The Atlantic Glider. Some final notes
Joined: Sep 2001
Posts: 356
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From: 38N
Spy
We can go-round some more on this when the official report is published. A problem with discussion in a substantially fact-free environment is that the same hypothetical oil keeps lubricating increasingly circular commentary.
On the surface of it, the misuse of crossfeed - for a long enough interval to sacrifice the critical fuel reserve - seems like a rookie oversight. Surely there is a very specific explanation for this - which we do not yet know as a matter of fact.
Other than for passing time in idle chatter, the interest in understanding the underlying failure of performance of the aggregate process is directed toward improving systems - whether mechanical or electronic or human - to lower the probability of a similar or analogous reoccurrence. Since the frequency of events like this is mercifully low, each one deserves a great deal of attention and introspection before the 'causes and effects' account is closed out.
Your explanation tends to focus on a presumed defect of skill or character or alertness on the part of the two flying crew members. While that may be correct, at some level, it is also true that all humans are prone to occasional excursions away from perfection in the conduct of their duties. That is the main reason we strive so hard to wrap multiple levels of systems redundancy around humans who are working in critical-path processes. Somewhere, somehow, one or more of those protective envelopes has failed dramatically here - with the drama heightened a bit by the cool and focussed way the crew handled and resolved the final mess they were in.
I find it particularly interesting to consider whether the 2-person ETOPS crew had adequate resources to identify and diagnose their problem in the time that was available. The facts seem to show they didn't. Your position, if I may presume to restate it, is that they "should have" been able to solve the problem with the means at hand. But one round in the chamber trumps ten on the shelf: the fact they did not resolve it as you suggest says prima facie they lacked some critical insight or datum at the moment of need.
Historically, pilots have had to work with a a chronic shortage of information about what is happening inside their aircraft, along their flight path, with weather, traffic, etc. Just quite recently the tables have turned so that vast amounts of information are available - in very current form. The connundrum has shifted in a span of decades from figuring out how to make up for missing data to figuring out what portion of a mountain of data to use and which to ignore. Perhaps this is a pivotal factor in the uninterrupted progress of Air Transat incident?
The extent to which the flying crew can also be maintenance technicians is controlled by the quality and fitness-to-task of the tools available and also by the mindset of the individuals. The perspectives of the decisive aircraft Commander versus the skill-rich and very time-sensitive Pilot versus the plodding but persistent diagnostic Technician are somewhat mutually incompatible in exactly the sort of circumstances that occurred. The pre-dawn hour and mid-ocean location provided a near worst-case scenario for access to ground-based backup resources, complicating matters further. In any what-if scenario one can cook up, the cycle probably could have been interrupted for a more favorable result if a highly-skilled and authoritative 3rd party or team could have gotten inside the process by radio and telemetry early in the situation.
What-ifs abound here. This incident was/is both symbolic and symptomatic of the transition from one era of aviation to another. It would be an opportunity wasted to write it off simply as a 1-dimensional bolix.
We can go-round some more on this when the official report is published. A problem with discussion in a substantially fact-free environment is that the same hypothetical oil keeps lubricating increasingly circular commentary.
On the surface of it, the misuse of crossfeed - for a long enough interval to sacrifice the critical fuel reserve - seems like a rookie oversight. Surely there is a very specific explanation for this - which we do not yet know as a matter of fact.
Other than for passing time in idle chatter, the interest in understanding the underlying failure of performance of the aggregate process is directed toward improving systems - whether mechanical or electronic or human - to lower the probability of a similar or analogous reoccurrence. Since the frequency of events like this is mercifully low, each one deserves a great deal of attention and introspection before the 'causes and effects' account is closed out.
Your explanation tends to focus on a presumed defect of skill or character or alertness on the part of the two flying crew members. While that may be correct, at some level, it is also true that all humans are prone to occasional excursions away from perfection in the conduct of their duties. That is the main reason we strive so hard to wrap multiple levels of systems redundancy around humans who are working in critical-path processes. Somewhere, somehow, one or more of those protective envelopes has failed dramatically here - with the drama heightened a bit by the cool and focussed way the crew handled and resolved the final mess they were in.
I find it particularly interesting to consider whether the 2-person ETOPS crew had adequate resources to identify and diagnose their problem in the time that was available. The facts seem to show they didn't. Your position, if I may presume to restate it, is that they "should have" been able to solve the problem with the means at hand. But one round in the chamber trumps ten on the shelf: the fact they did not resolve it as you suggest says prima facie they lacked some critical insight or datum at the moment of need.
Historically, pilots have had to work with a a chronic shortage of information about what is happening inside their aircraft, along their flight path, with weather, traffic, etc. Just quite recently the tables have turned so that vast amounts of information are available - in very current form. The connundrum has shifted in a span of decades from figuring out how to make up for missing data to figuring out what portion of a mountain of data to use and which to ignore. Perhaps this is a pivotal factor in the uninterrupted progress of Air Transat incident?
The extent to which the flying crew can also be maintenance technicians is controlled by the quality and fitness-to-task of the tools available and also by the mindset of the individuals. The perspectives of the decisive aircraft Commander versus the skill-rich and very time-sensitive Pilot versus the plodding but persistent diagnostic Technician are somewhat mutually incompatible in exactly the sort of circumstances that occurred. The pre-dawn hour and mid-ocean location provided a near worst-case scenario for access to ground-based backup resources, complicating matters further. In any what-if scenario one can cook up, the cycle probably could have been interrupted for a more favorable result if a highly-skilled and authoritative 3rd party or team could have gotten inside the process by radio and telemetry early in the situation.
What-ifs abound here. This incident was/is both symbolic and symptomatic of the transition from one era of aviation to another. It would be an opportunity wasted to write it off simply as a 1-dimensional bolix.
Joined: Nov 2000
Posts: 142
Likes: 47
From: Montgomery, NY, USA
Arcniz hit it on the head;
"The connundrum has shifted in a span of decades from figuring out how to make up for missing data to figuring out what portion of a mountain of data to use and which to ignore. Perhaps this is a pivotal factor in the uninterrupted progress of Air Transat incident?"
As someone who has spent 25+ years in the information technology industry, I can attest to the fact that this is precisely where computer technology is falling short, if not burying us. We are confronted with information overload at a growing rate. Email, voicemail, all of the warning beeps from your Ipod, PDA, VCR, DVD, microwave, HDTV, etc. Your PC and the wonderful world of Windows. We wind up staring at the device wondering what the heck it is thinking, and usually powering it off and on to fix it. The trouble is that when you do this in an aircraft, you are wasting precious time. The problem in this incident, IMHO, was either information that was not presented in a purely logical fashion, or there was not enough training (procedures)for the crew to decipher it.
Computer technology in aircraft does not have the luxury of time that its ground-based counterparts have. There can be no confusion factor. Confusion can only be eliminated in extremely accurate design and clear, conscise training. That responsability falls on both the manufacturer and the airlines.
"The connundrum has shifted in a span of decades from figuring out how to make up for missing data to figuring out what portion of a mountain of data to use and which to ignore. Perhaps this is a pivotal factor in the uninterrupted progress of Air Transat incident?"
As someone who has spent 25+ years in the information technology industry, I can attest to the fact that this is precisely where computer technology is falling short, if not burying us. We are confronted with information overload at a growing rate. Email, voicemail, all of the warning beeps from your Ipod, PDA, VCR, DVD, microwave, HDTV, etc. Your PC and the wonderful world of Windows. We wind up staring at the device wondering what the heck it is thinking, and usually powering it off and on to fix it. The trouble is that when you do this in an aircraft, you are wasting precious time. The problem in this incident, IMHO, was either information that was not presented in a purely logical fashion, or there was not enough training (procedures)for the crew to decipher it.
Computer technology in aircraft does not have the luxury of time that its ground-based counterparts have. There can be no confusion factor. Confusion can only be eliminated in extremely accurate design and clear, conscise training. That responsability falls on both the manufacturer and the airlines.
Alba Gu Brath
Joined: Oct 2000
Posts: 745
Likes: 3
From: Merseyside
just to pick up on one of arcniz's points:
Is technology leading us down a road of ignorance and blind faith in the software we all use day after day? It is not that long ago that even the most advanced machines in the world were controlled by levers and pullies. The average human being was brought up with a reasonable understanding of how things worked (pull this and that goes up technology). A large number of people (particularly men) took pride in the fact that they knew how the internal combustion engine worked and could strip and re-assemble one. A lot of this knowledge has been lost due to the fact that the car engine is no longer 'user maintenance friendly'. Who would consider changing their own brake pads these days? Not only are we becoming a service industry driven world, we are developing a service industry mentality, i.e. if it breaks buy a new one or get someone else to fix it. The days of people being able to fix things themselves would appear to be disappearing into history.
Whilst I would not question the piloting competancy of the crew, one wonders how knowledgeable they (and indeed many younger pilots) are of how and why the mechanics of their chariot function and interact.
The extent to which the flying crew can also be maintenance technicians is controlled by the quality and fitness-to-task of the tools available and also by the mindset of the individuals.
Whilst I would not question the piloting competancy of the crew, one wonders how knowledgeable they (and indeed many younger pilots) are of how and why the mechanics of their chariot function and interact.
Ground instructor
Joined: May 2001
Posts: 120
Likes: 0
From: UK
The oil pressure/temp problem was due to the location of the leak and the cooling effect of the leaking cold fuel.
Maybe the 2 things, apparent low fuel level and low oil temperature should have started a thought process, but of course it will be dependent on systems knowledge, not flying skills.
No one in the program came up with the 'obvious' (to me) relationship.
Hopefully, you professional pilots here will have your memories jogged if something similar happens to you.
Automation dependency is one of the reasons Human Factors training is so important nowadays.
As was said in the program by one of the passengers "Do I think the pilot was a hero?, no. Do I think he was a bloody good pilot?, yes." ......and I would agree, if only on the unpowered landing skills.
Joined: Dec 2001
Posts: 189
Likes: 0
From: London
Spy's myth-dispelling most welcome, but I wonder about subtle differences in wording and whether the post Transat checklist fixed it. The Transat checklist appeared to say "don't open crossfeed if a leak is suspected" which is subtly different from (quoting from memory) "you a required to confirm there is no leak before opening the crossfeed". Maybe this is the hole they fell into, in that they felt (if they had been checking fuel state at 30-minute intervals) they had no reason to suspect a leak.
Joined: Nov 2003
Posts: 109
Likes: 0
From: UK
On the grounds they got close enough to glide to the airfield I would say without doubt had the leak been detected earlier they would have landed on one engine.
However, here is the real question, would they have made it on a 180 minute flight plan at the ETP with minimum fuel required? Which ever way you look at this incident they were very lucky! A very nasty position to find yourself in over the Atlantic.
However, here is the real question, would they have made it on a 180 minute flight plan at the ETP with minimum fuel required? Which ever way you look at this incident they were very lucky! A very nasty position to find yourself in over the Atlantic.
Last edited by spy; 26th July 2004 at 11:29.
Joined: Nov 2000
Posts: 142
Likes: 47
From: Montgomery, NY, USA
For those of you who have been following this thread and commenting on the challenges of new technology, read this article on Avweb. It details the travails of a DC-10 crew struggling with intermittent failures.
http://www.avweb.com/news/columns/187705-1.html
http://www.avweb.com/news/columns/187705-1.html
Joined: Jul 2004
Posts: 10
Likes: 0
From: LUT 270/20
"However, here is the real question, would they have made it on a 180 minute flight plan at the ETP with minimum fuel required? Which ever way you look at this incident they were very lucky! A very nasty position to find yourself in over the Atlantic."
So, given early diagnosis, would they have had fuel enough to make any runway with power. And what does that say about ETOPS.
Joined: Nov 2003
Posts: 109
Likes: 0
From: UK
The A330 can fly safely and land with one side empty!
You can’t dump fuel from only one side unless of course one side is already empty! You would never dump fuel to correct an imbalance anyway. Also not all A330's have fuel dump as the aircraft can be landed if needs must at max take-off weight.
The two situations that have always given me pause for thought have been a major fuel leak or fire over the Atlantic. Not that either of these problems would be any better in a three or four engined aeroplane, so this is not an ETOPS only problem!
From what I understand given the location of the leak, the leak would have stopped had the crew used the leak from engine QRH drill and they could then have used fuel from both wings. However, to be fair to the crew they had no way of knowing where the leak was from and it would have been a brave call to shut the engine down given they had not decided they even had a leak.
The point is had this leak occurred further from land we would now be talking about an accident not an incident.
You can’t dump fuel from only one side unless of course one side is already empty! You would never dump fuel to correct an imbalance anyway. Also not all A330's have fuel dump as the aircraft can be landed if needs must at max take-off weight.
The two situations that have always given me pause for thought have been a major fuel leak or fire over the Atlantic. Not that either of these problems would be any better in a three or four engined aeroplane, so this is not an ETOPS only problem!
From what I understand given the location of the leak, the leak would have stopped had the crew used the leak from engine QRH drill and they could then have used fuel from both wings. However, to be fair to the crew they had no way of knowing where the leak was from and it would have been a brave call to shut the engine down given they had not decided they even had a leak.
The point is had this leak occurred further from land we would now be talking about an accident not an incident.
Last edited by spy; 26th July 2004 at 21:29.
Joined: Jul 2004
Posts: 10
Likes: 0
From: LUT 270/20
The A330 can fly safely and land with one side empty!
And I'm impressed. Is that special to the A330, or all big twins built that well?
Last edited by middenview; 27th July 2004 at 08:17.
