Re: [SystemSafety] 737 tail strike caused by typo on a tablet

From: Matthew Squair < >
Date: Thu, 19 Nov 2015 07:43:40 +1100


The assessment of the second error as a 'transposition' error committed by the second pilot seems dodgy to me.

Matthew Squair

MIEAust, CPEng
Mob: +61 488770655
Email; Mattsquair_at_xxxxxx
Web: http://criticaluncertainties.com

> On 19 Nov 2015, at 6:44 AM, Gareth Lock (Human in the System) <gareth_at_xxxxxx
> 
> Interesting discussion and one which exemplifies the Efficiency Thoroughness Trade Off (ETTO) which exists.
> 
> The most thorough (and safe?) way would be to have two pilots to do two individual calculations using different media (both electronic but different algorithms, or manual and electronic) and then do the same in the other medium, then cross compare to ensure that the answers are the same. If not, go back in and try to work out where the error was. This would have been the only way to trap the error from this incident due to the same answers but different modes of failure (http://atsb.gov.au/media/5727742/ao-2014-162_final.pdf). This has a time implication as highlighted by Klaus below.
> 
> However, in the real world, time is a real driver with many low cost airlines only at the gate for 30-60mins before leaving again and given the massive number of take-offs and landings taking place with similar process, and the lack of accidents, the airlines are making a calculated risk that the current methodology is acceptable. The regulators must also think this is the case too.
> 
> Despite all of the calculations being correct, you can have issues with crew taxing to the incorrect part of the runway, being convinced that they are at the end of the runway because of the visual cues present, turn around and take-off some 2000ft further into the runway than they thought...as they passed the upwind threshold thinking that was quicker than thought and then looking on Google Maps to see that the taxi chart didn't quite represent the real world...!! An incident report was filed by the crew so others could learn from their mishap.
> 
> Regards
> 
> Gareth Lock
> Managing Director
> Human in the System Consulting
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>> SPRIGGS, John J 18 November 2015 at 10:25 via Postbox
>> José beat me to it; I was writing something similar.
>> One point I have in addition is that the person doing the pen and paper check should not be the person who used the tool to do it. When there is a discrepancy, the checker must not assume that the senior person (no doubt the one with the iPAD) is correct and that (s)he has made a mistake somewhere in the working. The two people should swap methods and do it again.
>>
>> John
>>
>> From: systemsafety-bounces_at_xxxxxx >> Sent: 18 November 2015 10:18
>> To: Klaus
>> Cc: <systemsafety_at_xxxxxx >> Subject: Re: [SystemSafety] 737 tail strike caused by typo on a tablet
>>
>> >> "The calculation is double checked using pen and paper, and so two dissimilar faults were necessary to invoke the failure vector."
>>
>> Again and again, safety arguments include claims about human/manual behaviour that should urgently be re-visited (not to simply say, ruled out).
>>
>> You are a system operator; You have a machine that calculates a value for you; You use it and get an answer; You go and calculate it manually "to confirm"; How biased is you manual calculation already?
>>
>> Simple and harmless personal story: I was 14 years old, doing a math test. For one of the exercises, I was able to mentally figure out the result (value 4), before writing down the equations. Along the writing, I made a mistake and end up with a expression resulting in square root of 36. My brain didn't even notice and I just wrote down that SQRT 36 equals 4 and moved to the next exercise.
>> When you're in a hurry, 16 isn't "that different" form 36 when you already "know" the result, and are not really doing the calculation.
>>
>> Jose'
>>
>> On Wed, Nov 18, 2015 at 10:13 AM, Klaus <klaus_sievers_at_xxxxxx >> Well, hm...
>> I fly 747 since 1987. Copilot, Captain...
>> Distractions have increased, procedure design hasn´t quite
>> kept up with all the things going on during the last minutes
>> before departure.
>>
>> 20 years back, the data for takeoff were calculated by hand,
>> using tables, and everything was ready 15, 20 minutes before
>> pushback.
>>
>> Today, preliminary calculations are done 15, 20 minutes
>> before pushback, but then updated with the latest info of
>> + or - 5 passengers, a bit of cargo - whatever. THEN, with
>> sheduled time of departure coming near, then things are
>> recalculated and finally transferred, manually, into the airplane
>> computers .
>>
>> Distractions ? You better be immune to them - which no-one
>> can really be.
>>
>> About the 737: looks like a 10 ton error to me, maybe 15 % of
>> takeoff-weight. May have been contributing, but I have doubts
>> it was the main reason for the tail-strike.
>>
>> 747s , which are much larger than 737, have been known to
>> scrape the runway, yes, but then the error was more than 25%
>> of takeoff weight. 2xx tons instead of 3xx tons....
>>
>> Solution: try to keep a calm working athmosphere in the cockpit
>> and do as much preparation as can be done : every moment counts.
>> And: do the checklists, the required crosschecks.
>>
>> Hope that this was interesting,
>>
>> Best,
>> Klaus Sievers
>>
>>
>> Am 18.11.2015 um 09:01 schrieb Peter Bernard Ladkin:
>> -----BEGIN PGP SIGNED MESSAGE-----
>> Hash: SHA256
>>
>> Deja vu all over again. http://www.rvs.uni-bielefeld.de/publications/Papers/LadkinHESSD2009.pdf
>>
>> PBL
>>
>> On 2015-11-18 06:57 , Heath Raftery wrote:
>> This news article is likely to be of interest to the list members. A jumbo's tail struck the
>> runway on take-off, and root cause was found to be an incorrect take-off weight entered in the
>> thrust parameter calculator. The fact the calculator is an app running on an iPad may or may
>> not be important to the story, but it does give it that everyday appeal.
>>
>> The calculation is double checked using pen and paper, and so two dissimilar faults were
>> necessary to invoke the failure vector. Is there anything more that can reasonably be done to
>> avoid this safety issue?
>>
>> http://tech.slashdot.org/story/15/11/16/174213/737-tailstrike-caused-by-typo-on-a-tablet
>>
>>
>> Prof. Peter Bernard Ladkin, Faculty of Technology, University of Bielefeld, 33594 Bielefeld, Germany
>> Je suis Charlie
>> Tel+msg +49 (0)521 880 7319 www.rvs.uni-bielefeld.de
>>
>>
>>
>>
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>> systemsafety_at_xxxxxx >> José Faria 18 November 2015 at 10:18 via Postbox
>> >> "The calculation is double checked using pen and paper, and so two dissimilar faults were necessary to invoke the failure vector."
>>
>> Again and again, safety arguments include claims about human/manual behaviour that should urgently be re-visited (not to simply say, ruled out).
>>
>> You are a system operator; You have a machine that calculates a value for you; You use it and get an answer; You go and calculate it manually "to confirm"; How biased is you manual calculation already?
>>
>> Simple and harmless personal story: I was 14 years old, doing a math test. For one of the exercises, I was able to mentally figure out the result (value 4), before writing down the equations. Along the writing, I made a mistake and end up with a expression resulting in square root of 36. My brain didn't even notice and I just wrote down that SQRT 36 equals 4 and moved to the next exercise.
>> When you're in a hurry, 16 isn't "that different" form 36 when you already "know" the result, and are not really doing the calculation.
>>
>> Jose'
>>
>>
>>
>>
>> --
>> --
>> José Miguel Faria
>> Educed - Engineering made better
>> t: +351 913000266
>> w: www.educed-emb.com
>> e: jmf_at_xxxxxx >>
>> _______________________________________________
>> The System Safety Mailing List
>> systemsafety_at_xxxxxx >> Klaus 18 November 2015 at 10:13 via Postbox
>> Well, hm...
>> I fly 747 since 1987. Copilot, Captain...
>> Distractions have increased, procedure design hasn´t quite
>> kept up with all the things going on during the last minutes
>> before departure.
>>
>> 20 years back, the data for takeoff were calculated by hand,
>> using tables, and everything was ready 15, 20 minutes before
>> pushback.
>>
>> Today, preliminary calculations are done 15, 20 minutes
>> before pushback, but then updated with the latest info of
>> + or - 5 passengers, a bit of cargo - whatever. THEN, with
>> sheduled time of departure coming near, then things are
>> recalculated and finally transferred, manually, into the airplane
>> computers .
>>
>> Distractions ? You better be immune to them - which no-one
>> can really be.
>>
>> About the 737: looks like a 10 ton error to me, maybe 15 % of
>> takeoff-weight. May have been contributing, but I have doubts
>> it was the main reason for the tail-strike.
>>
>> 747s , which are much larger than 737, have been known to
>> scrape the runway, yes, but then the error was more than 25%
>> of takeoff weight. 2xx tons instead of 3xx tons....
>>
>> Solution: try to keep a calm working athmosphere in the cockpit
>> and do as much preparation as can be done : every moment counts.
>> And: do the checklists, the required crosschecks.
>>
>> Hope that this was interesting,
>>
>> Best,
>> Klaus Sievers
>>
>>
>>
>> _______________________________________________
>> The System Safety Mailing List
>> systemsafety_at_xxxxxx
> 
> _______________________________________________
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