According to the Preliminary Dutch Safety Board Report, “The Board is of the opinion that extra attention is needed for the role of the radio altimeter when using the automatic pilot and the automatic throttle system. The Board has issued a warning for Boeing today requesting extra attention to a part of a manual for the Boeing 737, in which is stated that in case of malfunction of the radio altimeter(s), the automatic pilot and throttle system that are connected to this may not be used for approach and landing. The Board would like Boeing to consider an investigation into whether this procedure is also applicable during flight. With the exception of the malfunction of the left radio altimeter the investigators of the Dutch Safety Board have not yet found any irregularities.
One question that remains now is how Boeing is going to follow up with the reminder for pilots to pay attention. Is this going to be handled with additional training or aircraft or procedure modifications? However–Boeing has said that the autopilot system is designed so that if it senses faulty data from the captain’s altimeter on the left side, the auto-throttle is supposed to switch to the altimeter on the right. In fact, AVweb summarizes it this way: ” The autopilot initiated a power-down of the engines in preparation for landing and the airplane slowed to near stall speed. The pilots responded to the situation too late.”
It seems to us like this is more of a problem of maintenance and pilot training at Turkish Airlines. How could the pilots not have noticed flying for more than a minute with no thrust?
We are eager to see what is going to be done to prevent a repetition of catastrophe. On Wednesday Boeing listed six warning signs that can alert a pilot that something is wrong with the altimeter. Maybe they should have included a Starbucks gift certificate for that extra jolt of caffeine-fueled pilot attentiveness.
The Dutch report indicates that the faulty radio altimeter initiated a sequence of events to which the pilots responded too slowly. The thing is that being a pilot means being aware. There is no margin for error.
Plus, any time I see that an automatic system did the thinking, it makes me pause: “the automatic system – with its engines at reduced power – assumed it was in the final stages of the flight.” If the autothrust/pilot starts to do something unusual, it is the pilot’s responsibility to disconnect it and fly the aircraft manually.
Another thing that seems crucial is the black box data:
“The black box – which can register 25 hours of flying time and which, in this case, covered 8 flights- showed that this problem had occurred twice previously in a similar situation, before landing.” It is crucial in conflicting ways. When it happened before, why was there no “crash” situation? How was it averted? (Probably the pilots flew in manually.)
And…if it happened before, doesn’t it make the faulty radio altimeter a “known problem” and therefore one which the carrier should have corrected before this plane ever went out again?
For those who survived, it really doesn’t matter why it happened.
The passengers–those who perished and those who were injured and those who lucked out and got away without a scrape (if there are any)–are innocents who purchased a ticket.
There’s no one on that plane who will ever board a plane again without thinking twice; some will suffer sleepless nights and develop phobias; and some have paid the ultimate price, losing their health, or their life.
Now they are owed a lot more than a refund.
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They say that time heals all wounds. And in a sense that may be true even for the families who lost loved ones in a plane crash, as long as we can interpret “healing” to mean that time eventually eases the sharpness of the pain of loss. And while that degree of healing is something that happens with people because our nervous systems are built for survival and allow us to adapt to even agonizing loss, the same thing is not true of mechanical equipment. While people bathed in time may get a little better, black boxes, radar components and computers that sit in salt water for a long period of time do not get better. In fact a scientist could present us a ratio of the time an item spends in ocean water : accessibility of evidence in terms of a diminishing ratio of accessibility. Or in other words, the longer evidence soaks in salt water, the more diminished our capacity to analyze it. Not that the same ratio applies across the board, of course–the frailty of paper in salt water is not the same as metal. And rice paper would differ from bond which would differ from cardstock. But in general, one can certainly say the longer evidence sits in the ocean, the more degraded that item will be. Ocean-time won’t heal evidence; but it sure helps damage or destroy it. So any evidence that we find now has been quietly degrading for almost 2 years.
So now we have the news that the fourth search for the black boxes has turned up something even more stupendous–they found identifiable remains. Great hosannas and praise by the submarine-load is being lavished by the audience of a world who is transfixed by the news. How amazing it is that on this fourth search for a needle in a haystack, after two years time and ocean currents, and countless storms and tides, with each passing moment making discovery that much less likely, after all this, a needle is found. But who is the world praising? The searchers, certainly. The searchers have as they say these days “mad” skills. But let’s not praise the sponsors of the search.
If not for the sponsors quitting, this discovery would have been found two years ago, or sometime between then and now. Because let us not forget the sponsors of the search, Air France and Airbus—both of whom could well afford to continue—have THREE TIMES quit. Quit the search, leaving key questions unanswered. Quit the search, the black boxes with their priceless knowledge, unfound. Quit the search, and left the families dissatisfied, and without closure.
Nevermind that this is such a timely find. Days after a judge takes the high road of French law and declares Airbus and Air France open to a criminal investigation for the crash of Air France 447, suddenly we have such a “feel good” media moment. Bodies found. Good job, searchers. Bad job Air France. Bad job Airbus.
If you had not given up, (and let’s face it, your reasons were purely financial,) what is lost would have been less dispersed by currents and time. And perhaps what is more important, the families would not be having their wounds reopened. Because these are not live family members found. This will not be true joy and true relief. This is just re-opening that sense of grief and pain, which is torturous after the anesthetic of two years. For those families whose lost are still lost. And for those families now able to receive their two lost loved ones, the grief and pain will be renewed. It will force them to relive the deaths all over again. Because even when they’re found, they’re still lost.
The question remains, why did you ever quit the search? This Pandora’s box of pain could have been closed and laid to rest by now, if you had not quit. Shame on you.
Costuma-se dizer que o tempo cura todas as feridas. Em certo sentido, isso até pode ser verdade para as famílias que perderam entes queridos em acidentes aeronáuticos, contanto que interpretemos essa “cura” como um alívio à agudeza da dor e do sofrimento. E embora esse nível de cura seja algo possível às pessoas porque nosso sistema nervoso é projetado para sobreviver, permitindo que nos adaptemos à mais agonizante perda, o mesmo não é verdade para equipamentos mecânicos. Ainda que pessoas banhadas pelo tempo possam ficar um pouco melhores, caixas-pretas, peças de radar e computadores abandonados em água salgada por um longo tempo não ficam nem um pouco melhor. Na verdade, um cientista poderia nos apresentar uma relação em função do tempo que um item permanece em baixo d’água, demonstrando uma taxa decrescente de acessibilidade das evidências. Em outras palavras, quanto mais tempo uma evidência fica submersa, menor é nossa capacidade de analisá-la. Isso não significa que uma mesma taxa se aplique a todas as evidências – é claro que a fragilidade do papel na água não se equipara à do metal. De modo geral, contudo, pode-se afirmar que quanto mais tempo um item permanecer no mar, mas degradado ele ficará. O tempo no mar não trará cura às evidências, mas certamente ajudará a danificá-las ou destruí-las. Logo, qualquer evidência que encontremos agora terá enfrentado uma lenta degradação por quase dois anos.
Agora somos surpreendidos pela notícia de que a quarta busca pelas caixas-pretas encontrou algo ainda mais estupendo: corpos que podem ser identificados. Graças e louvores pelas descobertas submarinas têm sido dadas pelo público mundial que se mantém atento às notícias. Como é incrível que nessa quarta busca de uma agulha no palheiro, já após dois anos, com correntes oceânicas e diversas tempestades e marés, e com o passar do tempo tornando qualquer descoberta cada vez mais improvável, uma agulha tenha sido encontrada. E quem está sendo saudado pelo mundo? As equipes de busca, com certeza. Elas demonstraram habilidades verdadeiramente fenomenais. Mas não vamos enaltecer os patrocinadores das buscas.
Se os patrocinadores não tivessem desistido, essas descobertas teriam sido feitas há dois anos, ou em algum momento entre a data do acidente e hoje em dia. Por isso, não vamos esquecer que os patrocinadores das buscas, Air France e Airbus, que bem podiam ter arcado com sua continuidade, abandonaram-nas por três vezes. Abandonaram as buscas, deixando importantes perguntas sem resposta. Abandonaram as buscas, deixando perdidas as caixas-pretas e suas valiosas informações. Abandonaram as buscas, deixando famílias insatisfeitas e sem uma conclusão.
Não importa que essa descoberta seja tão oportuna. Dias após um juiz aplicar os rigores da lei francesa e declarar que a Airbus e a Air France podem ser investigadas criminalmente pelo acidente com o voo 447 da Air France, temos de repente um “agradável” momento na mídia. Corpos são encontrados. Bom trabalho, equipes de busca. Grande falha, Air France. Grande fracasso, Airbus.
Se vocês não tivessem desistido (e, sejamos francos, seus motivos foram puramente financeiros), as perdas teriam sido menos dispersadas pelas correntes marítimas e pelo tempo. E talvez, ainda mais importante, as famílias não teriam suas feridas reabertas. Como não estamos falando do encontro de sobreviventes, essas descobertas não trarão verdadeiro alívio e verdadeira felicidade. Elas apenas servirão para recrudescer aquela sensação de dor e sofrimento, que é uma tortura após dois anos de anestesia. Para aquelas famílias cujos entes queridos não serão encontrados, e para as demais que agora receberão os restos de seus familiares, a dor e o sofrimento serão renovados. Isso as forçará a reviver as mortes mais uma vez.
Porque, mesmo encontrados, eles continuam perdidos.
A dúvida permanece: “Por que vocês desistiram das buscas?” Se vocês não tivessem desistido, essa Caixa de Pandora de dor já poderia ter sido fechada e enterrada a essa altura. Vocês deviam se envergonhar!
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While last night’s American Airlines Boeing crash landing in the Jamaican rain with limited visibility, with significant tailwinds on ungrooved pavement, with patches of residual tire rubber no less, was catastrophic for the plane, it is rather amazing that even though the Boeing was subjected to forces powerful enough to split the plane into at least three pieces, it neither caught fire, hydroplaned 10 more yards to end up in the bay, nor lost even a single one of the passengers.
An achievement in survival. A testament to piloting skill. Or maybe it is just an improvement in plane design.
I hope that someone out there is appreciating how different this crash is from the Tam (Airbus) crash in Brazil, where a bad landing in rainy conditions on an ungrooved surface was exacerbated by a malfunctioning thrust reverser, and the plane ended up crashing a perimeter fence, crossing a thoroughfare and causing a blazing fire that annihilated a warehouse across the street from the runway.
Someone more versed in plane design could explain the difference in dynamics between plane crashes; someone expert in runway physics could explain how the runway surfaces did or did not play a part, but that analysis will come later during the NTSB investigation.
For now, I predict that you’ll be seeing the powers that be blaming the pilots for breaking the airplane, rather than applauding the fact that no one died. There has already been at least one article blaming the crash on the fact that the pilots were in the 12th hour of their (up to )14 hour shift.
This is just a taste of the spin-doctoring to come. I’m sure we’ll see the crash “arm-chair” analyzed a dozen different ways, depending on the writer’s agenda. We will watch the groups lobbying for in-country maintenance flipping this story to blame it on out-of-the-country maintenance; the pilot fatigue people will be using this as a morality tale about long pilot hours; the Norman Manley International Airport improvement people will be talking about fixing runway surfaces or maybe doing other needed airport alterations.
For now, I think we should all spend a few moments taking a good hard look at the mess that used to be a Boeing 737-800. How did anyone live through that? In fact, everyone survived.
Some families in Jamaica will be hugging their loved ones just a little bit harder this season. Anyway you look at it, we had a little bit of a Christmas miracle this time.
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A plane wreckage is not simply trash. The wreckage is the story of the crash transcribed in twisted metal and broken gears, legible to experts who can read from it details that the layman can not determine. The wreckage is concrete evidence. Because damaged mechanics reflect forces that have acted on the plane, its legal and historical value is in its very tangibility: it is an actual record that can reveal the course of events, as well as being an important factor in determining the culpability of those involved.
Imagine, if you will, what would happen to paper records left to the mercy of passersby, out in the sun and wind and rain for fifty days. If the paper survives, anything written on it will be degraded by exposure to the elements. If anyone attempts to read it, their task will be 50 times more difficult. This is true whether the record is written on paper–or on crushed metal.
So why is it that the evidence in the Mangelore crash–the wreckage–was left to the elements for 50 days? Whose responsibility is it to maintain the evidence at its most accurate condition? What can be said about leaving evidence on the scene, in an area where the public has access, and/or allowing it to sit exposed to the elements for 50 days following the event?
This is not a crash like Air France Flight 447 where the greater mass of the wreckage is lost at sea, and if and when any evidence is found, it will have been inadvertently degraded by exposure that is beyond anyone’s control. In the causal relationship between conduct and result, in the Mangalore crash, who is responsible for maintaining the quality of the evidence so that it maintains its forensic value, especially in a crash within meters of the runway in a known and navigable area? Is there a chain of responsibility? Is that responsibility safeguarded from possible intrusion, alteration or negligence by vested parties? Is safeguarding the forensics the responsibility of the airline or its insurers? Because, while the airline has hardly any experience dealing with such details, its insurers have a long history of dealing with evidence in aviation cases. Is there not an obligation in the vested parties to maintain the forensic value of the evidence?
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Rolls said in a statement that the failure was confined to a specific component in the turbine area of the engine. This caused an oil fire. The British company added that it would replace the faulty part. Safety continues to be Rolls-Royce’s highest priority. See their statement
Qantas is grounding its Airbus A380 superjumbos until further notice, and Singapore Airlines is grounding 3 of its A380s. EASA is calling for inspections. See the directive.
What Happened
The cause of the Rolls Royce engine failure has been pinned down to a faulty bearing box, the underlying cause of the oil leak. The bearings allow the drive shaft to move. The leaking bearing box dripped oil into the QANTAS A380 whose engine exploded (uncontained) into the wing, and dropping its turbine onto a house in Batam. The wing damage included electrical cables and hydraulic lines inside the wing, so that pilots were dealing with hydraulic damage (inability to close the landing gear doors), and electrical damage (trouble shutting down the engine beside the damaged one.)
The Qantas meltdown is one of at least five documented A380 engine malfunctions.
Qantas A388 near Singapore on Nov 4th 2010
Lufthansa A388 near Frankfurt on Aug 6th 2010, engine shut down in flight
Emirates A388 near Zurich on Jul 13th 2010, engine shut down in flight
Singapore A388 near Krakow on Sep 27th 2009, engine shut down in flight
Singapore A388 near London on May 25th 2009, engine failure
Newer Trent 900 engines have a different bearing box. Although the new box promises to eliminate the problem, newer models also have system software to shut down the engine before the leak causes a meltdown similar to the QANTAS A380 event over Singapore.
George’s Point of View
Although one might say that regulators did not adequately check the engine before approving it for commercial use, I think of Boeing’s response to its recent 787 test flight, and I point out that no one made Boeing step back and pull the 787 back on to the drawing board for more tests and adjustments. Boeing did that, because such remediation is what testing is all about. It is part and parcel of the paradigm of safety in design. It is up to each manufacturer that every item off of their assembly lines be as well designed and as safe as humanly possible. This includes fixing design flaws as soon as they are known. So I wonder, if newer Trent 900 engines have an improved bearing box, this of course begs the question why the older ones were not replaced.
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When we are working on a case trying to get compensation for victims of a crash, we find that the court relies on friends and family to paint a picture of who the victim was, and how they used to fit in the world. Of course we all know that every human being is priceless; but it is the court’s duty oftentimes to put a numeric value on a person for the sake of compensation. Some courts can be remarkably indifferent to individuals. I was reminded of that truism when reading the word-pictures rendered by the boyfriend of one of the Kazan Airport Crash victims, Yana Baranova …”an incredibly focused and mature businesswoman. Her colleagues describe her as a “rising star” of their industry, and her drive would have doubtless carried her beyond her own expectations….” He barely glances over this description of her, but in his words, we do see the snapshot of a vital young woman lost in her prime.
Yana’s boyfriend is unaccustomed to dealing with the Russian bureaucracy, and refers to “indifference and a lack of surprise boarding on apathy” and officials who write off that attitude with “This is Russia.” As this young man notes, my experience too has been that Russian courts that can be apathetic.
It is true that the opposite of love is not hate; it is apathy. Elie Wiesel said that, and it is true. Apathy is the callus that has formed—like a healed blister over an injury— thickened, hardened, insensitive tissue formed over a wound to protect it. Over time, it may become expedient for an official not to stop and feel the pain, but it is a tragedy when that happens. Something of humanity is lost. When dealing with government and the courts, one has to remember that they have seen it all, not once but a hundred, a thousand times. Their souls are probably more blistered than your worst blistered feet in new shoes with no socks, worn day after day, in grueling conditions. No wonder they are calloused, insensitive, even hard. It is a grievous fact that too often robes of government, of jurisprudence, which should be worn to empower and embrace the rights of man and the rule of justice are often worn as shields and blades against the individual. For the law to work at its best, it should be objective, but never sacrifice sensitivity to the victims, or the families of the victims.
Sometimes it is up to our lawyers to remind the courts that the best and brightest of the legal profession went into the field because they were idealists who love the law; who stepped into their professions because they wanted to spearhead change for good, rights of man; who probably had specific agendas where they wanted to affect change; who believed they would be more effective than they are; who ran into barrier after barrier and who may have given up; who may have substituted apathy for the appearance of objectivity.
After consulting for forty years on a huge variety of cases, maybe I haven’t seen it all, but I’ve come pretty close. I can’t claim to have a crystal ball, but there’s not a whole lot that surprises me. I’ve developed a pretty good instinct about where and when courts go left instead of right.
In the US, our “rights-based” ethics system means that we all have the right to be treated as equal to others. Other countries may have “utilitarian ethics based on “good outcomes” vs “bad outcomes”, often with the rights of the individual getting crunched somewhere under the wheels of the system.
We can only hope to do our best to represent the individuals who were lost. We can only do our best to remind those who sit in judgement that underneath the armor and callouses we all wear to protect ourselves from being fragile in the face of all the storms of life, that we are all human, all deserving of hope, concern, and ethical treatment.
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Problems with airspeed indicators led to excessive speed for the Air France A330, triggering the sequence of events leading to the crash. Blame it on pitot tubes. If the pitot tubes froze up during the storm, pilots would get mis-readings on their speed, accelerate, and subject the plane to stresses the structure was unable to withstand.
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