Sunday, February 10, 2019

ProPublica and the Navy Times on the McCain and Fitzgerald collisions

This weekend, ProPublica's website is running two blockbuster hard-hitting reports on the McCain and Fitzgerald destroyer accidents of the summer of 2017:

The two reports make a strong case that technology by itself is worse than meaningless; you have to invest in people. Training, communications, support: all these things are critical.

Copeman fired off a couple more memos before retiring, hoping he might at last get the leadership’s attention.

The first warned of the fleet’s increasing “configuration variance” problem: The same systems operated in dozens of different ways on different ships, confusing sailors as the Navy shifted them from one vessel to another.

“I liken it to this,” Copeman told ProPublica. “You have a car with a steering wheel and a gas pedal and one day you walk out and get in your car and an iPad sits were your steering wheel used to be and the gas pedal is no longer there.”

Copeman enlisted a four-star admiral, Bill Gortney, to sign the memo and distribute it in the upper echelons of the Navy. His memo would prove prescient. Four years later, confusion over the McCain’s new steering system caused the ship to turn in front of an oil tanker.

See also this set of articles in the Navy Times:

a lack of training in basic seamanship fatally combined with material deficiencies to create “a culture of complacency, of accepting problems, and a dismissal of the use of some of the most important, modern equipment used for safe navigation.”

Wow, there's a lot to think about in these articles.

It's interesting, although perhaps a stretch, to consider the above information against the recent report of the Lion Air tragedy in Indonesia: Lion Air’s deadly flight was a 13-minute struggle between man and machine:

A little over a week after the crash, Boeing put out a bulletin advising airline operators on how to deal with erroneous sensor information that would lead to “uncommanded nose down” maneuvers, while the FAA ordered flight manuals to be updated with the process to follow in such a situation. Boeing has said that the aircraft is safe, and that it is working with regulators and investigators to understand the factors leading up to the crash.

The directives prompted several of the biggest US pilots’ unions to say this was the first time they were hearing of the new anti-stall system. “Before the crash we were not provided any information on the MCAS or even its existence,” captain Dennis Tajer, spokesman for the Allied Pilots Association, the union for American Airlines pilots, told Quartz.

He added that bulletins after the crash provided clarity on differences between the override process for this 737 variant compared with the older 737NG model, which the Max succeeds. “We have those differences… [and] are asking further questions to better understand our airplane’s automated flight control systems,” said Tajer.

Tajer added that the directives and bulletins describe a “fairly complex emergency situation,” involving a system that can engage soon after takeoff, when the plane is still at a low altitude, and a number of alerts that could prove confusing or distracting.

Powerful technology is worse than useless if you can't figure out how to operate it.

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