Digital dysfunction; not a new concept.
Before going anywhere near the flight deck end of this tale, and seeing as it is an ATSB thread we need to start in the ‘experts’ corner.
P2 – “These proactive actions included a rare 'safety recommendation' addressed to the FAA, who responded respectively, appropriately and timely:”
Why just the FAA? Why not CASA? Clearly there has been some good work done and a genuine attempt to resolve the matter, the report certainly good enough for the FAA to take seriously and acknowledge.
P2 – “However that was in January 2011 and since that time there would appear to have been a stalling of any further proactive actions to address the other IMO significant safety factors...”
I suspect there are three reasons for ATSB to go running to the grown ups.
1) Kudos – the FAA will think well of ATSB. A credible report and a SR enhances the notion that ATSB are a good unit, on the ball and ‘doing’ good things. This all helps come audit time, it also helps fuel the notion that Pel-Air was, indeed, an aberration; not the norm. I doubt it would occur to the FAA to take a peep at the ATSB follow up: they would simply assume that CASA was ‘in the loop’ and proactive change was afoot. They would be startled to discover that ATSB simply accepted the operators ‘fix’ and put the whole thing back on the shelf. They would also be interested in why CASA was not formally included and the cosy little arrangements in place which allow a matter like this to be quietly left gathering dust.
2) The ‘white hats’ in ATSB know, full well, they are flogging a dead horse trying to get action on a SR from CASA; even if they were allowed to issue one. However, by roping in the FAA ‘weight’ is added to the argument and the lack of CASA action is bracketed. This serves two obvious purposes; when the time comes and awkward questions are being asked. The ATSB arse is covered.
3) By keeping the matter buried, but alive ATSB can watch and wait, then with no expense or effort, the big guns will come up with a ‘working’ solution; when that happens, ATSB will unearth their buried treasure and come up clean, smelling of roses with a golden treasure. Everyone happy – except the poor sap, who’s engines ingested a bus on the highway which was not part of the runway. Guess who cops the blame and shame then; no prizes for a no brainer.
Operationally; this is a biggy. I reckon we could sit about the camp fire for week and still not reach a consensus on ‘how to’ prevent flight all deck data errors. The question of ‘Why’ incorrect data is used has been around since the garden of Eden; ever see an eagle try to take off carrying three or four times it’s body weight; how many times have you dialled the wrong number; how often have you buggered up ‘data entry’ on the PC? It happens and it is a ‘problem’; but how to prevent it?
If you sketch up one of little bollocks things Walker is so enamoured of, with the flight deck in the centre, surrounded by the incoming ‘data’ points you will see that the cockpit is surrounded by ‘incoming’ data bombs. Expand backwards to a simple, single point, say for a parcel consigned as freight. Then look and see the number of potential ‘error’ points; when you add them all up; the percentile chances of ‘something’ going awry are immense. But so are the defences; the chances of a pallet being grossly overweight are very slim, it happens – but very rarely. But if it did, the crew can’t possibly know. So we can safely eliminate the chances of an external factor; within reasonable, acceptable tolerances; I think so. There is check after check after check – land side; all designed to prevent, if not eliminate the small chance.
Which leaves the last link in the chain firmly in the cockpit; there are no external checks to prevent an error. There are SOP and there are ‘cross checks’ which the crew will do as routine. But 27% is a big number. You can look at scheduling and 100 other things which may be sheeted home to ‘common local conditions’. It is a nightmare for operators who must juggle crew duty schedules, slot times, fuel loads, weather, traffic etc. make a dollar and keep the travelling public ‘happy’. In the end, it all comes down to rest on the two wee heads parked in the very front row.
Here we walk into another hall of puzzles; the human one. A student of human factors would do well to search out some of the old fashioned ‘tech-logs’ (trip sheets, post flight reports etc.). Try to find one, without error; more may learned about a fellow aviator from studying the ‘trip sheet’ than you’ll ever discover playing poker or strapping ‘em to a trickcyclists Ouija board. I’ve operated with some beauties; guys who can pick out the smallest error in my own scruffy paperwork; pilots who simply cannot add up; pilots who get pounds and Kg confused; some of the manually extracted performance data should be framed for posterity. And yet we muddle through. It is a huge topic to cover, well beyond the scope of my half baked twiddle. But for myself, I have found a solution which works; it may delay me a minute or even two, but done properly it rarely does. I simply cross check – I read out the data – Chummy enters that data; then Chummy reads back that data and I look at the box and make sure the numbers called are entered; same-same TOLD card. Often it is the very last thing done. “Tell the bloody tug to wait; now then, call those numbers”. "Late off blox – here, use my phone, call someone who gives a toss".
Can’t see the Witless Walker sorting this lot out with a bollocks, no organisational issues diagram; best wait a while for the coronial inquiry. Then for the Senate inquiry, then for the Royal Commission; maybe, in another ten years or so the answer will be obfuscated sufficiently. Meanwhile; do I press enter twice?
Toot - head scratch - toot.
Before going anywhere near the flight deck end of this tale, and seeing as it is an ATSB thread we need to start in the ‘experts’ corner.
P2 – “These proactive actions included a rare 'safety recommendation' addressed to the FAA, who responded respectively, appropriately and timely:”
Why just the FAA? Why not CASA? Clearly there has been some good work done and a genuine attempt to resolve the matter, the report certainly good enough for the FAA to take seriously and acknowledge.
P2 – “However that was in January 2011 and since that time there would appear to have been a stalling of any further proactive actions to address the other IMO significant safety factors...”
I suspect there are three reasons for ATSB to go running to the grown ups.
1) Kudos – the FAA will think well of ATSB. A credible report and a SR enhances the notion that ATSB are a good unit, on the ball and ‘doing’ good things. This all helps come audit time, it also helps fuel the notion that Pel-Air was, indeed, an aberration; not the norm. I doubt it would occur to the FAA to take a peep at the ATSB follow up: they would simply assume that CASA was ‘in the loop’ and proactive change was afoot. They would be startled to discover that ATSB simply accepted the operators ‘fix’ and put the whole thing back on the shelf. They would also be interested in why CASA was not formally included and the cosy little arrangements in place which allow a matter like this to be quietly left gathering dust.
2) The ‘white hats’ in ATSB know, full well, they are flogging a dead horse trying to get action on a SR from CASA; even if they were allowed to issue one. However, by roping in the FAA ‘weight’ is added to the argument and the lack of CASA action is bracketed. This serves two obvious purposes; when the time comes and awkward questions are being asked. The ATSB arse is covered.
3) By keeping the matter buried, but alive ATSB can watch and wait, then with no expense or effort, the big guns will come up with a ‘working’ solution; when that happens, ATSB will unearth their buried treasure and come up clean, smelling of roses with a golden treasure. Everyone happy – except the poor sap, who’s engines ingested a bus on the highway which was not part of the runway. Guess who cops the blame and shame then; no prizes for a no brainer.
Operationally; this is a biggy. I reckon we could sit about the camp fire for week and still not reach a consensus on ‘how to’ prevent flight all deck data errors. The question of ‘Why’ incorrect data is used has been around since the garden of Eden; ever see an eagle try to take off carrying three or four times it’s body weight; how many times have you dialled the wrong number; how often have you buggered up ‘data entry’ on the PC? It happens and it is a ‘problem’; but how to prevent it?
If you sketch up one of little bollocks things Walker is so enamoured of, with the flight deck in the centre, surrounded by the incoming ‘data’ points you will see that the cockpit is surrounded by ‘incoming’ data bombs. Expand backwards to a simple, single point, say for a parcel consigned as freight. Then look and see the number of potential ‘error’ points; when you add them all up; the percentile chances of ‘something’ going awry are immense. But so are the defences; the chances of a pallet being grossly overweight are very slim, it happens – but very rarely. But if it did, the crew can’t possibly know. So we can safely eliminate the chances of an external factor; within reasonable, acceptable tolerances; I think so. There is check after check after check – land side; all designed to prevent, if not eliminate the small chance.
Which leaves the last link in the chain firmly in the cockpit; there are no external checks to prevent an error. There are SOP and there are ‘cross checks’ which the crew will do as routine. But 27% is a big number. You can look at scheduling and 100 other things which may be sheeted home to ‘common local conditions’. It is a nightmare for operators who must juggle crew duty schedules, slot times, fuel loads, weather, traffic etc. make a dollar and keep the travelling public ‘happy’. In the end, it all comes down to rest on the two wee heads parked in the very front row.
Here we walk into another hall of puzzles; the human one. A student of human factors would do well to search out some of the old fashioned ‘tech-logs’ (trip sheets, post flight reports etc.). Try to find one, without error; more may learned about a fellow aviator from studying the ‘trip sheet’ than you’ll ever discover playing poker or strapping ‘em to a trickcyclists Ouija board. I’ve operated with some beauties; guys who can pick out the smallest error in my own scruffy paperwork; pilots who simply cannot add up; pilots who get pounds and Kg confused; some of the manually extracted performance data should be framed for posterity. And yet we muddle through. It is a huge topic to cover, well beyond the scope of my half baked twiddle. But for myself, I have found a solution which works; it may delay me a minute or even two, but done properly it rarely does. I simply cross check – I read out the data – Chummy enters that data; then Chummy reads back that data and I look at the box and make sure the numbers called are entered; same-same TOLD card. Often it is the very last thing done. “Tell the bloody tug to wait; now then, call those numbers”. "Late off blox – here, use my phone, call someone who gives a toss".
Can’t see the Witless Walker sorting this lot out with a bollocks, no organisational issues diagram; best wait a while for the coronial inquiry. Then for the Senate inquiry, then for the Royal Commission; maybe, in another ten years or so the answer will be obfuscated sufficiently. Meanwhile; do I press enter twice?
Toot - head scratch - toot.