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	<title>Comments on: The Qantas nosedive &#8211; what happened</title>
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		<title>By: Nabakov</title>
		<link>http://larvatusprodeo.net/2008/10/15/the-qantas-nosedive-what-happened/comment-page-1/#comment-539832</link>
		<dc:creator>Nabakov</dc:creator>
		<pubDate>Sun, 19 Oct 2008 17:29:19 +0000</pubDate>
		<guid isPermaLink="false">http://larvatusprodeo.net/2008/10/15/the-qantas-nosedive-what-happened/#comment-539832</guid>
		<description>Fortunately Airbus have already tested their fly by wire system to &lt;a href=&quot;http://au.youtube.com/watch?v=-kHa3WNerjU&quot; rel=&quot;nofollow&quot;&gt;destruction&lt;/a&gt;.


Now I wanna see Boeing do the same with the 787 Dreamliner and its Melbourne-cooked cutting-edge composite flight control surfaces.</description>
		<content:encoded><![CDATA[<p>Fortunately Airbus have already tested their fly by wire system to <a href="http://au.youtube.com/watch?v=-kHa3WNerjU" rel="nofollow">destruction</a>.</p>
<p>Now I wanna see Boeing do the same with the 787 Dreamliner and its Melbourne-cooked cutting-edge composite flight control surfaces.</p>
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		<title>By: FDB</title>
		<link>http://larvatusprodeo.net/2008/10/15/the-qantas-nosedive-what-happened/comment-page-1/#comment-539527</link>
		<dc:creator>FDB</dc:creator>
		<pubDate>Sun, 19 Oct 2008 07:56:07 +0000</pubDate>
		<guid isPermaLink="false">http://larvatusprodeo.net/2008/10/15/the-qantas-nosedive-what-happened/#comment-539527</guid>
		<description>&quot;The idea of having redundancy both between &lt;b&gt;actual deciding units&lt;/i&gt; and the software or systems implemented has been explored and found mostly to be unsatisfactory.&quot;

Are you referring to the humans present? If not I think you&#039;ve missed my point, which came from Cap&#039;n Tom&#039;s description of bariers to to overriding autopilot. What I&#039;m thinking of is a simple check that what the human is trying to do (contra what the computer says should happen) is not OBVIOUSLY group suicide (or 9/11 for that matter). This condition being satisfied, control is transferred to &#039;manual&#039; (I do understand that it&#039;s not truly manual).

I&#039;m not suggesting anything that would replace existing systems, which have been shown to work extremely well compared with &#039;manual&#039; systems, but a referee system for situations like these that happen once every decade or so.</description>
		<content:encoded><![CDATA[<p>&#8220;The idea of having redundancy both between <b>actual deciding units and the software or systems implemented has been explored and found mostly to be unsatisfactory.&#8221;</p>
<p>Are you referring to the humans present? If not I think you&#8217;ve missed my point, which came from Cap&#8217;n Tom&#8217;s description of bariers to to overriding autopilot. What I&#8217;m thinking of is a simple check that what the human is trying to do (contra what the computer says should happen) is not OBVIOUSLY group suicide (or 9/11 for that matter). This condition being satisfied, control is transferred to &#8216;manual&#8217; (I do understand that it&#8217;s not truly manual).</p>
<p>I&#8217;m not suggesting anything that would replace existing systems, which have been shown to work extremely well compared with &#8216;manual&#8217; systems, but a referee system for situations like these that happen once every decade or so.</b></p>
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		<title>By: Robert Merkel</title>
		<link>http://larvatusprodeo.net/2008/10/15/the-qantas-nosedive-what-happened/comment-page-1/#comment-539179</link>
		<dc:creator>Robert Merkel</dc:creator>
		<pubDate>Sat, 18 Oct 2008 21:27:05 +0000</pubDate>
		<guid isPermaLink="false">http://larvatusprodeo.net/2008/10/15/the-qantas-nosedive-what-happened/#comment-539179</guid>
		<description>Jacques: ah, yes, N-version programming.  Your summary of the situation is basically correct.</description>
		<content:encoded><![CDATA[<p>Jacques: ah, yes, N-version programming.  Your summary of the situation is basically correct.</p>
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		<title>By: Jacques Chester</title>
		<link>http://larvatusprodeo.net/2008/10/15/the-qantas-nosedive-what-happened/comment-page-1/#comment-539029</link>
		<dc:creator>Jacques Chester</dc:creator>
		<pubDate>Sat, 18 Oct 2008 16:24:45 +0000</pubDate>
		<guid isPermaLink="false">http://larvatusprodeo.net/2008/10/15/the-qantas-nosedive-what-happened/#comment-539029</guid>
		<description>&lt;blockquote&gt;Do we need an entirely separate and almost always redundant system to resolve conflict in control between humans and the computer? A simpler, cruder version of the altitude/attitude sensors, that can be an automatic umpire if flesh and chips disagree?&lt;/blockquote&gt;

This just moves your risk to another area.

Aerospace code is probably the most reliable in the world, because the consequences of failure are so dire. Boeing and Airbus spend serious money and effort on making sure it&#039;s as safe as possible; but even so mistakes get made. Aviation has had disasters caused by various sorts of systemic, procedural or engineering failures since the very beginning.

The idea of having redundancy both between actual deciding units and the software or systems implemented has been explored and found mostly to be unsatisfactory. Boeing did a very large study and found that having multiple independent implementations of a critical piece of software did not reduce the number of bugs; rather they found that each group tended to make bugs in the same complex areas of work.</description>
		<content:encoded><![CDATA[<blockquote><p>Do we need an entirely separate and almost always redundant system to resolve conflict in control between humans and the computer? A simpler, cruder version of the altitude/attitude sensors, that can be an automatic umpire if flesh and chips disagree?</p></blockquote>
<p>This just moves your risk to another area.</p>
<p>Aerospace code is probably the most reliable in the world, because the consequences of failure are so dire. Boeing and Airbus spend serious money and effort on making sure it&#8217;s as safe as possible; but even so mistakes get made. Aviation has had disasters caused by various sorts of systemic, procedural or engineering failures since the very beginning.</p>
<p>The idea of having redundancy both between actual deciding units and the software or systems implemented has been explored and found mostly to be unsatisfactory. Boeing did a very large study and found that having multiple independent implementations of a critical piece of software did not reduce the number of bugs; rather they found that each group tended to make bugs in the same complex areas of work.</p>
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		<title>By: Jack Hackett</title>
		<link>http://larvatusprodeo.net/2008/10/15/the-qantas-nosedive-what-happened/comment-page-1/#comment-538682</link>
		<dc:creator>Jack Hackett</dc:creator>
		<pubDate>Sat, 18 Oct 2008 04:40:39 +0000</pubDate>
		<guid isPermaLink="false">http://larvatusprodeo.net/2008/10/15/the-qantas-nosedive-what-happened/#comment-538682</guid>
		<description>Thanks for the analogy to driving around a roundabout. Capt. Tom. Any I am glad you are a Capt., not a Major, Major Tom had to communicate with ground control with disastrous consequences for him.

To be serious though I approach every flight as my last. I buckle up and stay so unless in the loo. I listen to the flight instructions and check my exit. I assume it will crash and being of a fatalistic bent, it doesn&#039;t bother me.

Some say I am safer in a plane than driving to the airport, but in the latter case I have some control over the management of disaster than I do in a plane. 

And it does concern me that pilots have so little control over adverse computer events.

Then again I have had a taxi driver from the Urals smelling strongly of alcohol and with needle marks on his forearms drive me to Eagle Farm airport, and I survived that.

Jack Hackett</description>
		<content:encoded><![CDATA[<p>Thanks for the analogy to driving around a roundabout. Capt. Tom. Any I am glad you are a Capt., not a Major, Major Tom had to communicate with ground control with disastrous consequences for him.</p>
<p>To be serious though I approach every flight as my last. I buckle up and stay so unless in the loo. I listen to the flight instructions and check my exit. I assume it will crash and being of a fatalistic bent, it doesn&#8217;t bother me.</p>
<p>Some say I am safer in a plane than driving to the airport, but in the latter case I have some control over the management of disaster than I do in a plane. </p>
<p>And it does concern me that pilots have so little control over adverse computer events.</p>
<p>Then again I have had a taxi driver from the Urals smelling strongly of alcohol and with needle marks on his forearms drive me to Eagle Farm airport, and I survived that.</p>
<p>Jack Hackett</p>
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		<title>By: Colonel of Truth</title>
		<link>http://larvatusprodeo.net/2008/10/15/the-qantas-nosedive-what-happened/comment-page-1/#comment-538279</link>
		<dc:creator>Colonel of Truth</dc:creator>
		<pubDate>Fri, 17 Oct 2008 14:02:53 +0000</pubDate>
		<guid isPermaLink="false">http://larvatusprodeo.net/2008/10/15/the-qantas-nosedive-what-happened/#comment-538279</guid>
		<description>A little OT but I must take issue with comments about Qantas service. I&#039;m just back from a Brisbane-Barcelona cattle class trip on a QF/BA codeshare. First time I&#039;ve flown QF internationally for ~20 years and what a pleasant surprise. Seat pitch, cabin crew attitude/service, cleanliness, cockpit information, toilet availability all great. Even the food was better than edible. And the little touches made a difference (frequent water topups in flight, hot towels, a time line on the menu so one knew what would happen when). I was happy to give QF a pat in a passenger survey. Pity it seems not to trickle down to all QF domestic flights, although some are good. But don&#039;t ask about BA; &#039;excruciating&#039; is putting it kindly.</description>
		<content:encoded><![CDATA[<p>A little OT but I must take issue with comments about Qantas service. I&#8217;m just back from a Brisbane-Barcelona cattle class trip on a QF/BA codeshare. First time I&#8217;ve flown QF internationally for ~20 years and what a pleasant surprise. Seat pitch, cabin crew attitude/service, cleanliness, cockpit information, toilet availability all great. Even the food was better than edible. And the little touches made a difference (frequent water topups in flight, hot towels, a time line on the menu so one knew what would happen when). I was happy to give QF a pat in a passenger survey. Pity it seems not to trickle down to all QF domestic flights, although some are good. But don&#8217;t ask about BA; &#8216;excruciating&#8217; is putting it kindly.</p>
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		<title>By: RumRebellious</title>
		<link>http://larvatusprodeo.net/2008/10/15/the-qantas-nosedive-what-happened/comment-page-1/#comment-537932</link>
		<dc:creator>RumRebellious</dc:creator>
		<pubDate>Fri, 17 Oct 2008 03:23:30 +0000</pubDate>
		<guid isPermaLink="false">http://larvatusprodeo.net/2008/10/15/the-qantas-nosedive-what-happened/#comment-537932</guid>
		<description>Ouch Joe2 @31!  Just curious, is there any truth to the conspiracy that Lufthansa completely replaced their on-board flight navigation systems in the 1990&#039;s because they discovered they could be controlled remotely?</description>
		<content:encoded><![CDATA[<p>Ouch Joe2 @31!  Just curious, is there any truth to the conspiracy that Lufthansa completely replaced their on-board flight navigation systems in the 1990&#8217;s because they discovered they could be controlled remotely?</p>
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		<title>By: steveh</title>
		<link>http://larvatusprodeo.net/2008/10/15/the-qantas-nosedive-what-happened/comment-page-1/#comment-537908</link>
		<dc:creator>steveh</dc:creator>
		<pubDate>Fri, 17 Oct 2008 02:01:15 +0000</pubDate>
		<guid isPermaLink="false">http://larvatusprodeo.net/2008/10/15/the-qantas-nosedive-what-happened/#comment-537908</guid>
		<description>Hi Robert,
   Thanks to you and Tom for the info, I must admit I was a bit surprised that the limits on controllability would allow such a dramatic command at this stage of flight (that said I don&#039;t have the figures for rotational rates).
Another problem is the crew can end up spending a fair amount of time attempting to diagnose what-the-hell is going on. The Adam Air accident (PK-KKW) shows how this can get to an extreme point - albeit with poor maintenance practices thrown in. 
One large factor is the limitation on what error messages are/n&#039;t displayed. 
In lab instrumentation it&#039;s fine to have a tome showing every error code under the sun, but for time-critical applications it has to be limited. From my reading of accident reports (not an LAME mind you!) it seems that sensor failures aren&#039;t unknown and the software limits what is displayed. If a &quot;redundancy breakthrough&quot; occurs then there may be no indication - thus leading to the good old &quot;disconnect everything and go to primary instruments&quot;.
Tom - my limited understanding is that the automation can be quite difficult to disconnect on the modern aircraft - is this true?</description>
		<content:encoded><![CDATA[<p>Hi Robert,<br />
   Thanks to you and Tom for the info, I must admit I was a bit surprised that the limits on controllability would allow such a dramatic command at this stage of flight (that said I don&#8217;t have the figures for rotational rates).<br />
Another problem is the crew can end up spending a fair amount of time attempting to diagnose what-the-hell is going on. The Adam Air accident (PK-KKW) shows how this can get to an extreme point &#8211; albeit with poor maintenance practices thrown in.<br />
One large factor is the limitation on what error messages are/n&#8217;t displayed.<br />
In lab instrumentation it&#8217;s fine to have a tome showing every error code under the sun, but for time-critical applications it has to be limited. From my reading of accident reports (not an LAME mind you!) it seems that sensor failures aren&#8217;t unknown and the software limits what is displayed. If a &#8220;redundancy breakthrough&#8221; occurs then there may be no indication &#8211; thus leading to the good old &#8220;disconnect everything and go to primary instruments&#8221;.<br />
Tom &#8211; my limited understanding is that the automation can be quite difficult to disconnect on the modern aircraft &#8211; is this true?</p>
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		<title>By: FDB</title>
		<link>http://larvatusprodeo.net/2008/10/15/the-qantas-nosedive-what-happened/comment-page-1/#comment-537821</link>
		<dc:creator>FDB</dc:creator>
		<pubDate>Thu, 16 Oct 2008 23:47:11 +0000</pubDate>
		<guid isPermaLink="false">http://larvatusprodeo.net/2008/10/15/the-qantas-nosedive-what-happened/#comment-537821</guid>
		<description>Do we need an entirely separate and almost always redundant system to resolve conflict in control between humans and the computer? A simpler, cruder version of the altitude/attitude sensors, that can be an automatic umpire if flesh and chips disagree?</description>
		<content:encoded><![CDATA[<p>Do we need an entirely separate and almost always redundant system to resolve conflict in control between humans and the computer? A simpler, cruder version of the altitude/attitude sensors, that can be an automatic umpire if flesh and chips disagree?</p>
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		<title>By: Robert Merkel</title>
		<link>http://larvatusprodeo.net/2008/10/15/the-qantas-nosedive-what-happened/comment-page-1/#comment-537763</link>
		<dc:creator>Robert Merkel</dc:creator>
		<pubDate>Thu, 16 Oct 2008 22:18:43 +0000</pubDate>
		<guid isPermaLink="false">http://larvatusprodeo.net/2008/10/15/the-qantas-nosedive-what-happened/#comment-537763</guid>
		<description>Tom, thanks for your comments.  I suppose - as the computer guy here - my counterpoint to the concern about fly-by-wire is that controlled flights into terrain - that is, a functioning aircraft being flown into the ground under pilot control - happen on a yearly or so basis.</description>
		<content:encoded><![CDATA[<p>Tom, thanks for your comments.  I suppose &#8211; as the computer guy here &#8211; my counterpoint to the concern about fly-by-wire is that controlled flights into terrain &#8211; that is, a functioning aircraft being flown into the ground under pilot control &#8211; happen on a yearly or so basis.</p>
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		<title>By: joe2</title>
		<link>http://larvatusprodeo.net/2008/10/15/the-qantas-nosedive-what-happened/comment-page-1/#comment-537725</link>
		<dc:creator>joe2</dc:creator>
		<pubDate>Thu, 16 Oct 2008 20:26:27 +0000</pubDate>
		<guid isPermaLink="false">http://larvatusprodeo.net/2008/10/15/the-qantas-nosedive-what-happened/#comment-537725</guid>
		<description>Thanks for the interesting comments Capt Tom and I plan to wear my seatbelt more conscientiously. I have a few matters for your further consideration, though. If you look further back in this thread you will see that another similar event HAS actually happened , strangely, in the same area near Exmouth 

I wonder , further, if it has occurred to you that your honest assessment of the computer system with a mind of its own and the more recent adoption of fly by wire system, might be counterproductive to your role a fear of flying mentor.</description>
		<content:encoded><![CDATA[<p>Thanks for the interesting comments Capt Tom and I plan to wear my seatbelt more conscientiously. I have a few matters for your further consideration, though. If you look further back in this thread you will see that another similar event HAS actually happened , strangely, in the same area near Exmouth </p>
<p>I wonder , further, if it has occurred to you that your honest assessment of the computer system with a mind of its own and the more recent adoption of fly by wire system, might be counterproductive to your role a fear of flying mentor.</p>
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		<title>By: BilB</title>
		<link>http://larvatusprodeo.net/2008/10/15/the-qantas-nosedive-what-happened/comment-page-1/#comment-537684</link>
		<dc:creator>BilB</dc:creator>
		<pubDate>Thu, 16 Oct 2008 18:17:06 +0000</pubDate>
		<guid isPermaLink="false">http://larvatusprodeo.net/2008/10/15/the-qantas-nosedive-what-happened/#comment-537684</guid>
		<description>Capt Tom B,

It would seem that the manual overide through the computer was not compromised by the faulty ADC. Would the pilots have flown the aircraft manually to its landing in this event? Or were they able to isolate the fault and continue on autopilot? And in the manual flight mode would the faulty altitude information coming from the ADC have affected the pilot&#039;s flight instrumentation requiring them to guess the aircraft&#039;s altitude?</description>
		<content:encoded><![CDATA[<p>Capt Tom B,</p>
<p>It would seem that the manual overide through the computer was not compromised by the faulty ADC. Would the pilots have flown the aircraft manually to its landing in this event? Or were they able to isolate the fault and continue on autopilot? And in the manual flight mode would the faulty altitude information coming from the ADC have affected the pilot&#8217;s flight instrumentation requiring them to guess the aircraft&#8217;s altitude?</p>
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		<title>By: Capt  Tom Bunn LCSW</title>
		<link>http://larvatusprodeo.net/2008/10/15/the-qantas-nosedive-what-happened/comment-page-1/#comment-537635</link>
		<dc:creator>Capt  Tom Bunn LCSW</dc:creator>
		<pubDate>Thu, 16 Oct 2008 16:22:38 +0000</pubDate>
		<guid isPermaLink="false">http://larvatusprodeo.net/2008/10/15/the-qantas-nosedive-what-happened/#comment-537635</guid>
		<description>There was an autopilot malfunction which had the same effect as if the pilots pushed forward on the controls. When you go around a curve in your car at only 55 MPH, it is easy to turn sharp enough to cause a person to fall over, or even be thrown about the car, if they are not wearing a seat belt.

Normally, a driver does not make a violent maneuver, but to avoid hitting another car, if a passenger is not wearing a seat belt, the passenger can be thrown about the car, and possibly injured even if the other car is missed.

Consider going ten times that fast. When going 550 MPH, any change in the direction the plane is pointed -- just as in your car -- can cause a person to be thrown about if they are not wearing a seat belt.

People simply will not follow directions. It seems to make no difference how many times flight attendants tell people to wear a seat belt, even when there is no turbulence and even when the seat belt sign is not on. Some will not do it.

Some people simply will not wear their seat belts in a car, either. But if you do, on a plane, you will be fully protected in case there is either unexpected turbulence or an autopilot malfunction, as in this case.

It is simple: wear the seat belt and no harm will come to you.

As to the specific problem, it was the Air Data Computer, a device that processes air density information and translates it — in computer code — into altitude. And here is the potential problem with the newest airplanes: we NEVER had a problem with a malfunction of the ADC with airplanes like the 747, 757, 767 which are flown — not by computers alone — but simply use computers to supply information. In the old system, the ADC and the computers had limited authority over the plane. But the newer planes by Airbus and the 777 are “fly by wire” which means — maybe I’m saying this too strongly — but it means the computers have taken over. THEY run the plane, and for a human to intervene, he or she has to aim the intervention at the computer. What if the computer says, “fuck you” and keeps doing what you want it to stop doing. The earlier planes let the pilot really take control and disconnect the computer. With the newer planes, you only ask the computer if it wouldn’t mind doing what you want the plane to do. 

That approach was shocking to some of us old guys. Back when Airbus first built the A—320, we older and more conservative pilots says, “Screw that; we don’t want the computer in charge; WE want US in charge - period.” At UAL, our chief pilot – who we respected for his engineering knowledge — went to Airbus, studied the plane and said it was fine; we had nothing to worry about.

OK. Maybe. But though it has taken fifteen or so years for us to have a tricky situation like this where the computer was totally in control and had a malfunction of one of its information systems (that told it it was at the wrong altitude and tried to change it) those of us who had reservations about “fly by wire” (meaning by computer; even when flying manually, you tell the computer what to do to point the plane, using a joystick – not a control wheel connected to the controls) are thinking “told you so”.

So, clearly, though this kind of thing is rare (once in fifteen years) it did happen. That’s good or bad depending upon your perspective. But the ADC was shipped to the manufacturer in the U.S. to let them figure out the problem and come up with a fix.

That&#039;s the logic. The there is an emotional issue as well. Most people can accept that something like this could go wrong every few years. Others have such anxiety around rare events that it makes flying difficult or impossible. 

I have tried to give a good understanding of how flight anxiety works in a video at http://www.youtube.com/watch?v=Zcx6ZsvKHSA&amp;feature</description>
		<content:encoded><![CDATA[<p>There was an autopilot malfunction which had the same effect as if the pilots pushed forward on the controls. When you go around a curve in your car at only 55 MPH, it is easy to turn sharp enough to cause a person to fall over, or even be thrown about the car, if they are not wearing a seat belt.</p>
<p>Normally, a driver does not make a violent maneuver, but to avoid hitting another car, if a passenger is not wearing a seat belt, the passenger can be thrown about the car, and possibly injured even if the other car is missed.</p>
<p>Consider going ten times that fast. When going 550 MPH, any change in the direction the plane is pointed &#8212; just as in your car &#8212; can cause a person to be thrown about if they are not wearing a seat belt.</p>
<p>People simply will not follow directions. It seems to make no difference how many times flight attendants tell people to wear a seat belt, even when there is no turbulence and even when the seat belt sign is not on. Some will not do it.</p>
<p>Some people simply will not wear their seat belts in a car, either. But if you do, on a plane, you will be fully protected in case there is either unexpected turbulence or an autopilot malfunction, as in this case.</p>
<p>It is simple: wear the seat belt and no harm will come to you.</p>
<p>As to the specific problem, it was the Air Data Computer, a device that processes air density information and translates it — in computer code — into altitude. And here is the potential problem with the newest airplanes: we NEVER had a problem with a malfunction of the ADC with airplanes like the 747, 757, 767 which are flown — not by computers alone — but simply use computers to supply information. In the old system, the ADC and the computers had limited authority over the plane. But the newer planes by Airbus and the 777 are “fly by wire” which means — maybe I’m saying this too strongly — but it means the computers have taken over. THEY run the plane, and for a human to intervene, he or she has to aim the intervention at the computer. What if the computer says, “fuck you” and keeps doing what you want it to stop doing. The earlier planes let the pilot really take control and disconnect the computer. With the newer planes, you only ask the computer if it wouldn’t mind doing what you want the plane to do. </p>
<p>That approach was shocking to some of us old guys. Back when Airbus first built the A—320, we older and more conservative pilots says, “Screw that; we don’t want the computer in charge; WE want US in charge &#8211; period.” At UAL, our chief pilot – who we respected for his engineering knowledge — went to Airbus, studied the plane and said it was fine; we had nothing to worry about.</p>
<p>OK. Maybe. But though it has taken fifteen or so years for us to have a tricky situation like this where the computer was totally in control and had a malfunction of one of its information systems (that told it it was at the wrong altitude and tried to change it) those of us who had reservations about “fly by wire” (meaning by computer; even when flying manually, you tell the computer what to do to point the plane, using a joystick – not a control wheel connected to the controls) are thinking “told you so”.</p>
<p>So, clearly, though this kind of thing is rare (once in fifteen years) it did happen. That’s good or bad depending upon your perspective. But the ADC was shipped to the manufacturer in the U.S. to let them figure out the problem and come up with a fix.</p>
<p>That&#8217;s the logic. The there is an emotional issue as well. Most people can accept that something like this could go wrong every few years. Others have such anxiety around rare events that it makes flying difficult or impossible. </p>
<p>I have tried to give a good understanding of how flight anxiety works in a video at <a href="http://www.youtube.com/watch?v=Zcx6ZsvKHSA&amp;feature" rel="nofollow">http://www.youtube.com/watch?v=Zcx6ZsvKHSA&amp;feature</a></p>
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		<title>By: MikeM</title>
		<link>http://larvatusprodeo.net/2008/10/15/the-qantas-nosedive-what-happened/comment-page-1/#comment-536949</link>
		<dc:creator>MikeM</dc:creator>
		<pubDate>Thu, 16 Oct 2008 01:57:54 +0000</pubDate>
		<guid isPermaLink="false">http://larvatusprodeo.net/2008/10/15/the-qantas-nosedive-what-happened/#comment-536949</guid>
		<description>The referenced Risks Digest post by Peter Ladkin relates to an almost identical incident that affected a Malaysian Airlines Boeing B777 flying the same route in 2005.

On 1 August 2005, shortly after departing from Perth, Australia, bound for
Kuala Lumpur, Malaysia, a Boeing B777-200 passenger aircraft suffered a
flight upset while climbing through 38,000 feet. It began when the aircraft
spontaneously pitched sharply upward, reaching 41,000 feet and activating
stall warnings. After pilots regained control they returned to Perth.

The incident was triggered by a second accelerometer failure in the
aircraft&#039;s air data inertial reference unit (ADIRU). This unit is designed
to be highly redundant and fault-tolerant but the first failed
accelerometer&#039;s failure mode was not one that had been anticipated during
unit design and development. (It had been assumed that a failure would
always result in zero voltage output, but this failed device was producing a
high output value.) The twin failures exposed a latent software fault, which
resulted in the unit feeding incorrect aircraft acceleration data to other
flight control systems.

Boeing B777-200 aircraft first entered service in 1995 and this is the first
reported instance of the particular software fault, which was apparently
present in the unit&#039;s original design, affecting operation of an aircraft.
The incident highlights the fact that software testing can never eliminate
all risk.

The Australian Transport Safety Bureau&#039;s investigation report is at
http://www.atsb.gov.au/publications/investigation_reports/2005/AAIR/aair200503722.aspx</description>
		<content:encoded><![CDATA[<p>The referenced Risks Digest post by Peter Ladkin relates to an almost identical incident that affected a Malaysian Airlines Boeing B777 flying the same route in 2005.</p>
<p>On 1 August 2005, shortly after departing from Perth, Australia, bound for<br />
Kuala Lumpur, Malaysia, a Boeing B777-200 passenger aircraft suffered a<br />
flight upset while climbing through 38,000 feet. It began when the aircraft<br />
spontaneously pitched sharply upward, reaching 41,000 feet and activating<br />
stall warnings. After pilots regained control they returned to Perth.</p>
<p>The incident was triggered by a second accelerometer failure in the<br />
aircraft&#8217;s air data inertial reference unit (ADIRU). This unit is designed<br />
to be highly redundant and fault-tolerant but the first failed<br />
accelerometer&#8217;s failure mode was not one that had been anticipated during<br />
unit design and development. (It had been assumed that a failure would<br />
always result in zero voltage output, but this failed device was producing a<br />
high output value.) The twin failures exposed a latent software fault, which<br />
resulted in the unit feeding incorrect aircraft acceleration data to other<br />
flight control systems.</p>
<p>Boeing B777-200 aircraft first entered service in 1995 and this is the first<br />
reported instance of the particular software fault, which was apparently<br />
present in the unit&#8217;s original design, affecting operation of an aircraft.<br />
The incident highlights the fact that software testing can never eliminate<br />
all risk.</p>
<p>The Australian Transport Safety Bureau&#8217;s investigation report is at<br />
<a href="http://www.atsb.gov.au/publications/investigation_reports/2005/AAIR/aair200503722.aspx" rel="nofollow">http://www.atsb.gov.au/publications/investigation_reports/2005/AAIR/aair200503722.aspx</a></p>
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		<title>By: Robert Merkel</title>
		<link>http://larvatusprodeo.net/2008/10/15/the-qantas-nosedive-what-happened/comment-page-1/#comment-536851</link>
		<dc:creator>Robert Merkel</dc:creator>
		<pubDate>Thu, 16 Oct 2008 00:29:28 +0000</pubDate>
		<guid isPermaLink="false">http://larvatusprodeo.net/2008/10/15/the-qantas-nosedive-what-happened/#comment-536851</guid>
		<description>Ambigulous: I&#039;m not suggesting for a moment that passengers are supposed to be capable of correctly estimating how far a plane drops in such circumstances.  It&#039;s just that the observations of passengers as reported by media organizations are a very unreliable guide to the severity of any incident, because:

* they don&#039;t have any access to the instrument data
* they don&#039;t know what the plane is actually capable of handling (as distinct from what a plane typically does on an uneventful flight)
* a lot of people have a phobia of flying.
* journalists, when choose a grab to run after a flight incident, will naturally gravitate to the person who gives the most exciting story.</description>
		<content:encoded><![CDATA[<p>Ambigulous: I&#8217;m not suggesting for a moment that passengers are supposed to be capable of correctly estimating how far a plane drops in such circumstances.  It&#8217;s just that the observations of passengers as reported by media organizations are a very unreliable guide to the severity of any incident, because:</p>
<p>* they don&#8217;t have any access to the instrument data<br />
* they don&#8217;t know what the plane is actually capable of handling (as distinct from what a plane typically does on an uneventful flight)<br />
* a lot of people have a phobia of flying.<br />
* journalists, when choose a grab to run after a flight incident, will naturally gravitate to the person who gives the most exciting story.</p>
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		<title>By: derrida derider</title>
		<link>http://larvatusprodeo.net/2008/10/15/the-qantas-nosedive-what-happened/comment-page-1/#comment-536828</link>
		<dc:creator>derrida derider</dc:creator>
		<pubDate>Thu, 16 Oct 2008 00:16:51 +0000</pubDate>
		<guid isPermaLink="false">http://larvatusprodeo.net/2008/10/15/the-qantas-nosedive-what-happened/#comment-536828</guid>
		<description>On the wider question of Qantas&#039; maintenance, it does seem very poor business strategy.  Qantas basically has just two competitive advantages:

- a government in its pocket on the question of flight and airport rights (see eg the cosy duopoly on the Sydney-LA route).  That in turn depends on them being a big employer of Australians, which outsourcing endangers in the long run.

- its reputation as the safest airline in the world.  They fill a niche for those who are willing to pay more and put up with lousy service to reduce their fear of flight.  This is far more valuable than any savings on maintenance costs.</description>
		<content:encoded><![CDATA[<p>On the wider question of Qantas&#8217; maintenance, it does seem very poor business strategy.  Qantas basically has just two competitive advantages:</p>
<p>- a government in its pocket on the question of flight and airport rights (see eg the cosy duopoly on the Sydney-LA route).  That in turn depends on them being a big employer of Australians, which outsourcing endangers in the long run.</p>
<p>- its reputation as the safest airline in the world.  They fill a niche for those who are willing to pay more and put up with lousy service to reduce their fear of flight.  This is far more valuable than any savings on maintenance costs.</p>
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		<title>By: FDB</title>
		<link>http://larvatusprodeo.net/2008/10/15/the-qantas-nosedive-what-happened/comment-page-1/#comment-536806</link>
		<dc:creator>FDB</dc:creator>
		<pubDate>Wed, 15 Oct 2008 23:59:43 +0000</pubDate>
		<guid isPermaLink="false">http://larvatusprodeo.net/2008/10/15/the-qantas-nosedive-what-happened/#comment-536806</guid>
		<description>Sounds pretty fanciful - unshielded, unbalanced cabling in flight control systems? Crazy talk.</description>
		<content:encoded><![CDATA[<p>Sounds pretty fanciful &#8211; unshielded, unbalanced cabling in flight control systems? Crazy talk.</p>
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		<title>By: joe2</title>
		<link>http://larvatusprodeo.net/2008/10/15/the-qantas-nosedive-what-happened/comment-page-1/#comment-536782</link>
		<dc:creator>joe2</dc:creator>
		<pubDate>Wed, 15 Oct 2008 23:37:01 +0000</pubDate>
		<guid isPermaLink="false">http://larvatusprodeo.net/2008/10/15/the-qantas-nosedive-what-happened/#comment-536782</guid>
		<description>&quot;BTW Is North West Cape Exmouth still transmitting? Or has it shut down?&quot;

Claims naval base signal caused Qantas nosedive.....
http://www.abc.net.au/news/stories/2008/10/16/2392534.htm</description>
		<content:encoded><![CDATA[<p>&#8220;BTW Is North West Cape Exmouth still transmitting? Or has it shut down?&#8221;</p>
<p>Claims naval base signal caused Qantas nosedive&#8230;..<br />
<a href="http://www.abc.net.au/news/stories/2008/10/16/2392534.htm" rel="nofollow">http://www.abc.net.au/news/stories/2008/10/16/2392534.htm</a></p>
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		<title>By: Ambigulous</title>
		<link>http://larvatusprodeo.net/2008/10/15/the-qantas-nosedive-what-happened/comment-page-1/#comment-536749</link>
		<dc:creator>Ambigulous</dc:creator>
		<pubDate>Wed, 15 Oct 2008 23:07:44 +0000</pubDate>
		<guid isPermaLink="false">http://larvatusprodeo.net/2008/10/15/the-qantas-nosedive-what-happened/#comment-536749</guid>
		<description>Yes David,

A Singapore Airlines PR bloke yesterday implied on ABC radio that QANTAS&#039;s paying immediate compensation to &quot;The Exmouth 69&quot; was a very good investment by QANTAS in attempting to recover from a(nother) nosedive for their reputation.</description>
		<content:encoded><![CDATA[<p>Yes David,</p>
<p>A Singapore Airlines PR bloke yesterday implied on ABC radio that QANTAS&#8217;s paying immediate compensation to &#8220;The Exmouth 69&#8243; was a very good investment by QANTAS in attempting to recover from a(nother) nosedive for their reputation.</p>
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		<title>By: David Rubie</title>
		<link>http://larvatusprodeo.net/2008/10/15/the-qantas-nosedive-what-happened/comment-page-1/#comment-536709</link>
		<dc:creator>David Rubie</dc:creator>
		<pubDate>Wed, 15 Oct 2008 22:43:38 +0000</pubDate>
		<guid isPermaLink="false">http://larvatusprodeo.net/2008/10/15/the-qantas-nosedive-what-happened/#comment-536709</guid>
		<description>The Risks Digest piece Robert pointed out is very interesting - especially the mention of the cruise ship grounding where the software expected a failed GPS unit to &quot;fall silent&quot;, except it didn&#039;t.  It&#039;s those kinds of problems that are extremely hard to program around (other than with multiple redundancies and voting systems I suppose).

That the airbus took a nose dive seems to indicate two of the flight computers were wrong, not just one.  Might be a wiring fault, but given Qantas&#039; recent problems (which it seem are all due to poor maintenance) I reckon it&#039;s time they sat back down with their cost-cutting spreadsheet and started factoring in the real costs of these incidents vs the cost of a few extra ground crew and more down time.  Clearly their sums are currently wrong.</description>
		<content:encoded><![CDATA[<p>The Risks Digest piece Robert pointed out is very interesting &#8211; especially the mention of the cruise ship grounding where the software expected a failed GPS unit to &#8220;fall silent&#8221;, except it didn&#8217;t.  It&#8217;s those kinds of problems that are extremely hard to program around (other than with multiple redundancies and voting systems I suppose).</p>
<p>That the airbus took a nose dive seems to indicate two of the flight computers were wrong, not just one.  Might be a wiring fault, but given Qantas&#8217; recent problems (which it seem are all due to poor maintenance) I reckon it&#8217;s time they sat back down with their cost-cutting spreadsheet and started factoring in the real costs of these incidents vs the cost of a few extra ground crew and more down time.  Clearly their sums are currently wrong.</p>
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