Wednesday, February 23, 2011

Much to Learn from Lucky Landings

Working on my back deck with a friend in 2010
Last summer, while replacing some of the planks on my back deck, I distractedly turned on my cordless circular saw and upon feeling the end of my work glove starting to twist, looked down to see I was just about to saw off a couple of fingers. I had a lot to say at the time, none of which I'll repeat here. But from the safe distance of time, I will now calmly describe the episode as they do in aviation as a "near miss."

I was reminded of my folly this week in Geneva, while reading one news story lauding a decrease in air accidents and another suggesting an increase in cockpit automation errors may be cause for alarm.

I'm thinking that this is a healthy sign. Certainly avoiding airplane crashes is desirable, but to maintain and improve on aviation's enviable level of safety, it's not only accidents that need attention but the glove twisting, "oh s--t" inducing, stomach churning, mostly unreported and often unknowable near-misses.

I've written about  the theory behind my philosophy in my last blog post about the miracle landing of Qantas Flight 32 in Singapore last November. It would take a very active imagination to come up a longer list of things to go wrong than what did go wrong on that flight.

To recap, a Rolls Royce engine failed on the Qantas Airbus A380 shortly after takeoff from Changi airport, sending parts into the wing and fuselage of the world's largest passenger plane. And yet, after two hours sorting through the error messages, the pilots did in fact bring the plane back to a safe landing. Having gotten it on the ground without loss of life certainly doesn't mean this happy ending is the end of the story. Far from it.

In a story on NPR last week, my friend and colleague in the Comprehensive Medical Aviation Safety Database, Capt. Patrick Veillette described an automated approach he was making to the Salt Lake City airport last fall. Patrick, a commercial pilot and and highly accomplished safety specialist told NPR, "What I anticipated the aircraft to do was to continue this descent," he told the reporter. "Well instead, the aircraft immediately pitched up, very abruptly and much to my surprise. And both of us reached for the yoke, going, 'What's it doing?' and there's that shock of, 'Why did it do that, what's it going to do next?'"

Pilot accounts provided to the NASA aviation safety reporting system detail many frightening encounters with automated flight controls as I reported last year in The New York Times and several posts here on my blog. At the same time automation has made many aspects of flying safer.

Tonight, I had a fascinating conversation with an engineer from a European aerospace laboratory who is here in Geneva to learn more about the digital transition in cockpit communication and air traffic control. The digitization of all things flight-related has left the station. That all this high-technology may sometimes err is as certain as the fallibility of low-tech humans.

That is why it has never been more important to thoroughly explore the factors that lead us to almost make a mess of it, whether that's understanding how pilots maintain the presence of mind to pull out after a computer goes astray, or figuring how why we cannot stay focused when the power (and the power tool) is totally under our own control.
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