[Rhodes22-list] Bad Tack

[Brad Haslett]

Good morning gentlemen,

Bill, you are correct.  Airlines and cruise operators look for a quick and
dirty explanation they can get out to the press.  By the time the NTSB
investigation is complete (sometimes years) the public has lost interest or
forgotten about the incident and the operator's responsibility is swept
under the carpet.  There is probably some element of truth to this story but
the real sequence of events is much more complicated.  We talk about
"breaking the accident chain" a great deal in Human Factors training, also
known as Cockpit Resource Management (CRM).  In most accidents there are a
series of small and seemingly unrelated events that when combined, add up to
the final ugly result.  If the crew can recognize, prevent, or correct any
one link in the chain the outcome will be avoided.  The average number of
links in the accident chain is sixteen.

My take on the boat incident is that there was a man/machine interface
issue.  This was a new boat with no doubt the latest of electronic
navigation and steering systems.  These things are designed by engineers and
are often not necessarily user friendly to pilots and ship captains.  What
the junior officer did may have been stupid, but was probably a trap set in
the design of the machine waiting to be discovered.  Airbus crashed an A300,
piloted by their chief test pilot, in the woods off the runway at the Paris
Air Show when the airplane was introduced.  It was a classic example of
"what's it doing now?"  The newspaper report about the boat alluded to the
officer questioning the autopilot and then over correcting.  We'll see.

Herb, I don't read much fiction but did read that one.  Yup, lots of
politics involved.  My favorite was the Egypt Air flight that the pilot
dunked in the Atlantic.  The Clinton administration tried to keep the NTSB
out of the investigation at the request of the Egyptian government.  The
Egyptians didn't want it to be known that perhaps the guy flying the plane
was nuts!

Which reminds me, Egypt air has a new flight available.  It goes from JFK to
JFK, Jr.

I have to go fly myself this afternoon.

Enjoy your day.

Brad




On 7/28/06, Bill Effros <bill at effros.com> wrote:
>
> Brad,
>
> In airplane crashes the operators always call it pilot error and the
> union always looks for mechanical problems.  What's your take?
>
> Bill Effros
>
> Brad Haslett wrote:
> > Got a phone call today from the dealer who sold us our new dump truck in
> > Gulfport about a plane crash.  The dealer was flying two customers to
> the
> > Mayo Clinic but the Citation Jet landed in Cresco, Iowa, ran off the
> > runway,
> > killed the pilots, and seriousily injured the two passengers.  As
> > usual, the
> > news agencies don't know squat about aviation or the accident, but
> > write the
> > story as if they were experts. I can only guess that if they're so FOS
> > about
> > airplanes, they are probably FOS about everything else they
> > cover. Disgusting! Anyway, while researching that, I came across several
> > news accounts of the cruise line incident that happened last week.
> > Here is
> > an explanation that seems on the surface to make the most sense.
> > Sounds like
> > it was a tack gone bad.
> >
> > Brad
> >
> > -------------------------------
> >
> >   WESH.COM I-Team: Cruise Ship's List Caused By Human Error
> > Jul 21,2006 00:00 by WESH.COM
> > *ORLANDO, Fla. -- *WESH 2 News has learned the accident involving a
> > Princess
> > Cruise ship was due to human error, not a mechanical malfunction.
> >
> > Two hundred and forty passengers were hurt when the Crown Princess
> > listed in
> > the open sea off the Brevard County coast.
> >
> > Two investigators from the National Transportation Safety Board and
> > two more
> > from the U.S. Coast Guard are riding along on the bridge of the Crown
> > Princess as it heads back to its home port in New York.
> >
> > They're running final tests on the automatic pilot system, but a high
> > level
> > source has told the WESH 2 I-Team that human error, not the automatic
> > pilot,
> > caused the accident.
> >
> > A series of still pictures aboard the Crown Princess on Tuesday
> afternoon
> > showed the chaos and confusion on what was supposed to be the last leg
> > of a
> > pleasure cruise. The ship, 11 miles out in the Atlantic, tilted
> > sharply to
> > the port side.
> >
> > Federal investigators boarded the ship, and almost immediately figured
> > out
> > what happened. It wasn't a computer glitch. It wasn't a mechanical
> > problem.
> >
> > A high-level source, who asked not to be identified for fear of losing
> > his
> > or her job, told the WESH 2 I-Team it was simple human error.
> >
> > "The public needs to know. The ship is safe. There is nothing wrong
> > with the
> > automatic pilot system. It was human error. They made a mistake.
> Mistakes
> > happen," the source said.
> >
> > Here's how our source explains what happened.
> >
> > After clearing Port Canaveral, the captain set the ship's automatic
> > pilot to
> > head to New York. He then left the cruise line's bridge. All standard
> and
> > appropriate procedure.
> >
> > As the automatic pilot found its course back to New York, it started
> > making
> > a left turn when the person in charge on the bridge -- a junior
> > officer --
> > noticed the ship's automatic pilot needle was far to the left.
> >
> > Our source goes on to tell us that the junior officer "panicked," then
> > took
> > the ship out of automatic pilot thinking the meter was showing that
> > the ship
> > was turning too sharply to one side.
> >
> > But instead of turning the Crown Princess back to the right, the junior
> > officer accidentally kept the ship in an even sharper left hand turn --
> > almost like over-correcting in a car.
> >
> > This caused the massive 113,000-ton cruise ship to list severely,
> > tumbling
> > passengers, pool water and everything else on board into chaos...
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