Boeing at X-Roads?
As a retired system guy I don't think it's fair to characterize taping of static ports as a pitot-static system failure. The ports correctly passed the sensed port pressure to the air data system and the system gave the correct airspeed and altitude indications for the sensed presssures. (I'm thinking of AeroPeru)
It's certainly true that very silly basic mistakes can cause catastrophic events but let's distinguish between human error and systems failure.
It's certainly true that very silly basic mistakes can cause catastrophic events but let's distinguish between human error and systems failure.
Thinking about Aeroperu 603 physically distresses me, but all they had to do was chill out, level the airplane, and set typical power/pitch/flaps while they got situational awareness and came up with a rational plan. I think these are memory items although maybe not at the time. Still: They had plenty of time flying level. They had the illuminated coast in view if close enough. They had hours. Not realizing that secondary radar (transponder) altitude would be BS if the aircraft had unreliable altitude is a really profound mistake that would not be made after a minute or three of putting the aircraft into a reasonably safe configuration and taking a few deep breaths.
What pilot doesn't know that ATC can't give you a reliable altitude if your aircraft doesn't have one? I would hope, ZERO.
AF 447 was pilot error 100%. Temporarily frozen pitot wasn't an unexpected or even unusual condition.
Birgenair harder to catch, but again, a rejected takeoff based on clearly understood airspeed difference AND clear operational rules would have made it a nothing burger.
XL888, idk, dual AoA failure combined with the aircraft's reliance on AoA and complex changes to flight laws and modes, tough one to solve.
Last edited by remi; 8th Mar 2024 at 01:07.
I expect the number is FAR greater than zero but it this lack of systems knowledge that ended up killing all on board. With reasonable systems knowledge the AeroPeru crew could have flown pitch and thrust and executed a hold over the ocean while they decended below RADALT max altitude. They could then have flown RAD ALT, pitch, and thrust and been vectored for a landing. Every time I read that accident report I get very angry. Of course it's easy to be wise after the event.
Also, again IIRC, there was very limited visibility at the time - although I do wonder why they didn't look at Radio Altimeter before they flew into the ocean...
IIRC, the current training for unreliable Air Data was a result of the Aeroperu accident - hard to fault the crew for failing to use training they never got.
Also, again IIRC, there was very limited visibility at the time - although I do wonder why they didn't look at Radio Altimeter before they flew into the ocean...
Also, again IIRC, there was very limited visibility at the time - although I do wonder why they didn't look at Radio Altimeter before they flew into the ocean...
The JAL 123 accident bothers me not because the pilots didn't do their best but because Japanese authorities let injured pax who MIRACULOUSLY survived uncontrolled flight into a mountainside lie on the ground and die with an oafish SAR response.
Alaska because if the pilots had understood what was wrong with the airplane, and they came tantalizingly close, they probably could have landed it.
And AeroPeru because there were common sense things that just didn't get done and there was an agonizingly long opportunity to take stock and greatly simplify the situation.
Administrator
As a retired system guy I don't think it's fair to characterize taping of static ports as a pitot-static system failure. The ports correctly passed the sensed port pressure to the air data system and the system gave the correct airspeed and altitude indications for the sensed presssures. (I'm thinking of AeroPeru)
It's certainly true that very silly basic mistakes can cause catastrophic events but let's distinguish between human error and systems failure.
It's certainly true that very silly basic mistakes can cause catastrophic events but let's distinguish between human error and systems failure.
You might compare JAL123 but the bulkhead repair underwent inspection multiple times, along with (hopefully) careful scrutiny while being performed, and so it was a failure of multiple teams over a protracted period of time.
Getting an aircraft with an undetectable guaranteed catastrophic failure because of a mistake a first grader would have recognized, that shouldn't happen.
Join Date: Apr 2015
Location: Under the radar, over the rainbow
Posts: 788
Likes: 0
Received 0 Likes
on
0 Posts
Yes, exactly this. As (merely) a well-informed outsider, I'm pretty sure that simple oversights and process failures by OEMs are not straightforward single causes of typical serious accidents in commercial aviation.
Thread Starter
Join Date: Apr 2015
Location: Under the radar, over the rainbow
Posts: 788
Likes: 0
Received 0 Likes
on
0 Posts
Pegase Driver
Join Date: May 1997
Location: Europe
Age: 74
Posts: 3,694
Likes: 0
Received 0 Likes
on
0 Posts
Working conditions of your employees and company cultures are not going to change much by distrusting quick money.
Amazing how top management today thinks only about Bonuses , and naturally expect solving their production problems by reducing or increasing bonuses of their line managers.
Working conditions of your employees and company cultures are not going to change much by distrusting quick money.
Working conditions of your employees and company cultures are not going to change much by distrusting quick money.
Most Boeing employee's receive (or are at least eligible) for an annual bonus - not just management. For the union workers (mainly IAM and SPEEA - machinists and Engineers/Techs, respectively), it's written into the contract, and a similar bonus formula is used for most non-union employees. The bonus payments are based on various performance targets - production rate, earnings, etc. and are calculated as equivalent to a certain number of days of pay (IIRC, 'nominal' performance got you an extra ten days, exceeding targets could result in up to 20 days, obviously sub-nominal meant less days). Boeing liked the bonus because it gave the employees some skin in the game, while not increasing the 'baseline' costs the way a pay raise would.
I see putting 'quality' as the prime (60%) driver on the formula as a very positive step. Again, giving the everyday employees some skin in the game, but now instead of a financial focus, it's a 'quality' focus.
Of course, the devil is in the details of how they work the formula, but like I said I see this as a very positive step.
Amazing how top management today thinks only about Bonuses , and naturally expect solving their production problems by reducing or increasing bonuses of their line managers.
Working conditions of your employees and company cultures are not going to change much by distrusting quick money.
Working conditions of your employees and company cultures are not going to change much by distrusting quick money.
System safety and short term profit enhancement are mutually exclusive, something that I just don’t see the current C suite wanting to understand.
The problem at Spirit and indeed in most of Boeing suppliers is too few, too new people, trying to do too, much too fast. This is a direct result of Boeing prioritizing low production costs over everything else. It is telling that the FAA had to tell Boeing that they could not increase the MAX production rate. This obvious step to get a grip on the well known production QA problems speaks volumes on what the C Boeing C Suite priorities are…
Ambivalent here - not only because motivated cooking of numbers, but the difficulty in making a measurable metric that can be influenced by workers. Measuring profit is a fundamental business operation.
What happens if Boeing makes a record profit but says, "Bud, in the sheet metal shop, received a particularly nasty paper cut from a string tag, so no bonuses for the workers this year" ?
It sounds like a great idea, but are the workers around Bud supposed to tackle him to the ground when they see him using a string tag in an unsafe manner? Sure, for activities that are inherently dangerous - operating a fork truck or using an overhead crane or ensuring the handrails are in place on elevated platforms - but there is a continuum of possible problems, so where is the line drawn that management says "No bonuses for you!"?
Look at the f'ery at Wells Fargo where sales/tellers were given goals of a certain number new of accounts each month or they would be fired. No order was given from the top to forge customer approval to fraudulently open accounts using customer information, but that's exactly what happened.
Depending on what safety problems there are, it can be the case that addressing them can improve short term output by getting badly defined procedures reworked. For example - if holes are being mislocated that's probably because there is a flaw in the tooling, not just a case of being rushed. The rush might be from having to tweak and wrestle the part in the fixture. Redesign the fixture to better index the part and now no more mislocated holes and no more time wasted tweaking the part location. Without the safety (whatever nebulous meaning that has) push the motive to make that examination of the process may not have been an obvious priority.
What happens if Boeing makes a record profit but says, "Bud, in the sheet metal shop, received a particularly nasty paper cut from a string tag, so no bonuses for the workers this year" ?
It sounds like a great idea, but are the workers around Bud supposed to tackle him to the ground when they see him using a string tag in an unsafe manner? Sure, for activities that are inherently dangerous - operating a fork truck or using an overhead crane or ensuring the handrails are in place on elevated platforms - but there is a continuum of possible problems, so where is the line drawn that management says "No bonuses for you!"?
Look at the f'ery at Wells Fargo where sales/tellers were given goals of a certain number new of accounts each month or they would be fired. No order was given from the top to forge customer approval to fraudulently open accounts using customer information, but that's exactly what happened.
Depending on what safety problems there are, it can be the case that addressing them can improve short term output by getting badly defined procedures reworked. For example - if holes are being mislocated that's probably because there is a flaw in the tooling, not just a case of being rushed. The rush might be from having to tweak and wrestle the part in the fixture. Redesign the fixture to better index the part and now no more mislocated holes and no more time wasted tweaking the part location. Without the safety (whatever nebulous meaning that has) push the motive to make that examination of the process may not have been an obvious priority.
I don't think you understand the Boeing employee 'bonus' system.
Most Boeing employee's receive (or are at least eligible) for an annual bonus - not just management. For the union workers (mainly IAM and SPEEA - machinists and Engineers/Techs, respectively), it's written into the contract, and a similar bonus formula is used for most non-union employees. The bonus payments are based on various performance targets - production rate, earnings, etc. and are calculated as equivalent to a certain number of days of pay (IIRC, 'nominal' performance got you an extra ten days, exceeding targets could result in up to 20 days, obviously sub-nominal meant less days). Boeing liked the bonus because it gave the employees some skin in the game, while not increasing the 'baseline' costs the way a pay raise would.
I see putting 'quality' as the prime (60%) driver on the formula as a very positive step. Again, giving the everyday employees some skin in the game, but now instead of a financial focus, it's a 'quality' focus.
Of course, the devil is in the details of how they work the formula, but like I said I see this as a very positive step.
Most Boeing employee's receive (or are at least eligible) for an annual bonus - not just management. For the union workers (mainly IAM and SPEEA - machinists and Engineers/Techs, respectively), it's written into the contract, and a similar bonus formula is used for most non-union employees. The bonus payments are based on various performance targets - production rate, earnings, etc. and are calculated as equivalent to a certain number of days of pay (IIRC, 'nominal' performance got you an extra ten days, exceeding targets could result in up to 20 days, obviously sub-nominal meant less days). Boeing liked the bonus because it gave the employees some skin in the game, while not increasing the 'baseline' costs the way a pay raise would.
I see putting 'quality' as the prime (60%) driver on the formula as a very positive step. Again, giving the everyday employees some skin in the game, but now instead of a financial focus, it's a 'quality' focus.
Of course, the devil is in the details of how they work the formula, but like I said I see this as a very positive step.
The only changes that absolutely must be made for a change in company culture are a complete replacement of the C-suite and board with people obsessed with safety and with engineering backgrounds as necessary.
This is just a way to punish employees for the past and present failings of management. I mean, seriously, they put a sales lady in charge of the MAX program. What do you think is going to happen?
Anyone that thinks that employees alone can change the culture of their company has never had a job in the US.
Also: A wheel falling off onto a parking lot full of cars, you know they are praying in the Boeing executive dining room that there are some mechanics at United that can't read or are drunk on the job. I would be willing to bet that there have been more people falling from the wheel wells of airliners than wheels falling off during takeoff.
Last edited by remi; 8th Mar 2024 at 21:16.