Bok verdt å lese - Curt Lewis

WHEN COMPUTERS DO THE WRONG THING: FROM AIR FRANCE 447 TO THE BOEING 737 MAX By Roger Rapoport Flight Safety Information Senior Editor Working on the Air France 447 story I have had the privilege of getting to know some of the best minds in the aviation business. As we all know some bloggers, magazine and newspaper writers, indeed entire publishing companies, are dedicated to the proposition that every crash is the direct result of pilot error. Those words resonate with me. They happen to be the title of a feature film I produced a few years back, http://www.pilot-errormovie.com, and are part of the insidious and self-defeating blame game that is the enemy of aviation safety. We believe that blaming all accidents on "pilot error" is a dangerously misleading way to perpetuate a failed safety management system. Ten years ago , in the wake of the first "computer crash," Air France 447, the industry got a wakeup call and chose to ignore it. The accident investigators who spent three years diligently studying the evidence warned that similar automation related crashes were inevitable unless major reforms were made in the aviation safety system. More than 50 crashes taking the lives of over 2,500 passengers since Air France 447 are a grim confirmation of this fact. A decade later the tragically similar crashes of two state of the art Boeing 737 Max aircraft parallel what went wrong on Air France 447. The safety management system at the heart of the aviation industry, including design, manufacturing, certification, training and regulation is failing the flying public. Created for the steam engine era and single point of failure electro-mechanical systems, this approach is hopelessly obsolete in the computer age. Today our incredible flying machines are dependent on automated software and hardware systems that are perfect, except when something goes wrong. The problem begins when the computer does exactly what it is programmed to do which unfortunately turns to be the wrong thing. At that point untrained humans are expected to quickly step into the breach and save the day. In 2009, when I arrived at Aeroport Charles de Gaulle to begin working on Angle of Attack and Pilot Error, the French aviation industry was struggling to understand how a stall proof plane crashed into the South Atlantic taking the lives of 228 people. This month Captain Malmquist and I had the honor of meeting with families of some of those victims. Had it not been for their tenacious struggle to persuade the French Ministry of Transport to keep the seemingly hopeless search for Air France 447 alive (they threatened a hunger strike), search teams might have never found the plane 13,000 feet below the surface. As it turns out, the evidence shows that the crash can not simply be chalked up to pilot error. Automation failure led directly to this tragic event well beyond the training of a first class flight crew. Now a teaching event in flight schools worldwide, the Air France 447 accident is slowly revolutionizing stall recovery training and has led to improvements in aircraft systems. Unfortunately these reforms have not, as yet, transformed the badly outdated aviation certification and regulatory system. In our new edition of Angle of Attack, Captain Malmquist and I present new evidence that many of these crashes could have been prevented if the industry had applied the important lessons learned from Air France 447. There is no question that, at a minimum, both of the recent Boeing 737 Max crashes would not have happened if the industry had followed the many important recommendations made by outstanding accident investigators following the 2009 Air France crash. We look forward to the industry implementing the long overdue safety management system reforms recommended in our book. A new edition of the acclaimed Angle of Attack (Curt Lewis Books/Lexographic Press) by Senior Editor Roger Rapoport and Boeing 777 Captain Shem Malmquist is now out https://www.amazon.com/dp/B07SVNPJ5T. The French edition has also just been published https://amzn.to/2ZK7pXG The author is at rogerdrapoport@me.com