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Which crashes in particular were caused by attention to systems problems? I believe you - I'm just curious.

by thenmar 12y ago

Bluestrike2 12y ago
Consider reading Breaking the Mishap Chain by Peter Merlin [1]. It's a pretty fascinating series of case studies where human error was a primary factor. Chapter 5 discusses the crash of M2-F2 during testing for NASA and the role that task saturation had in the incident. [1] http://www.amazon.com/Breaking-Mishap-Chain-Development-Aeronoutics/dp/1780398492 http://www.amazon.com/Breaking-Mishap-Chain-Development-Aero...
- parados 12y ago
  Or free from NASA: http://www.nasa.gov/connect/ebooks/break_mishap_chain_detail.html http://www.nasa.gov/connect/ebooks/break_mishap_chain_detail...
userbinator 12y ago
Here's one: http://en.wikipedia.org/wiki/Adam_Air_Flight_574 http://en.wikipedia.org/wiki/Adam_Air_Flight_574 I definitely remember reading about others but can't find them right now.
matznerd 12y ago
Outliers has a large section on plane crashes related to poor communication and attention...
teraflop 12y ago
http://en.wikipedia.org/wiki/Eastern_Air_Lines_Flight_401 http://en.wikipedia.org/wiki/Eastern_Air_Lines_Flight_401 Both pilots became so preoccupied with a burnt-out landing gear indicator light that they didn't notice the autopilot had become disengaged, and crashed into the Florida Everglades.
Patrick_Devine 12y ago
The recent crash at SFO was caused by mistakenly thinking the airplane was working a different way than it was actually working. The pilots thought the autothrottles were engaged when they weren't and were fixated on trying to land the plane manually; something they hadn't done in a long time. http://en.wikipedia.org/wiki/Asiana_Airlines_Flight_214 http://en.wikipedia.org/wiki/Asiana_Airlines_Flight_214
- ghaff 12y ago
  Which is the sort of problem we'll likely see more of as "mostly autonomous" systems become increasingly common. For example, it's easy to imagine that it will become possible (whether or not we elect to go down that route) to design cars that can be self-driving most of the time but which will require a human to take over in some scenarios. The good news is that those scenarios will presumably be mostly low speed ones--the handoff timeframe pretty much has to be of minute rather than second magnitude--but you could still end up with an increasing number of drivers who have very little actual driving experience.
StavrosK 12y ago
The Air France 447 crash was also caused by pilots thinking the autopilot was on when it was off.
- Tuxer 12y ago
  Honestly, that's not entirely true, and not very respectful to the pilots in that crash. AF447 was caused (partially) by the pilot's misunderstanding that holding the control stick all the way back was gonna make the aircraft go up at the best rate of climb, and not put the control surfaces all the way back. The AP (autopilot) was off for quite some time when the crash happened. What was supposed to be on though, as always, is the Airbus Fly-by-wire system in normal law, that is in between the pilot's controls and the actual commands sent to the control surfaces (ailerons, elevators...). This system was off (in it's direct control law, more precisely) due to the pitot tubes sending non accurate data, because of the icing problem. The pilot didn't notice that.
  - StavrosK 12y ago
    Yes, sorry, that's what I meant. They had turned the system to direct control law and one of the pilots was pulling back, and they were ignoring the "stall" warning blaring in the background. Honestly, first of all, who averages two sticks? Like, when is averaging the input of the two sticks ever a reasonable thing to do? This is a major design flaw, in my opinion. Second of all, why was the "stall" warning even on when the system was in normal law, and thus impossible to stall? All that did was desensitize the pilots, who learned to just ignore the warnings.
natfriedman 12y ago
This is a very nice American Airlines seminar on automation dependence called "Children of the Magenta." http://n631s.blogspot.com/2011/11/children-of-magenta-line.html http://n631s.blogspot.com/2011/11/children-of-magenta-line.h...

Which crashes in particular were caused by attention to systems problems? I believe you - I'm just curious.

by thenmar 12y ago

Which crashes in particular were caused by attention to systems problems? I believe you - I'm just curious.

Consider reading Breaking the Mishap Chain by Peter Merlin [1]. It's a pretty fascinating series of case studies where human error was a primary factor. Chapter 5 discusses the crash of M2-F2 during testing for NASA and the role that task saturation had in the incident. [1] http://www.amazon.com/Breaking-Mishap-Chain-Development-Aeronoutics/dp/1780398492 http://www.amazon.com/Breaking-Mishap-Chain-Development-Aero...

parados 12y ago
Or free from NASA: http://www.nasa.gov/connect/ebooks/break_mishap_chain_detail.html http://www.nasa.gov/connect/ebooks/break_mishap_chain_detail...

userbinator 12y ago

Here's one: http://en.wikipedia.org/wiki/Adam_Air_Flight_574 http://en.wikipedia.org/wiki/Adam_Air_Flight_574 I definitely remember reading about others but can't find them right now.

matznerd 12y ago

Outliers has a large section on plane crashes related to poor communication and attention...

teraflop 12y ago

http://en.wikipedia.org/wiki/Eastern_Air_Lines_Flight_401 http://en.wikipedia.org/wiki/Eastern_Air_Lines_Flight_401 Both pilots became so preoccupied with a burnt-out landing gear indicator light that they didn't notice the autopilot had become disengaged, and crashed into the Florida Everglades.

Patrick_Devine 12y ago

The recent crash at SFO was caused by mistakenly thinking the airplane was working a different way than it was actually working. The pilots thought the autothrottles were engaged when they weren't and were fixated on trying to land the plane manually; something they hadn't done in a long time. http://en.wikipedia.org/wiki/Asiana_Airlines_Flight_214 http://en.wikipedia.org/wiki/Asiana_Airlines_Flight_214

ghaff 12y ago
Which is the sort of problem we'll likely see more of as "mostly autonomous" systems become increasingly common. For example, it's easy to imagine that it will become possible (whether or not we elect to go down that route) to design cars that can be self-driving most of the time but which will require a human to take over in some scenarios. The good news is that those scenarios will presumably be mostly low speed ones--the handoff timeframe pretty much has to be of minute rather than second magnitude--but you could still end up with an increasing number of drivers who have very little actual driving experience.

StavrosK 12y ago

The Air France 447 crash was also caused by pilots thinking the autopilot was on when it was off.

Tuxer 12y ago
Honestly, that's not entirely true, and not very respectful to the pilots in that crash. AF447 was caused (partially) by the pilot's misunderstanding that holding the control stick all the way back was gonna make the aircraft go up at the best rate of climb, and not put the control surfaces all the way back. The AP (autopilot) was off for quite some time when the crash happened. What was supposed to be on though, as always, is the Airbus Fly-by-wire system in normal law, that is in between the pilot's controls and the actual commands sent to the control surfaces (ailerons, elevators...). This system was off (in it's direct control law, more precisely) due to the pitot tubes sending non accurate data, because of the icing problem. The pilot didn't notice that.
- StavrosK 12y ago
  Yes, sorry, that's what I meant. They had turned the system to direct control law and one of the pilots was pulling back, and they were ignoring the "stall" warning blaring in the background. Honestly, first of all, who averages two sticks? Like, when is averaging the input of the two sticks ever a reasonable thing to do? This is a major design flaw, in my opinion. Second of all, why was the "stall" warning even on when the system was in normal law, and thus impossible to stall? All that did was desensitize the pilots, who learned to just ignore the warnings.

natfriedman 12y ago

This is a very nice American Airlines seminar on automation dependence called "Children of the Magenta." http://n631s.blogspot.com/2011/11/children-of-magenta-line.html http://n631s.blogspot.com/2011/11/children-of-magenta-line.h...