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Sunwings Incident Writeup

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  • #16
    Originally posted by Gabriel View Post
    I don't think that two qualified (i.e. competent) pilots would make this same mistake independently. I don't understand why you are asking your question. Heck, I don't even think that two stupid incompetent pilots would make the SAME mistake independently. And the investigation did not determine so far how the mistake was done: "The investigation will consider how such a data entry error could have been made".

    But this is not you said. Let me quote you again:



    This is not 2 persons making the same mistake independently. It is one person making one mistake and the other person failing to find the mistake already done by the other person. Which is a much more probable outcome than both of them making the same mistake independently. And happens all the time.


    Even if they got it right 99.99% of the time? And I am asking literally, exactly 99.99%. Because even then we will still have 300 incidents like this per year.
    As you pointed out, the computer cross-checks the entries. This should make the odds of this happening (among 'competent pilots', which is unfortunately a subset of 'all commercial pilots', which is the problem) much more remote than 0.01%.
    But, if the pilots are like the kids I knew in high school who didn't want to do the 'boring' work and would whisper "hey what did you put for #4?" and just copy your work, well then the entire cross-check procedure fails.
    When both pilots don't look-up the data independently, I can see this happening 500 times a year.

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    • #17
      Originally posted by Evan View Post
      I can see this happening 500 times a year.
      And does our actual incident rate seem to be in this ballpark?
      Les règles de l'aviation de base découragent de longues périodes de dur tirer vers le haut.

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      • #18
        Originally posted by 3WE View Post
        And does our actual incident rate seem to be in this ballpark?
        Reported or unreported?

        Comment


        • #19
          Originally posted by Evan View Post
          Reported or unreported?
          Is there significant lack of reporting in the industry?
          Les règles de l'aviation de base découragent de longues périodes de dur tirer vers le haut.

          Comment


          • #20
            Originally posted by 3WE View Post
            Is there significant lack of reporting in the industry?
            Absolutely yes!!!! mistakes are made in (almost) EVERY flight, and most of them are not reported (not saying that all of them should be reported).

            In this incident, for example, if the plane was very light or the runway too much longer than needed, they would have not hit runway lights and very likely they would not have reported it (heck, probably they would have not even noticed that they made an error (heck2, even hitting the lights they probably didn't notice that they made an error or understood what error they made, since it took two independent investigation teams finding what exact set of mistakes were needed to duplicate the result)).

            --- Judge what is said by the merits of what is said, not by the credentials of who said it. ---
            --- Defend what you say with arguments, not by imposing your credentials ---

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            • #21
              Originally posted by Evan View Post
              As you pointed out, the computer cross-checks the entries. This should make the odds of this happening (among 'competent pilots', which is unfortunately a subset of 'all commercial pilots', which is the problem) much more remote than 0.01%.
              But, if the pilots are like the kids I knew in high school who didn't want to do the 'boring' work and would whisper "hey what did you put for #4?" and just copy your work, well then the entire cross-check procedure fails.
              When both pilots don't look-up the data independently, I can see this happening 500 times a year.
              Again, I totally agree with that. But, for the third time, I was challenging this, which is totally different:

              If you filled out a form and I checked your work and we both were well aware of the consequences of not paying close attention and very concerned about our lives and the lives of hundreds of others, I'm betting this wouldn't happen.
              and this, which is also totally different than that.

              I have some experience writing code. There are short editing tasks where a simple character error will break the entire script and require a lot of work to hunt down. You concentrate during this short period. You don't make mistakes. Now imagine there are 150 souls depending on that short bit of careful concentration. That is what makes you pilot material.

              That said, mistakes will happen. So we also have a computerized cross-check procedure. Two pilots not giving this short period of dreadful importance their careful concentration = shut it down, turn out the lights, go work in a bakery.
              Don't you see the difference or you are just pretending that you did not say what you did say?

              --- Judge what is said by the merits of what is said, not by the credentials of who said it. ---
              --- Defend what you say with arguments, not by imposing your credentials ---

              Comment


              • #22
                Originally posted by Gabriel View Post
                ...not saying that all of them should be reported...
                Well, I’m getting the message that there’s 500 unreported significant issues a year with temperature entries and worry if we are safe.
                Les règles de l'aviation de base découragent de longues périodes de dur tirer vers le haut.

                Comment


                • #23
                  Originally posted by 3WE View Post
                  Well, I’m getting the message that there’s 500 unreported significant issues a year with temperature entries and worry if we are safe.
                  We are not. You are guaranteed a fiery death every time you step into a plane. [/blue]

                  --- Judge what is said by the merits of what is said, not by the credentials of who said it. ---
                  --- Defend what you say with arguments, not by imposing your credentials ---

                  Comment


                  • #24
                    Originally posted by Gabriel View Post
                    We are not [safe].
                    Slightly off topic- but I am wondering how you (and or Eric and or Schwartz) are going to design TOPMS to not take errant temperature entries (or other errant entries like weight) and correctly tell the pilots that the takeoff is progressing as it should (or shouldn't). Does TOPMS take it's own temperatures and calculate a nice, buffered takeoff and just give a yellow light that says you might want to go to 100% power...and then a red flashing one that says go to cook-the-engine-but-save-your-a$$ settings?
                    Les règles de l'aviation de base découragent de longues périodes de dur tirer vers le haut.

                    Comment


                    • #25
                      Originally posted by Gabriel View Post
                      Don't you see the difference or you are just pretending that you did not say what you did say?
                      Yes, I see the difference. The first statement was an analogy in response to Schwartz's comparison to writing code and the second was about the actual preflight procedure as you have described it. The first scenario is unlikely. The second scenario is highly unlikely. A third scenario (let's call it the 'elaw scenario') in which the computer cross-checks both independent pilot entries against external data, would make such an error virtually impossible. Why aren't we doing that? I think because the danger is not fully recognized by engineering. But, as we both agree, the current safeguard of having both pilots make independent entries is defeated if they 'cheat on the exam".

                      Originally posted by 3WE
                      Well, I’m getting the message that there’s 500 unreported significant issues a year with temperature entries and worry if we are safe.
                      We are only as safe as the pilots are competent. Competent means more than being able to fly an air tractor through a barn door. It means careful concentration and diligent adherence to procedures that are there to protect you from yourself. This seemingly minor error came VERY close to killing 186 passengers, about as close as you can come without doing so. The industry should be seeing it as a very lucky warning sign revealing a stealth factor BEFORE if kills anyone, and making changes to remove the possibility of a repeat occurrence. Hopefully they are, because 'competent pilots' are a subset of 'all commercial pilots', especially with the industry growing faster than the supply of 'competent pilots'.

                      Comment


                      • #26
                        Originally posted by Evan View Post
                        We are only as safe as the pilots are competent. Competent means more than being able to fly an air tractor through a barn door. It means careful concentration and diligent adherence to procedures that are there to protect you from yourself. This seemingly minor error came VERY close to killing 186 passengers.
                        The link between 'seemingly minor errors' and 'competent, careful concentration and diligence to procedures' may not be as absolute as you see it. Sure there's correlation, but there's always those asymptotic tails on frequency distributions...
                        Les règles de l'aviation de base découragent de longues périodes de dur tirer vers le haut.

                        Comment


                        • #27
                          Originally posted by Evan View Post
                          Yes, I see the difference. The first statement was an analogy in response to Schwartz's comparison to writing code and the second was about the actual preflight procedure as you have described it. The first scenario is unlikely. The second scenario is highly unlikely. A third scenario (let's call it the 'elaw scenario') in which the computer cross-checks both independent pilot entries against external data, would make such an error virtually impossible. Why aren't we doing that? I think because the danger is not fully recognized by engineering. But, as we both agree, the current safeguard of having both pilots make independent entries is defeated if they 'cheat on the exam".
                          Evan, you proposed that if, in an independent entry by the 2 pilots, the FSM ever detects that the entries don't match, these pilots should leave the cockpit at once and forever and go work in a bakery.
                          Your words, not mine.

                          Second, the system that crosschecks with the measured OAT exists and it is called Flight Management Computer software revision U12.0 or later, which the AAIB is recommending to the FAA mandate with AD.

                          3rd, we still don't know a) what was the procedure that these pilots were required to follow and b) what went wrong. It could be a poor procedure or a poor adherence.
                          The investigation will consider how such a data entry error could have been made.

                          Did you read the very 1st post?

                          --- Judge what is said by the merits of what is said, not by the credentials of who said it. ---
                          --- Defend what you say with arguments, not by imposing your credentials ---

                          Comment


                          • #28
                            Originally posted by Gabriel View Post
                            Evan, you proposed that if, in an independent entry by the 2 pilots, the FSM ever detects that the entries don't match, these pilots should leave the cockpit at once and forever and go work in a bakery.
                            In Evan's defense, I'm fairly certain he feels that way about ALL pilots, especially now that the only airline he's ever admitted to actually having ridden on is defunct.

                            Comment


                            • #29
                              Originally posted by ATLcrew View Post
                              In Evan's defense, I'm fairly certain he feels that way about ALL pilots, especially now that the only airline he's ever admitted to actually having ridden on is defunct.
                              But he does have 5,991 post's!

                              Comment


                              • #30
                                Originally posted by Gabriel View Post
                                Evan, you proposed that if, in an independent entry by the 2 pilots, the FSM ever detects that the entries don't match, these pilots should leave the cockpit at once and forever and go work in a bakery.
                                Your words, not mine.
                                No, my words were:

                                Originally posted by Evan
                                Two pilots not giving this short period of dreadful importance their careful concentration = shut it down, turn out the lights, go work in a bakery.
                                And I stand by that. Even careful concentration will yield errors, but they will be rare and they won't be repeated on the other side of the cabin in the same way at the same time. Not if everyone is concentrating. Carefully.

                                And my point is that, if both pilots aren't entering the data independently, the bad data WILL NOT be detected by the FSM. That's where the danger lies.

                                Second, the system that crosschecks with the measured OAT exists and it is called Flight Management Computer software revision U12.0 or later, which the AAIB is recommending to the FAA mandate with AD.
                                That's good to know, but I'm not entirely surprised to hear it. It's such a no-brainer for such a critical issue. A mandate is needed before someone mows down something less 'frangible'.

                                Did you read the very 1st post?
                                Yes, and there's a big IF involved in what I'm addressing, but I simply can't believe that a crew with their head in the game and a respect for procedure could make the same error at the same time like that.

                                Maybe it was something else. I guess I have to add that disclaimer.

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