Re: Revisiting the Aviation Safety vs. Networking discussion

[Scott Howard <scott () doc net au>]

On Thu, Dec 24, 2009 at 6:27 PM, George Bonser <gbonser () seven com> wrote:

> So you can put a lot of process around changes in advance but there
> isn't quite as much to manage incidents that strike out of the clear
> blue.  Too much process at that point could impede progress in clearing
> the issue.  Capt. Sullenberger did not need to fill out an incident
> report, bring up a conference bridge, and give a detailed description of
> what was happening with his plane, the status of all subsystems, and his
> proposed plan of action (subject to consensus of those on the conference
> bridge) and get approval for deviation from his initial flight plan
> before he took the required actions to land the plane as best as he
> could under the circumstances.



"*mayday mayday mayday. **Cactus fifteen thirty nine hit birds, we've lost
thrust (in/on) both engines we're turning back towards LaGuardia*" - Capt.
Sullenberger

Not exactly "detailed", but he definitely initiated an "incident report"
(the mayday), gave a "description of what was happening with his plane", the
"status of [the relevant] subsystems", and his proposed plan of action -
even in the order you've asked for!

His actions were then "subject to the consensus of those on the conference
bridge" (ie, ATC) who could have denied his actions if they believed they
would have made the situation worse (ie, if what they were proposing would
have had them on a collision course with another plane). In this case, the
conference bridge gave approval for his course of action ("*ok uh, you need
to return to LaGuardia? turn left heading of uh two two zero.*" - ATC)

5 seconds before they made the above call they were reaching for the QRH
(Quick Reference Handbook), which contains checklists of the steps to take
in such a situation - including what to do in the event of loss of both
engines due to multiple birdstrikes.  They had no need to confer with others
as to what actions to take to try and recover from the problem, or what
order to take them in, because that pre-work had already been carried out
when the check-lists were written.

Of course, at the end of the day, training, skill and experience played a
very large part in what transpired - but so did the actions of the people on
the "conference bridge" (You can't get much more of a "conference bridge"
than open radio frequencies), and the checklists they have for almost every
conceivable situation.

  Scott.