- Job, Macarthur.
Air Disaster, Vol. 3.
Fyshwick, Australia: Aerospace Publications, 1998.
ISBN 1-875671-34-X.
-
In the early 1970s I worked for a company that
sold remote batch computing services on
UNIVAC mainframes. Our
management visited Boeing headquarters in Seattle to pitch for some
of their business (unlikely, as Boeing had their own computer service
bureau at the time, but you never know unless you try). Part of the
presentation focused on how reliable our service was, averaging
better than 99.5% uptime. The Boeing data processing manager didn't
seem too impressed with this. He asked, “When you came up
here from San Francisco, did you fly on one of our airplanes?” “As a
matter of fact, we did.”, answered the president of our company. The
Boeing guy then asked, “Well, how would you feel if I told you Boeing
airplanes only crash about once every two hundred flights?” The
meeting moved on to other topics; we never did get any business from
Boeing.
Engineering is an art we learn from failure, and the aviation
safety community is the gold standard when it comes to
getting to the probable cause of a complicated disaster
and defining achievable steps to prevent it from
recurring. There is much for practitioners of other branches
of engineering to admire and learn from looking over the shoulders
of their colleagues in air accident investigation, and Macarthur
Job's superb Air Disaster series, of which this is the third
volume (Vol. 1,
Vol. 2) provides precisely
such a viewpoint. Starting from the official accident reports,
author Job and illustrator Matthew Tesch recreate the circumstances
which led to each accident and the sometimes tortuous process through
which investigators established what actually happened. The
presentation is not remotely sensationalistic, yet much more
readable than the dry prose of most official accident reports. If
detail is required, Job and Tesch do not shrink from providing it;
four pages of text and a detailed full page diagram on page 45
of this volume explain far more about the latching mechanism of the
747 cargo door than many people might think there is to know, but
since you can't otherwise understand how the door of a United 747
outbound from Honolulu could have separated in flight, it's all
there.
Reading the three volumes, which cover the jet age from the de
Havilland Comet through the mid 1990s, provides an interesting view
of the way in which assiduous investigation of anomalies and
incremental fixes have made an inherently risky activity so safe that
some these days seem more concerned with fingernail clippers than
engine failure or mid-air collisions. Many of the accidents in the
first two volumes were due to the machine breaking in some way or
another, and one by one, they have basically been fixed to the extent
that in this volume, the only hardware related accident is the 747
cargo door failure (in which nine passengers died, but 345 passengers
and crew survived). The other dozen are problems due to the weather,
human factors, and what computer folks call “user
interface”—literally so in several cases of mode confusion and
mismanagement of the increasingly automated flight decks of the
latest generation of airliners. Anybody designing interfaces in
which the user is expected to have a correct mental model of
the operation of a complex, partially opaque system will find
many lessons here, some learnt at tragic cost in an environment
where the stakes are high and the margin of error small.
June 2005 