George’s Point of View
Time goes by quickly but not quickly enough when you are dealing with grief and mourning a loved one. Was it only two years ago? In 2007, on July 17, 187 people in Porto Alegre boarded a Tam Airlines Airbus A320. For six of them, it was just another day at work. 187 of them had plans in São Paulo, Brazil. There were also a dozen others already in Sao Paulo who were going about what they thought would be a normal day–but it was the last day of their lives.
On July 17, people filled out their date books, never knowing it would be for the last time. They made phone calls, packed suitcases, shook their heads over the rising cost of gasoline.
On July 17, husbands and wives and children parted at their doors or at the airport, said their goodbyes, had hugs and kisses as they went off to work, on business trips or on vacation, never knowing that this kiss, this hug, this goodbye was the final goodbye.
I know these families. I have sat in rooms with you, listening to your voices break as you recall those you lost. To many people, July 17 may be just a day, but as for you, I have seen on your face tears that will never dry. Those who were lost on that Tam flight will always be remembered on this sad day. President Lula may have ordered four days of mourning, after which the rest of the world moved on; but there are 199 families for whom the days of mourning will never end.
For you, July 17 will always wear a face.
What is there to say to those 199 lives that have left holes in the world?
We remember you. We remember you. We remember you.
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Airbus Design Flaws Forced Pilots into Bad Decisions
In George’s Point of View
In the operation of the Airbus 330, a percentage of man-made decisions are taken away from humans in the cockpit. When you closely consider the Air France Airbus Flight 447 crash, it is easy to see that bad pilot decisions occurred when the pilots were not getting accurate feedback about what was happening. In old programmer lingo, this is “garbage in-garbage out.” And, unfortunately, when the data comes out of a computer, people tend to believe it, especially pilots in a falling plane, whose lives rely on that particular “garbage.”
Sure, mistakes were made. The pilot retired, leaving the cockpit to the copilots. If he had stayed in the cockpit, none of this would have happened.
Of the two remaining co-pilots, one still should have realized the other’s mistaken attitude (flying at a nose-up attitude with falling speeds.) Even something as basic as tandem cockpit control (where the flight controls move in tandem in the left and right cockpit), would have revealed to the second co-pilot what the other pilot was doing. But cockpit controls in the A330 are asymmetrical, and move independently.
If one co-pilot had caught that the junior co-pilot was flying at the nose-up attitude while the speed was dropping, none of this would have happened.
Not only did the failure of pitot tubes (the malfunctioning equipment that reads/relays airspeed) occur when they iced up, any failsafes that should have kicked in, didn’t. Thales Pitot tube icing was a known factor prior and considered by Airbus an “optional” fix. Because these tubes were frozen (iced over) airspeed data was incorrect.
If Airbus had demanded that the flawed Thales pitot tubes be replaced, the airspeed data would have been correct, and none of this would have happened.
The plane flew for a while with falling speeds, nose up. Then, the idiosyncrasy of the stall warning alarm system kicked in. When airspeed slowed too much, the warning went off, but when it slowed even more, it stopped. The pilots were in a feedback deadzone. Flying at a crawl, the warning quit. Speeding up from a crawl to slow turned set the warning off again. So when they tried to increase to the proper speed, the stall system went off.
If the stall warning system had been calibrated to go off at dangerously low speeds and keep going off until proper flight speed was attained instead of indicating to the pilots that they were wrong to increase the speed, then none of this would have happened.
It is a given that correct data and feedback are essential to a pilot. In the Airbus 330, the underlying design failed to provide accurate data and feedback. Could any pilots fly a plane if they did not know what is happening? It all comes down to a whole integration of synchronicity: a coetaneous concurrence of problems and failures converged on the pilots at once. Pilot error alone does not a crash make. Not even on an A-330.
The Callous Abandonment of Air France Flight 447
It’s difficult for me to comprehend why we cancelled earlier searches. I’m certain we do not have any new technology now that we didn’t already have 2 years ago. The subs used have been gradually fine-tuned, but not significantly in the past two years.
It is common knowledge now that the Woods Hole Oceanographic Institute team, running a couple of AUVs (Autonomous Underwater Vehicle) Remus 6000’s were barely a week into the fourth search when they discovered the location of pieces of the wreckage of the fallen Airbus, flight 447 in an area thought of as an underwater “Himalayas”. Mike Purcell, Senior Engineer of the Woods Hole team, has attributed the discovery to the ability of the Remus being able to submerge to 6000 meters (which means being able to follow the underwater mountain range cliffs, ravines, and slopes); and to the decision to start close to the last known position of the plane.
I do wonder why this was the fourth search; there should have been only one— a single search that continued until the wreckage was found.
Maybe there is no correct time to be critical, and if I am critical, it is not of the search team who did a splendid, if not all but impossible job, in finding the wreckage. It is entirely the human effort that made the difference, because although the AUVs are autonomous, they are not truly intelligent. They had to be daily programmed, and with three units running, this means three times the (sonar) data had to be daily downloaded, processed and analyzed. The team learned how to deal with managing the challenging demersal topography, and reading the visual output which were sonar abstractions that look like etch-a-sketch scribbles. The expert on board analysts had 15 years of experience in interpreting this data.
For the search team, I have only praise.
My point of criticism is for the decision makers, and it is founded on behalf of concern for the families.
We are hearing how well preserved the remains were, due to the temperature and water pressure. We are hearing about how only some of the remains were retrieved.
Why only some?
All the bereaved families should have the right to retrieve their loved ones. All of the families should have the right to place their loved ones in a known and tangible resting place.
It is a chilling callousness on behalf of the planners to advise their team to knowingly leave behind even so much as a single hair, if that hair was known to be that of one of the victims. The decision betrays a chilling callousness; an act of deliberate abandonment. It reminds me of those all fallen into a “deep place…where the sun is silent”, in Dante’s hell. “Abandon all hope, all ye who enter here.”
And now, we’re back to where we started, only worse. Many bodies were not recovered. Are they lost forever?
I can all but guarantee you that the future holds some grisly Titanic/Disney-esque treasure-seeking macarbre (or sugared) revisitation of the tragic ground, private touring expeditions seeking out the latitude and longitude, with camera, wallet, and catching net in hand. Movie rights and treasure hunters-a marriage made in hell, or Hollywood.
This is no Dante’s tale. For the bereaved families there will be no poetic justice. They will live knowing forever that their loved ones were found…came this close to being returned…and left behind, if not in the nine circles of hell, then across the oceans in that “deep place…where the sun is silent” and all hope abandoned.
The NTSB Sends Two Alerts on the 787 Post Flight Fire in Boston
First, it does appear that there were two different 787 events at Logan. One was a fire that came about due to overheating and explosion of a battery in a lower bay. Both of the reports below refer to the same event, which grounded the plane. The second event was either a fuel leak or overfueling, which only delayed and did not cancel a different flight four hours while the problem was fixed.
My criticism is that it APPEARS we are moving too quickly because what is surfacing are minor events that could lead to major events. A battery fire could cause a plane crash, especially on a transatlantic flight. I would like to feel confident that Boeing will easily handle any battery or electrical problem as one of those new plane new plane glitches that one might consider teething. And if this problem “dogs” Boeing shares (as one headline indicates), then better that it dog shares than kill 400 people.
Here are the NTSB press releases regarding the Dreamliner Battery Fire. The first one…
NTSB INVESTIGATORS LOOKING INTO BOEING 787 SMOKE EVENT IN BOSTON
Jan. 7, 2013
WASHINGTON– Investigators with the National Transportation Safety Board are gathering information regarding reports of smoke aboard a Boeing 787 at Boston’s Logan Airport today.
The Japan Airlines 787 was on the ground and empty of passengers at the time of the incident.
The NTSB has dispatched an investigator to Boston. Based on a review of the factual information gathered, the NTSB will determine the extent of its investigation.
and the second one…
NTSB PROVIDES INVESTIGATIVE UPDATE ON BOEING 787 FIRE INCIDENT IN BOSTON
Jan. 8, 2013
WASHINGTON – The National Transportation Safety Board today released an update on its formal investigation of Monday’s fire aboard a Japan Airlines Boeing 787 at Logan International Airport in Boston. There were no passengers or crew on board at the time. One firefighter received minor injuries.
In addition to an investigator already on scene who visually inspected the airplane last night, the NTSB has sent two additional investigators to Boston and formed investigative groups to look at airworthiness and fire and airport emergency response. Senior Air Safety Investigator David Helson has been designated as the investigator-in-charge.
Parties to the investigation are the Federal Aviation Administration and The Boeing Company. In addition, the Japan Transport Safety Board has appointed an accredited representative and Japan Airlines will assist the JTSB as technical advisors.
Initial investigative findings include:
• The NTSB investigator on scene found that the auxiliary power unit battery had severe fire damage. Thermal damage to the surrounding structure and components is confined to the area immediately near the APU battery rack (within about 20 inches) in the aft electronics bay.
• Preliminary reports from Japan Airlines representatives indicate that airplane maintenance and cleaning personnel were on the airplane with the APU in operation just prior to the detection of smoke in the cabin and that Boston Logan Airport Rescue and Fire Fighting were contacted.
• Rescue and fire personnel and equipment responded to the airplane and detected a fire in the electronics and equipment bay near the APU battery box. Initial reports indicate that the fire was extinguished about 40 minutes after arrival of the first rescue and fire personnel. One firefighter received minor injuries.
Here is the 2nd NTSB Press Release: