Warning: the author makes significant conclusions that are not corroborated by the NTSB. All of the commentary on the violation of the sterile cockpit rule and argument before departure are irrelevant to the actual cause, despite the author stating otherwise.
There are some great lessons to learn from this (better flight control handovers during emergency, double checking which engine failed, applying thrust to both engines when nothing else works). The violation of the sterile cockpit rule and the asshole nature of the captain were not factors here as determined by the NTSB.
The first officer gave him bad info and he accepted it. That is not a failure mode caused by being obstinate nor a “team player”.
The author explicitly points out the nonappearance of the captains rant within the NTSB report.
The author points out that NTSB report does allude to the captain's many instances of dubious judgment during the emergency.
The author also highlights the protracted diatribe spanning thirty minutes, transpiring even during the hallowed period of the "sterile cockpit," implying a discernible lack of concentration on the imminent mission.
The captain's unclear headspace became evident by his protracted tirade. He was likely mentally unfit for the task of captaining that day, and the rant was evidence of it.
> The captain's unclear headspace became evident by his protracted tirade. He was likely mentally unfit for the task of captaining that day, and the rant was evidence of it.
You jumped to the same conclusion the author did, which was that the rant was evidence of anything. Some people rant all of the time and sometimes it’s about sexist, racist, whatever things. It does not imply they are mentally unfit for captaining.
> All of the commentary on the violation of the sterile cockpit rule and argument before departure are irrelevant to the actual cause
Which is just as false a statement as it is to say "The violation of the sterile cockpit rule and argument before departure were a significant cause". The fact is, we don't know if it was, but it's not wrong to say that it might be.
Real life is rarely about evidence or not evidence, which is a categorical decision (in contrast to evidence in court, which can be circumstantial).
Some more context in addition to the sibling comment: The classical example is this. You want to test the effectiveness of two drugs A and B in some sort of clinical trial. You gather a lot of data and learn that drug A has an average effectiveness of 4.0, while drug B has 4.9 (more is better). You apply a statistical test and it tells you B is not significantly different from A.
Can you conclude that B is not better than A? You can't. The absence of evidence is not evidence of absence. There could be any number of reasons why we don't have significant evidence, e.g. because the experiment was done with a sample too small. B might be better than A, but there is no evidence it is.
The NTSB gathers a lot of data regarding the crash. The board looks at all the factors and deliberates whether they contributed to the crash. It determines that there is no significant evidence that the mental state of the pilot was relevant.
Can you conclude that the mental state was irrelevant? You can't. It's likely the pilot experienced stress but it is impossible to determine whether this stress was significant. It might well be, but there is no evidence it was.
Parent seems to think it was not a factor. But by relying on a flawed argument we will not find out why he actually thinks that way, ultimately leading to an unproductive discussion.
> The NTSB would have called it out if that were the case.
If there’s protracted conversation unrelated to the safe operation of flight, apparently agitated conversation, being conducted during a critical phase of flight, it seems odd that the official report would not mention what led the NTSB to exclude psychological factors and/or cockpit distractions as a contributing factor. But I don’t read these reports frequently; so maybe that’s not how they are structured. I imagined that they were structured like scientific papers where the conclusions typically anticipate reviewers’ critiques and dealt with them in advance. Then again, there’s no intent of peer review here.
> In the end, the NTSB declined to mention these conversations in its final report, *which is normal — most of the time, the agency doesn’t wade into pilots’ personal disputes*
> Some people rant all of the time and sometimes it’s about sexist, racist, whatever things. It does not imply they are mentally unfit for captaining.
Given the whole idea behind the sterile cockpit rule, I'd say this is clearly wrong. It's true that ranting about mysogynist murder fantasies is probably no worse from a safety perspective (albeit wildly more offensive) than other topics, but ranting about anything is just a no-go in the air. When you're flying the plane you're supposed to be talking about flying the plane, and nothing else.
It really seems like you and other posters here want this blog post to be some kind of woke tirade you need to rebutt. But that's not how most of us are reading it. They mysogyny is the evidence, not the crime. Really the article is pretty dry.
> Some people rant all of the time and sometimes it’s about sexist, racist, whatever things. It does not imply they are mentally unfit for captaining.
That would be even worse: If the captain consistently disregards their training by engaging in unnecessary conversations during designated sterile cockpit periods, it indicates a consistent lack of suitability for the position of captaining an airplane.
There have been some very smart racists in the past. Depending on your definition of racism, it could even include Nobel prize winners from the last century.
> “These are the kind of women you don’t wanna get married to,” he said. “You know, some men, they lose their temper and the next thing you know, the wife is dead, you know… they start punching them and kicking them, and they lost their minds, you know… they kill the woman… it’s the woman who can drive you to do crazy stuff, you know?”
My guess is that the NTSB wants to focus on causes that they can issue guidance for, rather than assign blame. Sure, the captain's state of mind most likely contributed to the incident, but it also revealed a couple of issues that warranted new guidance, which is a big part of what the reports are for.
The NTSB should have issued guidance that if the pilot or copilot is in a distraught emotional state, takeoff should not happen. And it is the responsibility of the other to abort takeoff.
This is organizationally hard to do within an airline. But it is easy to do if regulators back it up, and the questionable state is backed up by dialog during the "sterile cockpit".
No, this is absolutely incorrect. The NTSB focuses on the cause, regardless of whether or not guidance can be issued based on it.
The guidance itself will be focused on relevance, but the root cause is never tainted that way. If the NTSB thought the rant had absolutely anything to do with this, they would have mentioned it.
> The captain's unclear headspace became evident by his protracted tirade. He was likely mentally unfit for the task of captaining that day, and the rant was evidence of it.
Reading through the article, that's not the feel I get. As presented by the article, the captain state of mind did had an effect, he was not at 100% of its mental capacities.
But reading through the CVR transcript, the communication between the first officer and captain was good, and the crew did fly the plane from take-off up until the end which implies that the breach of the "sterile cockpit" rule before take-off did not had any major effect. They were fully focused on the task of flying immediately before and during the emergency.
They simply both made mistakes/bad judgement calls.
In fairness, the captain did make more mistakes, and some of these mistakes maybe may have been avoided if he was in a different state of mind. But at the same time he was placed in a situation where these mistakes could occur and become catastrophic (very old and unreliable plane lacking maintenance and ways to easily troubleshoot an engine failure).
In my opinion, he, or any other pilot could have made the same mistakes even in a right state of mind. It's also an unreasonable assumption that pilots will always operate at 100% of their capacity.
The question of whether the CVR recording demonstrates good communication is something of a red herring. As the article and NTSB report make clear, the crew deviated significantly from the correct procedure, which should have led to the unambiguous identification of the working engine. While the crew were not arguing, cockpit discipline had still broken down, with the result that the pilots talked themselves into believing that they had a double engine failure.
The deviations started with the captain struggling with an overloaded radio channel, which should have been cut short by squawking 7700. Th article notes that the controller was a woman. Was that an issue in what followed? It’s a possibly-relevant factor that we will never get a certain answer to.
No one is assuming that pilots will always operate at 100% capacity, which is one of the reasons for having procedures intended to catch common errors.
Would the 30min discussion during cargo loading count against the sterile cockpit rule? Obviously the ground is less than 10,000 ft but surely there's a point in time that defines the "start" of the flight when the rule goes into effect.
Most of the pre-flight work on a plane on the ground is safety critical, with rules around them written in the blood of somebody who wasn't paying enough attention and missed them.
Paying attention to things like weight checks, fuel checks, and systems bringup should take priority over gossip.
Imagine if your prod system was on fire, and while waiting for a diagnostic query to run, you talk your coworkers ear off about how you really dislike working with another coworker. It's just not the time to do that. Every single flight requires your attention, and letting things become routine is called "normalization of deviance" and is step one to an event that kills people.
It's not a transcription of the NTSB report. This is a post on a dedicated and reasonably well-thought-of aviation safety blog. I think it's reasonable to expect some editorializing and be expected to weigh the arguments on their merits.
The NTSB is great. They're not the final word on anything in particular.
It’s an armchair analyst injecting their pet peeves into an otherwise narrated report of what the NTSB found.
It’s disingenuous to do a publication the final report and cause of a crash and blend in your own views without big disclaimers that they aren’t supported.
It’s no different than the author focusing on the ethnicity or religion of the pilots or even the phases of the moon and planets. There is what the NTSB said, and what the author pulled out of his ass. They are unfortunately blended together and pretty severely conflict in this case.
It does seem to me that the author has injected their own theory of the state of mind of the crew, but in what way does this theory conflict with the NTSB's account? I agree that if there was evidence that the state of mind of the crew was a significant factor in the cause of the accident that they would have mentioned it, but this simply means they did not find sufficient evidence for this theory, not that the theory is incorrect.
Him, the topic here is aviation safety and this particular incident. I didn’t add any analysis of the cause of the incident. The author made conclusions up whole cloth.
The NTSB is great precisely because they deal in facts.
This article does not, yet presents speculation as fact, without critical context that the NTSB certainly considered.
Facts are important because you can learn from them, speculation about human behavior is sensationalist bullshit because you can't prove it and can't reliably prevent human error in the first place.
For example: only a handful of 372's were ever ETOPS certified and I'm pretty sure this plane was not one of them. Should airframes with lower reliability like that even be allowed to operate in areas like Hawaii in the first place? Clearly these pilots weren't prepared to handle the situation, what needs to happen (and what the NTSB aims to do) is to avoid putting any other pilots in the same situation, from a holistic perspective
Well, in this case it was undeniably human behavior that crashed the plane: if the pilots would have, at any point during the flight except at the very end, realized that they were trying to fly using the damaged engine, and switched to the other engine instead, they probably could have salvaged the situation. So I think a psychological analysis of why this didn't happen is warranted, and the story about another copilot refusing to fly with the pilot because of his disregard for procedures is relevant context, even if the NTSB didn't mention it.
No, you don't know that. I'm just not sure why people are trying to read things into the narrative that simply no known.
The captain rather demonstrated proper CRM by delegating aviating to the co-pilot while he communicated with tower control. He also trusted the judgment of the fist officer as to which engine was out, although the information he was given was wrong.
The other pilot was told by the chief pilot to not fly with the captain.
Also, see this quote:
> “This is the way we work when I am with her, you know, you have to yell at her to force her to do things.”
This is ignoring the paid-in-blood lessons of the worst aviation accident in history (Tenerife) that could have been avoided if the captain listened to his crew. Crewmembers should always feel free to speak up in safetry critical situations. You don't "force them to do things".
I don't think this contributed to this particular incident because both pilots agreed on the wrong engine but it is very valid criticism IMO.
My original intent mentioning ETOPS was supposed to be a point about wild speculation being detrimental to reporting and recommendations, unfortunately the point got lost in a copy paste mistake while rearranging my comment.
ETOPS absolutely _could_ have made the difference here. Either by avoiding the engine failure in the first place my way of more strict maintenance requirements, or potentially by setting the expectation that the aircraft can operate with a single engine and causing the pilots to rethink which engine was underperforming.
But just like the original article, speculation like that is not practical for an NTSB report
Yes, really. The pilots checked flaps/gear multiple times trying to diagnose the speed & altitude issues. The article says the pilots assumed that was the expected performance of the old engines, but I haven't read the transcripts to see if that's another speculation/editorialization by the author. Theorizing that better expectations for single engine performance could have avoided the crash is no more of a leap than what the author made.
The point of ETOPS is to ensure that pilots can continue to operate the plane on a single engine, and that the likelihood of dual engine failure is vanishingly small. It explicitly requires manageable pilot workload (which was cited by the NTSB as a failure/contributor to this crash), and is implemented in part through more rigorous maintenance and inspection.
You're right that ETOPS would not be required for a flight like this but aside from the notable flight envelope difference (since ETOPS focuses on engine failure while cruising far from airports) the considerations for ETOPS are very similar to considerations that would go into prevention this crash in the future.
Pretty sure your point about 737-200 ETOPS certification is also not present in the NTSB report. Why is it OK for you to pontificate but not the linked author?
I meant to have a point that if you grab at tenuous connections every report would speculate to the point of uselessness, but that got lost to a cut and paste mistake while rearranging the comment.
Author of the article here. Reading this thread, some commenters get it, but others have not.
The sexism doesn't have anything to do with the crash, nor did I claim that it does. So why did I even bring it up? This is probably news to most of you, but I'm a woman, and let me tell you, when we hear a man say something like that, we pay attention. I was shocked when I read his statements in the CVR, and felt it would be eye-opening for some people to hear them. Nor is it character assassination to point out that the things he said are wrong and contribute to a hostile working environment for women.
What could—not DID, but COULD—have actually contributed to the crash was the stress that the captain was under as a result of the incident. The hypothesis that he was stressed before the flight is supported by the length of his discussion of this one stressful topic, extending into periods where off-topic conversation was banned. Note that I specifically characterize this as a hypothesis supported by evidence; I didn't portray it as established fact, and I specifically pointed out that I was going beyond the NTSB report. However, the NTSB report doesn't say anything one way or the other about whether this was a potential cause of the captain's stress (stress which the report did identify as a contributing factor). I'm not contradicting anything in the report, but rather highlighting a connection which really stood out to me, from my particular perspective. So to those who say "if it was a problem, the NTSB would have mentioned it," is it not equally true to say "if it wasn't a problem, the NTSB would have refuted it?" To me, silence on the topic leaves the door open to independent analysis. If the NTSB didn't want people to make this connection, they should have addressed it.
Lastly, I want to mention that I actually contacted the relevant NTSB investigators for comment before publishing this, but they declined interviews.
It seems problematic with pilots who get into arguments with others, based on those other people's gender, or in other cases maybe skin color or whatever. And who in that way make themselves upset, so they cannot concentrate on flying! Sexist pilots are an air safety risk?
It's interesting in another way too: I think the crazy thing he said, suggests that he is a bit dumb. (Both for having such thoughts, and for sharing them with others, whilst being recorded.) Which is of relevance, I think. And might indicate that there was a recruitment problem as well. (The airline company hires dumb and sexist pilots?)
Disagree. To me, the main point was that the human brain fails, under stress. It starts imagining things, forgetting things.
But checklists, they stay the same, don't change, under stress. So, follow the checklists. But they didn't.
(Of relevance for software too, I think: DevOps and Site Reliability Engineering)
The sexist things are not just interesting, but of some relevance to the crash, for other reasons I think -- see my reply to the sibling to your comment if you want.
Shutting off the good engine after an engine failure is an error that has caused at least three previous crashes.[1][2][3] It can be surprisingly difficult to tell which engine failed.
1) was a USAF aircraft, a 2-engine Bombardier aircraft. Despite the name, this is a small civilian jetliner. "Loud bang" and engine failure in cruise. "Because the warning signal did not immediately light up for the catastrophically damaged left engine — it took several seconds for its RPMs to drop below the point that would have triggered the signal — the crew didn’t immediately know which engine had blown. The pilots thought the right engine had experienced the emergency, leading them to shut it down instead of the left one. The shutdown meant the plane now had no engines operating, and happened relatively quickly, about 24 seconds after the fan blade broke." A restart of the wrong engine was attempted while the good engine was kept shut down.
2) is a well known disaster. "The aircraft was on a scheduled flight from London Heathrow Airport to Belfast International Airport when a fan blade broke in the left engine, disrupting the air conditioning and filling the cabin with smoke. The pilots believed this indicated a fault in the right engine, since earlier models of the 737 ventilated the cabin from the right, and they were unaware that the 737-400 used a different system. The pilots mistakenly shut down the functioning engine. They selected full thrust from the malfunctioning one and this increased its fuel supply, causing it to catch fire. Of the 126 people aboard, 47 died and 74 sustained serious injuries."
3) is from 1969, and is something of a period piece. This plane had three pilots; two in seats with controls, and a third one as "pilot in command" supervising but with no access to the controls. His comment, afterward, was “It is perhaps not quite correct to be ultimately responsible for the safe handling of an aircraft in an emergency unless occupying a seat from where this can be done. I feel, somehow, that had I been occupying either of the pilot’s seats I might have reacted differently; on the other hand, it is possible that had I not been present the two pilots might also have reacted differently.” That strange setup may have been a holdover from the British early WWII "aircraft commander" concept. This was borrowed from naval practice, where the officer of the deck tells the junior people who are actually driving the ship what to do. It turned out to be a terrible idea in the air, where things happened faster. But somehow British United Airways was doing it in 1969. Nobody questioned the pilot in command deciding, wrongly, which engine had failed.
Even more than that. There were a couple of incidents in the USSR. One with Tu-104 in 1961, when the pilot turned off the wrong engine, although in that case, instrumentation also failed properly to indicate the malfunctioning engine. Then there was a Tu-154 flight ЮХ372 in 2010, where incorrect engine failure indications prompted rash actions that resulted in a crash landing.
And the TransAsia Airways Flight 235 in 2015 with a very similar story to the one in the article.
I realise that the circumstances might not always allow for this and the issue may not always be visible, but if the plane is able to climb up to a stable altitude, why not have the captain or first officer leave the cockpit to go and visually confirm?
Your link mentioned it as one of the causal factors:
In this confusion, induced by the rushed approach, they did not catch that the copilot had brought up the throttle for the dead engine, and left the throttle for the good inboard engine at idle power. This made them a two-engine heavyweight aircraft without enough power to save themselves.
Excellent article. Taught me about the "sterile cockpit rule," which I think might be really useful at my work. Sometimes people start chatting at critical moments during operations and I think I might introduce the concept of "sterile cockpit" during those moments to get people's focus back.
When I used to work networking tech support we had rules about how if there was a P1 network down situation that sales and account managers got their own conference call… and engineers had their own. (obviously we would sync up at some point, eventually)
It was also understood that non technical managers and etc could not wander over to the tech support floor.
It was absolutely critical in order to maintain good technical communication and etc. No drama, just matter of fact check lists and technical discussions.
A big bank could have all their ATMs down (sorry I did that once) and the discussion was all technical and cool and calm.
Our technical staff customers loved it too as their management were on the other call too ;)
That’s a yes. I have personally been on public cloud major incident calls. They are strictly on-topic only and generally only the incident coordinator, their offsider, and one or two SMEs, are authorised to speak. There may be hundreds or even thousands of listeners around the globe, most of which are there to fan-out status to impacted internal teams and major customers. However there will also be multiple text-based side-channels going on with the involved service teams.
Telco guy here, similar story. Our standard procedure dictates who is on the crisis call, with increasingly high ranks being sucked in as the incident escalates the severity scale by meeting objective criteria - for the highest levels of outage (think "no more phone service in the whole country" or "ministry of defence lost all its fiber links"), it can theoretically mean waking up the CEO in the middle of the night. Representatives of involved teams may come in and out of the call but usually stay on to maintain liaison.
I'm surprised that's not already an thing in that ops center. Maybe being an outsider I've built up an unrealistic aura of awe around NASA/JPL type environments where those places would be quiet as a church unless something like landing or some other epic accomplishment where everyone was cheering. Otherwise, I'd expect everyone to know that when the shit hits the fan, everyone is hunkered down doing what needs to be done. Does the long lag between issuing commands kind of break that?
There's a well-choreographed dance of meetings (with polls, e.g. go / no go) and head-down sequence writing. Meetings have a pretty rigid structure and there are zero off-topic comments. But the time for getting the actual sequencing done often has chatter with varying amounts of on-topic-ness. Generally, people are really great at not distracting each other-- I've only occasionally had an issue and when I bring it up, chatter ends. It's just that having a term for it would make it easier to bring up.
"Socialize with your colleagues" is actually an item on one of our checklists!
Do you feel that something as long running as Curiosity that things become a little more lax as everyone gets to a level of complacency? I could see where that might happen, but at the same time the concept of I'm controlling something on the surface of another planet is hard to forget. Basically, super curious about the day to day of a job I'm very jealous of in a very respectful way
Interesting question about complacency. Hard for me to speak objectively on this since I'm too close to it to be unbiased, but I'll try. I actually think the level of acceptable risk is gradually dropping. Each time something goes wrong, we add procedures. It's much easier to add rules than to remove them.
I do think the risk tolerance of individuals on the project does tend to gradually increase with experience, but we have fairly high turnover. It's common for MSL roles to have a year or more of training before certification during which you spend a lot of time focusing on what can go wrong, so new people definitely trend cautious.
> Does the long lag between issuing commands kind of break that?
That would be my assumption.
For earth operations everyone would be focused and ready (especially if that involves people). With Mars there’s several minutes of comm lag, by the time you get an emergency signal it’s resolved one way or the other.
Signal travel time isn't really a significant delay in the planning cycle. What matters is waiting for orbiters to fly overhead for downlink, DSN scheduling, and the 6 to 8 hours it takes to write a typically 1 to 4 sol plan (set of commands). Also constraints of getting it done during regular work hours, ish.
I should say, the above response is with respect to ops for landed Mars missions, during the surface phase. I haven't been involved with ops for missions in deep space orbit or coast (& Entry Descent and Landing), lunar missions, etc. in which more of a real-time-ish paradigm is possible, so I don't know how that works.
We rely on both, and I think we've got the mix about right. Text for relatively simple things, when numbers and other identifiers need to be transmitted accurately, voice / video for complex discussions that require screen sharing and / or when there are multiple opinions that might need to be reconciled.
I imagine such rules are easier to apply when it is a singular context and physical delineation of space. It takes advantage of our subconscious human rules of behavior.
An office-example might be if you had the super-serious conference room that is exclusively used for super-serious things. The physical context would affect how likely people are to follow the desired norms.
> "Of course, the reason was because First Officer Ryan had set both thrust levers to idle, and because of the control handover, no one pushed them back up again."
> "In fact, with both engines at idle, the asymmetric thrust had disappeared, and it was trivial to keep the plane straight and level."
> "First Officer Ryan even seemingly forgot that the left engine was at idle power because he put it there himself not even two minutes earlier."
And here we have the primary cause of all the confusion. It was not trivial to keep the plane at level, if engines had no power. The "sexism", the "given their earlier conversation, he surely knew where arguing with Okai would get him (which was nowhere)" aren't the cause here.
No, sexism didn't cause the accident, but I'm glad the article brought it up. Those comments excusing men who murder their annoying wives were horrifying and frankly I think anyone who says stuff like that in the workplace (in this case, violating sterile cockpit) deserves to be exposed publicly (especially a divorce lawyer).
And, it is relevant context, given the kerffufle about whether to follow the checklist and how flustered Okai became.
> And, it is relevant context, given the kerffufle about whether to follow the checklist and how flustered Okai became.
No it’s not. The call to not follow the checklist came from the first officer (focusing on flying the plane was higher priority). The captain didn’t challenge him on it because he agreed with the call. There was no “kerffufle” or even disagreement.
I called it a kerfuffle because they started the engine shutdown checklist and then abandoned it after a couple of items, which seems pretty kerfuffly to me.
I thought the discussion with Moore was relevant because that argument had been about Okai not doing procedures by the book, and because Okai has been previously reprimanded for failing to follow an engine shutdown checklist.
> Those comments excusing men who murder their annoying wives were horrifying
You might think twice about your interpretation of this. It is mainstream psychology to recognize the effects that one human can have on another. Brainwashing happens. Induced mental trauma exists. Look at Charles Manson and the influence he had, look at Patty Hearst. Humans can have drastic influence over their victims (intentionally or unintentionally) and there should be no shame in the ensuing mental illness that results, and neither gender no perceived gender roles should diminish our sympathy for such victims.
To say carte blanche that no woman can mentally traumatize a man to the point that he should be considered a victim of brainwashing is a bit naive and likely sexist.
> To say carte blanche that no woman can mentally traumatize a man to the point that he should be considered a victim of brainwashing is a bit naive and likely sexist.
> Those comments excusing men who murder their annoying wives were horrifying and frankly I think anyone who says stuff like that in the workplace (in this case, violating sterile cockpit) deserves to be exposed publicly (especially a divorce lawyer).
These are obviously horrible things to say, but people "vent" all the time to their friends saying things they don't mean. I've head women who recently got broken up with say all men should die, people say they wish their manager got hit by a bus, etc.
"Excusing murder" seems like the worst-faith interpretation here, and anyone who vents their angry thoughts being "publicly exposed" seems like it would do a lot more harm than good.
That would indeed be bizarre if somebody did that. (History: This originally said "dead", another comment corrected it and it was changed and subsequently that other comment was deleted. My comment above was also confused, I was thinking Okai was a divorce lawyer, but actually that was Ryan.)
> As First Officer Ryan listened, interjecting only occasionally to affirm his captain
So, I think the sexism is important to the explanatory narrative because it demonstrates the scale of the power imbalance between the captain and the first officer - the captain sat there and blabbed for 32 minutes including something so objectionable as musing about how if annoying women get murdered, it's their fault. Quoth the article:
> “These are the kind of women you don’t wanna get married to,” he said. “You know, some men, they lose their temper and the next thing you know, the wife is dead, you know… they start punching them and kicking them, and they lost their minds, you know… they kill the woman… it’s the woman who can drive you to do crazy stuff, you know?”
But the first officer was not empowered to object to that - not empowered to object for sexism and murder, not for tabs vs spaces, not for anything. There was, therefore, possibly nothing the captain could have said in that 32 minutes that the first officer would have objected to.
> So, I think the sexism is important to the explanatory narrative because it demonstrates the scale of the power imbalance between the captain and the first officer
Exactly. Patriarchy isn't just a system where all men have power over all women. It's also about hierarchies of men. A good example is the FLDS [1], which Jon Krakauer wrote about in Under the Banner of Heaven. [2] There, the highest-status men are supported by other men who are rewarded with dominance over other lower-down people. That produces a bunch of surplus young men who are eventually driven off.
This sort of continually enforced dominance hierarchy, whatever you think of it morally, is poisonous to the kind of mindset and relationships you need to keep up our (extraordinarily good) airline safety record.
And let me also add a plug for Dekker's "The Field Guide to Understanding 'Human Error'", which is on the surface about understanding airplane crashes, but does a great job of conveying why important technological systems require a very different way of thinking about things to succeed. One of my top books of all time, especially for anybody in tech who cares about uptime.
Or the first officer just didn’t care. He didn’t call it up in the post interviews as something that he felt uncomfortable about. Sexism is shockingly rampant.
You don't think women might trade tirades about men when having off the record conversation with just two of them in the cockpit? People vent, it doesn't mean much by itself. If he had a fight with a male copilot, he may have had a different tirade.
Agreed. Women can be certainly be sexist and should be held to the same standard as men. If a woman crewmember said women can't be blamed for murdering annoying husbands while taxiing a 737, that would absolutely be inappropriate. And, the main point here wasn't that there was fight followed by sexist reflections on said fight, but that there was a fight.
> You don't think women might trade tirades about men when having off the record conversation
Just in case it's news to anyone: they absolutely do. It's very eye opening when you witness such things. Women can be and often are just as hateful as men.
Dang, that really sucks about your formative experiences. I'm sorry for you and hope you don't have to spend the rest of your life harboring a secret hatred for half of all humans. I'm guessing that at some level you realize women are people and it's not healthy or sensible to despise them as a group, but it's not an opinion you can just "fix". Have you tried counselling for this?
And frankly, yeah, it's disqualifying. Having read this comment, I wouldn't consider hiring you for any position or voluntarily working with you at all until I had some assurance that you're able to transcend this issue. (n.b. I'm a straight, cis, white, man)
At some point you have to deal with the fact that your formative years are not an excuse for holding a life-long grudge against such a large group of people. This makes no sense at all.
I’m having trouble parsing your comment. What behavior falls under “men being humans”? Like, “we’re all flawed” or the killing-your-wife idea from the article?
Also obviously on board with the other comments explaining that bad childhood experiences are not an excuse to form beliefs you know to be biased and false.
Not sure why the scare quotes. What he said was definitely sexist and doesn't need defending; and no one's claimed his sexism was the cause of the accident, so that argument doesn't need refuting either.
The idling was not the cause either - the problem as the report points out is the 1m40s the captain spent trying to talk to the tower, instead of going through the checklist to identify the failed engine. That was before they were set to idle.
That's some major scapegoating of flight crew, when their airline clearly has not maintained the plane properly and caused engine failure in the first place and airport failed to provide adequate ground control support. Easy to be a backsit driver/pilot when you are not flying a damaged plane over the ocean with nobody acknowledging that you have an emergency. Ideally sure, pilot and first office would have done everything by the book and maybe landed at airport safely. But life is never ideal, and I wonder if Transair offered a lot of paid time on simulator to periodically review every likely emergency scenario. Copilot saved captain's life by directing rescue crew to leave him alone in the water and focus on captain first, so I don't think they are horrible human beings.
I don’t think anybody thinks that they are horrible human beings. The article is certainly not implying that in any way about the copilot. The captain clearly has failings, as described by the article, but it is not implied in any way that he is a terrible human being.
> some major scapegoating of flight crew
I disagree. They had a perfectly flyable airplane and crashed it almost killing themselves. That is not good airmanship.
Yes, all of those other things were also factors. I totaly understand that. The point of hearing stories like this is to understand what went wrong and how we can learn from them to not commit the same mistakes. Zero scapegoating.
> That's some major scapegoating of flight crew, when their airline clearly has not maintained the plane properly and caused engine failure in the first place and airport failed to provide adequate ground control support.
Most disasters result from multiple things going wrong together, hence the importance of addressing them individually.
I don’t think the pilots are being scapegoated when they ditched a working plane in the ocean. There were a lot of things that led them there and a lot of reasons it happened, but this crash was avoidable with proper procedures.
For me, the biggest takeaway is "never fly under stress" - which can be dangerous even when flying small drones!
The problem is when corporate culture, and be it because of understaffing or penalizing people for calling out, disincentivizes people from following that basic principle.
A side note: The fact that such absurd crew confusion is still possible in 2021 doesn't exactly warm me up to the thought of twin-jets crossing over the Atlantic and Pacific oceans.
Most vehicles don't have hundreds of people onboard or the mass and kinetic energy to kill hundreds (or thousands, in case it crashes into a skyscraper) more on the ground.
The closest you can get is a couple dozens on a bus, and we regularly have issues with tired/stressed drivers there and catastrophic incidents - but unlike airspace, next to zero enforcement of protection rules :/
True, but all vehicles operate on the same road system that does have such vehicles and the kinetic energy of any vehicle at highway speeds is most impressive.
You are 100% right… Though I also suspect the percentage of stressed commuters is quite high. I know when I was commuting (greater LA area) that it was often quite stressful. Finding the way to do it and stay happy was kind of a tricky thing (and changed day to day).
If by confusion you mean getting the failed engine wrong, there are already technical mitigations that exist (as noted by the article). They just haven't been retrofitted to ancient 737s.
> And yet, despite this fact, the Boeing 737 still does not come with an EICAS. 737s are rolling off the assembly line at this very moment without the system. This is because adding an EICAS would disrupt the continuity between the various 737 models, forcing pilots to receive separate type ratings for 737s with EICAS and those without. This feature of the 737 series is so fundamental that when a rule requiring EICAS on new models certified in the US came into effect at the end of 2022, Boeing and 737 operators lobbied Congress to grant an exemption, allowing the FAA to finish certifying the new 737 MAX 10 and MAX 7 without an EICAS. The pressure was immense: after all, major airlines didn’t want to buy the MAX 10 and MAX 7 if their pilots would have to acquire a new type rating to fly them, and if the airlines weren’t going to buy the models, then Boeing wasn’t going to build them, resulting in job losses and a shortage of narrow body airliners on the market. As a result, in the immediate future, 737s will continue to fly around the world without the benefit of EICAS, even though nearly every other modern airliner now has the system. There were of course compelling reasons behind the exemption, but that doesn’t mean there isn’t a trade-off.
Of course those arguments are BS anyway, the airlines are not going to stop buying airliners just because of some type rating requirements. It's not as if they have any choice. Boeing is just worried they'll buy Airbus instead.
But at the same time, the UI design of the EPR readouts just sucks. It's hard to say whether the engine is idling or at the full power with a simple glance. And the fix would have been easy, just add a limiter at the 12 o'clock position and rescale the gauge accordingly.
Maintenance, Maintenance, Maintenance! Many things bother me about this avoidable crash, but maintenance is the worst. Engine rotor blades have to be x-rayed for cracks and corrosion on a semi-regular basis. The company must be held responsible, just imagine the loss of live if this would have happened over landed areas.
Also, the gauges tell the story, the captain should have verified what the 1st officer told him, especially with an engine failure. Thankfully, both survived.
>(Public service announcement: if a husband murders his wife because he thinks she’s annoying, that’s the husband’s fault. I shouldn’t need to say this.)
I'll tap this box open. The author goes out of their way to paint a bad picture of the pilot by switching "crazy" to "think's she's annoying". He absolutely should not rant about this on the company plane, however if a murderer has any history of mental illness, yes, a woman can literally drive you crazy.
I really liked the story and the way it was told. I could sit there with the guys and experience their stress and panic.
The point about sexism was unnecessary and detracting to the story. It's yet another sad sign of how political propaganda infects absolutely everything. I long the days where you could simply enjoy a story without having to endure references to any kind of cultural war (sex wars, identity politics, etc), or narcissistic virtue signaling from an author.
Yes, sexism bad. Yes, woman were unfairly treated at some points in history. Yes, people should have sex to whatever consenting adult entity they prefer. But do we really need to plaster every single wall in life with those messages? To me it's just tiring. I need places where the relentless totalitarian narrative "our tribe good, that tribe bad" stops and I can simply enjoy life and smell some flowers.
I can't help but think the author craved a tap on the back, and wanted to send a message saying: "please like me because I'm one of your gang. I despise sexism and this story is factual evidence that the rival gang (sexists) are incompetent assholes".
But using the HN ethos, I should assume a positive intention from the author. Such a reading would be: "women are good intuitive thinkers, and the woman who walked out that flight knew the pilot was not competent". But if that's the intention, there's no logic or arguments to support it in the story.
Before this pilot crashed his plane, he said into the black box that when a man kills his wife, it's the wife's fault. This is excellent evidence that that sexism is alive and relevant in our world.
The fact that the pilot ranted about his female co-worker for 30 minutes, after engine start, in violation of cockpit hygiene rules, is how we know that the pilot's sexism is relevant to this plane crash.
> he said into the black box that when a man kills his wife, it's the wife's fault.
That's not what I read. He said a woman can drive the man crazy. The use of the word "crazy" show that the captain understood that such an action would be madness. He simply highlighted how interactions with their wives could be so infuriating to some men that they do crazy things.
He absolutely did say that. He specifically references the female co-worker he had a shouting match with the previous day, and then says:
"These are the kind of women you don’t wanna get married to. You know, some men, they lose their temper and the next thing you know, the wife is dead... it’s the woman who can drive you to do crazy stuff, you know?"
The idea that this is some kind of passive, context-free observation that some men kill their wives after getting frustrated with them is absurd.
Whoa. Yes, the altercation with the woman copilot is the context. It doesn't change what the Captain said:
> "These are the kind of women you don’t wanna get married to. You know, some men, they lose their temper and the next thing you know, the wife is dead... it’s the woman who can drive you to do crazy stuff, you know?"
How do you go from the statement above to: when a man kills his wife, it's the wife's fault? He is simply saying the wife's behavior is a factor, nothing more.
> The point about sexism was unnecessary and detracting to the story. It's yet another sad sign of how political propaganda infects absolutely everything.
disagree. it goes to show what was on the Captain's mind when he should have been focusing on preparing for flight, and getting his head in the game.
he was obviously rubbed raw by the interaction, and blamed it on sexist things rather than considering that maybe he had a hand in the outcome of the conversation with the woman in question.
this lack of ownership of one's own actions as demonstrated by the captain was apparent throughout the entire article and was a factor in the crash, as described.
> he was obviously rubbed raw by the interaction, and blamed it on sexist things rather than considering that maybe he had a hand in the outcome of the conversation with the woman in question.
If we consider that the captain spoke for 32 minutes, I don't think a half dozen quotes are necessarily representative of the 32 minutes.
It's possible he spent 30 minutes talking about her poor technical performance and poor teamwork with other pilots, and 2 minutes making sexist remarks. But sexist remarks are much more sensational, plays to certain prejudices, and are more likely to drive clicks than criticism (perhaps warranted) of someone's professional behavior.
sexist remarks are also very indicative of where his head was at the time. he was not focused on the task in front of him.
please stop seeing things like this as virtue signaling. it's myopic, and negatively colors your view of what is going on.
mentioning the sexism is a very effective way to communicate what was going on in that pilot's mind to people who have a good handle on why sexism is a problem and where it is commonly observed. that's all it is.
there's no "I'm better than you because I say sexism is bad" in this article.
> sexist remarks are also very indicative of where his head was at the time. he was not focused on the task in front of him.
My point, which I will repeat again, is that you should not judge "where his head was at the time" based on a handful of quotes cherry picked from 32 minutes.
> please stop seeing things like this as virtue signaling
Please stop seeing things as reinforcing whatever prejudices you walked into this with.
> I can't help but think the author craved a tap on the back, and wanted to send a message saying: "please like me because I'm one of your gang. I despise sexism and this story is factual evidence that the rival gang (sexists) are incompetent assholes".
FWIW I think Admiral Cloudberg's not a guy. Fair chance they've experienced sexism themselves.
Based on the radio recordings, I wonder if the Captain would have had more immediate success with ATC if he had explicitly used the [seemingly?] recommended 'mayday' phraseology.
Eh, PANPAN is fine, but AFAIK the FAA and it's international counterparts views the use of MAYDAY in even a single engine failure as entirely appropriate.
Partly because the pilot cannot be certain that a single engine failure hasn't caused secondary damage, or that it's a not symptom of another deeper problem (i.e. running out of fuel). And in part because the FAA doesn't want pilots to hesitate calling MAYDAY and potentially making the situation worse by staying in the air longer then they absolutely have to.
It's not quite a typical case of left-right confusion, but I wonder if it could be partially related.
There seems to be a very wide range of abilities there. Some people seem to always know the difference, but for some of us we're giving directions by pointing, because a turn is coming up and we can't figure it out in time which is which.
I wonder if the people involved had trouble with direction and mirroring in general?
Other than the clickbait headline, this was a very good article. And it turns out the author's take of a 'self-delusion' crew was irrelevant to the crash. The pilot got communicate, navigate, aviate totally backwards, which cost critical checklist time, but that wasn't the biggest failure. It was the first officer's bad engine analysis that led them into the sea.
IMO this isn't even an instruments problem. There have been many crashes stemming from pilots diagnosing the wrong engine as the problem and shutting down a working engine.
Where's the NTSB recommendation on creating an official policy on HOW to diagnose an engine? The abnormal checklists only tell you to "shut down the broken engine" but leave it up to you to ad-hoc a way to diagnose the problem in an emergency, which is the wrong time to be inventing something non-trivial. Boeing/Airbus/GE/Rolls royce, whoever should have an official document describing a procedure to test an engine for failure that pilots are expected to refer to unless it would be unsafe
> As I mentioned in my article on the British Midland crash, the most effective way to prevent this kind of accident is by fitting airplanes with an Engine Indicating and Crew Alerting System, known as EICAS, or similar equipment. These systems automatically monitor engine performance and, should an engine fail, will produce a message informing the pilots which engine is the cause of the problem, dramatically reducing the probability of an incorrect identification. However, retrofitting the systems onto older 737s, which are most at risk, is not required and may be impractical or impossible.
Thanks for copying that snippet! It's probably the most interesting paragraph in the whole article. I'm baffled why it was left to very end. This should be the lead!
The author typically ends their articles with "what changes came about because of this type of crash, or exist today that would have prevented it", after describing all the factors that played a role.
> Following the crash and the publication of the NTSB’s damning final report, substantive changes were finally made to prevent similar accidents from happening again in the future. The FAA launched an industry-wide campaign to root out the myth of “ice bridging,” and it became standard practice to activate the deicing boots immediately upon entering icing conditions. The FAA mandated that all EMB-120s and several other aircraft types be fitted with automatic ice detection systems; Comair increased its minimum speed in icing conditions to 170 knots; and the FAA required all manufacturers to provide clear minimum maneuvering speed information for flight in icing conditions. The FAA also established standardized communication channels between FAA experts and POIs stationed at airlines; created a new database to more carefully track airworthiness matters involving foreign manufacturers; and most importantly, launched major research initiatives designed to ensure that the requirements of FAR Part 25 Appendix C were realistic and covered all ice shapes that were likely to form in flight, including thin layers of sandpaper-type ice. These resulted in a series of revisions to FAR part 25 to reflect state-of-the-art knowledge of aircraft icing, which continued all the way through 2016, including via the addition of further testing criteria not originally identified by the NTSB. As a result, it is now known exactly how every aircraft currently in service will react to all the types of in-flight icing which are likely to occur, and limitations exist to ensure that controllability is not compromised.
Detecting engine failure isn't trivial - a failed engine can still spin pretty fast with airflow going through it.
Modern predictive techniques could easily detect engine failure (ie. "Here is the history of the last 10 seconds of the throttle position, and here is the current RPM, is the engine failed?"). But aircraft designs don't like to use such techniques - they prefer simple thresholds. And with simple thresholds, a bunch of engine failures can get missed, especially partial failures.
I think the is a big issue across aviation. The system just gives up and dumps the problem on the pilot who then has to parse conflicting data quickly. I wonder if it would be better to treat this more like a navigation problem. Fuse together different data with known error levels and show the pilot the result. And include more solid state sensors like GPS, gravity sensors, and cameras in the mix.
I read the article in disbelief. It sounds more like a dumb-and-dumber situation than a real situation in a cockpit with decently competent pilots, especially the captain is depicted as totally incompetent, from the initial radio communication to the rest of the adventure. It sounds like the kind of pilot than can barely fly in regular conditions and the co-pilot that is part time doing the job and not too well.
I am not a commercial pilot, just GA pilot for 10 years. I know many cases of incompetence in GA, but never in commercial aviation, this is not how trained pilots should fly a 737 and I have no idea how they got the permission to do it.
Based on this article the keyword is "is depicted". It starts with an ad hominem attack on the captain. And I didn't even see many mentions or quotes from the actual accident report.
I did stop half way because it's simply too long for how much I care about the subject. I won't research it further either so I'll just end up with the pushing an agenda impression.
I don't think the captain was that incompetent; I was surprised after reading the article , how there was little in it to support the veiled attacks on the captain it started off with.
> I know many cases of incompetence in GA, but never in commercial aviation
You mean you have never heard of commercial aviation pilots making mistakes? This can't be right.
I heard about commercial pilots making mistakes, but not to be plain incompetent. Reading the article, even the transcription of the radio conversation is one example - I don't need the author of the article explain what is wrong there, I know it myself (2 weeks ago I had to renew my radio operator license, so I just had the refresher course). I don't even have too high standards for pilots, it is a basic expectations the airlines to hire and maintain competent pilots that will not crash planes on their first incident. This is because most of the plane accidents I know personally are either pilot error or technical problems that could be avoided or mitigated by any decent pilot.
The pilots of Air France 447 crashed a perfectly flyable plane into the ocean because they failed to apply one of the most basic principles of flight: raising the nose can cause a stall as the aircraft loses speed, whereas bringing down the nose allows you to pick up speed and pull out of a stall. One pilot kept pulling back on the yoke for several minutes until they crashed.
Would you say they just made mistakes, or were just plain incompetent?
NTSB conclusion released a few days ago practically calls the crew incompetent (with nice words: "crew's ineffective crew resource management, high workload and stress").
Sometimes the best decision is to turn around and walk away, and burn that bloody bridge behind. Better actually if that people will avoid you in the future.
There are some great lessons to learn from this (better flight control handovers during emergency, double checking which engine failed, applying thrust to both engines when nothing else works). The violation of the sterile cockpit rule and the asshole nature of the captain were not factors here as determined by the NTSB.
The first officer gave him bad info and he accepted it. That is not a failure mode caused by being obstinate nor a “team player”.