You are Not Alone!
Yesterday I spoke with the FAA and the subject of the ASAP program became a topic of discussion. The FAA investigators I spoke to, do not have access to these events. One of the inspectors said that ASAP was a successful program because of the anonymity.
I asked, "Is it?"
What indication identifies
ASAP is a Success?
I proceeded to explain the numerous events that could have been complete hull losses, as they came within seconds of impact and the associated fixes that did not address the underlying problems. I explained that ASAP reports were at an all time high, and the fixes at an all time low. I shared that a retired FAA prosecuting attorney, who is now an Administrative Law Judge, held the same concerns regarding rise of ASAP reports without the associated fixes.
Pilots need not be concerned, the FAA will not prosecute pilots for human factor errors. Unfortunately, it appears the ASAP program may be protecting airline management, as the root cause of the major incidents are due to substandard training, scheduling related events resulting in fatigue, and known mechanical deficiencies. These events won't be adequately addressed, because of the ASAP program. Those who could enforce airline compliance are not allowed to see what is really happening.
Point in example. The exact events that took down AF447 and the MAX crashes had occurred prior to those crashes and were reported as ASAP events. Nothing was done until after the same events resulted in crashes, where 574 people lost their lives. What about the Colgan Air crash of 2009, how many ASAP reports could have predicted that event?
Tuesday's post was about Reporting Culture versus an ASAP program. But also, how to report safety concerns and how to protect yourself if the company decides to take action against you. You are not alone, so please don't fear trying to make the system safer for all.
Accidents are not Surprise Events
They could have been prevented
But they are hidden by the ASAP system
"Status quo is Latin for, 'The mess we're in.' "
Ronald Reagan
Enjoy the Journey
XO Karlene
All of the crashes you mentioned have commonality of cause which, you are correct, is not being adequately addressed. Redundancy of sensors. Having multiple and backup sensors is still the preferred solution to failed or erroneous sensor data. However it is left to the flight crew to troubleshoot a problem caused by faulty sensor input to aircraft systems. As aircraft systems have become more computer controlled, they have also become much more complex for both aircraft mechanics and pilots to troubleshoot.
ReplyDeleteThis is a new problem. I recall one of my experiences as a very young aircraft mechanic while in the Air Force. I was a hydraulic and pneumatic system mechanic on a temporary (TDY) assignment to Germany in 1975. Because I didn’t have any work to do, I offered to help out an avionics mechanic work on air data system failures on C-141A cargo planes one day, when I couldn’t resolve a problem using the techniques he had taught me. Air data systems then, were pretty sophisticated for the time. But basically the same as those s used today in the 21st century. A digital computer takes inputs from mechanical sensors and processes it for display to the pilots on the flight deck. It was sophistical enough even then to offer built in testing (BITE). But, it wasn’t sophisticated enough to identify some of the possible failure modes that could render the air data system inoperative. Usually, the problem was caused by the air data computer itself, which could be remedied by removing and replacing the air data box itself. One day, after performing the typical ground tests, replacing the air data computer did not fix the problem. Even putting the old box back in place, thinking it might be an electrical connector pin problem, did not help this time.
My point here is that finds ng a fault with a sensor is still not as good as it should be. For at least on of the 737MAX accidents, a faulty sensor was not revealed prior to the accident flight.
Also, if you recall, at least two 757 accidents happened because of a insect-plugged pitot tube, and the other resulting from taped over static ports. both of these accidents created contradicting warnings in the flight deck which confused the pilots. Both those accidents also occurred an low altitudes during the initial climb.
The only flight crew information improvements was the institution of unreliable airspeed crew procedures. Which before than, we’re not even included as emergency checklist items. Today, there is a memory checklist procedure that can be used to deal with erroneous airspeed faults. The effects of such faults on highly automated aircraft systems is still only minimally included in crew training. instead, pilots mostly must rely on learning from how other crews did or did not respond to system system failures. Is this really the best way, sometimes even the only way to train pilots about sophisticated aircraft systems? It seems so, because after fifty years, we still rely on the experience of mechanics and pilots acquired by on the job skills.
Why have the aircraft manufacturers incorporate intelligent troubleshooting software in some of these flight critical aircraft systems that can automatically detect a faulty sensor and then inhibit its ability to output faulty or erroneous data to other critical aircraft systems? What can be done if multiple erroneous sensors are the problem (AF447)? Simply turning off the automation and flying the airplane manually isn’t always as innocuous solution in a critical phase of flight. Especially when the pilots are still subjected to contradictory warnings. There must be a better way to design out these kinds of problems.
Thank you for a great comment. That's a great idea about the trouble shooting! They have done this with the fly-by-wire aircraft. The computer aircraft today, run tests on themselves to identify pre-departure problems and enroute. My A350 will diagnosis itself and gives pre warnings if something has failed. Then enroute, it will tell us if the system is not feeling well...not out of limits...but working that way. There are warnings for awareness. For needed action. But, I think giving pilots all the tools to understand the systems and how to handle them if they do fail is the key. But also, if there is a redundant safety feature available, that should not be an option for the airline to decide against or not. If it's available, the FAA should mandate it. Then financially, everyone is on the same playing field. And safety doesn't become a choice. Thank you for the great comment!
DeleteYes, the would be a great idea. But it always boils done to costs. Costs to the customer, or profit centers for the manufacturer. Boeing makes literally millions of dollars offering non-regulatory required options to the customers who must take the time and make the effort to decide whether these options are beneficial or cost effective for them. Or, whether adding them will impact training costs. It is for this very rational decision making that Boeing is selling and certain customer airlines are still buying the 737 some 60 years after it was first developed. Engineers are tainted by the phrase “is a certain piece of new technology capable of buying its way onto the airplane?”. Or in other words, does the new technology offer cost benefits commensurate with the technology benefits? or, even more simply, is it worth spending extra money to have?
ReplyDeleteAs you say though, technology that is smart enough, intelligent enough to tell us humans whether it is working as it should is a great benefit to both safety and on time operations. But how much is the customer airline willing to pay for that technology? At some point all this new technology should be made mandatory by regulations that are intended to guarantee flight safety. But if the regulators are not informed enough to know these technologies need to be made mandatory, then what happens? It’s the ultimate chicken and the egg problem...which should have the priority?