved. This is true of all organisations, in all fields. Burying ones head in the sand and ignoring criticism only delays the inevitable.

The was pilot error involved in this incident - but the root causes went much deeper.