« Managing Secret Programs| Main | Robot Roundup »
737 Crash
As a commercial pilot who's never flown a big commercial aircraft, I think I've always dreamed of being on an airplane when they ask "Is there a pilot on board?", then leaping up to the cabin to save the day. Like those old "Airport" movies, it would be good to take all of that training and do something heroic with it. It looks like that is exactly the type of situation that happened today, as a Greek 737 lost cabin pressure and both pilots. Unfortunately, nobody was there to save the day, and all on-board were lost. Are there some lessons here?
As of this writing, both "black boxes", or flight data recorders, have been found. A long time ago, the aviation industry decided to track key performance variables throughout a flight, so that when accidents happen, the industry takes a long hard look at how to keep them from happening again. The idea is so powerful that now we are talking about flight video recorders to monitor the movements of the flight crew in an effort to make the human interface part of the controls safer. In order for this accident to happen, however, there had to have been multiple failures. Let's take a look at the cabin pressurization system.
There are rumors that the plane in question had experienced pressurization problems in the past. This leads me to believe the plane was probably flown with "squawks" regarding the Cabin Pressure Control System, pictured above. If I'm not mistaken, this is checked prior to flight. It will be very interesting to hear this part of the playback. I also believe there is dual oxygen system for the cabin, and the pilots have access to a separate O2 bottle under the seats. How, then, did the pilots end up dying while the passengers were alive in the back? At the altitude of 30,000 feet, people only have about a minute of useful consciousness if the cabin depressurizes. But surely that would be enough for the crew to try both backup systems -- and this is a exercise that is practiced religiously by 737 crews due to the danger involved. How did the passengers know what was going on in the cabin, as indicated by some text messages from the passengers to relatives? We will find out, because we track internal indicators that tell us what went wrong. This is why commercial aviation is one of the safest means of transport in the world.
Why not do the same thing to our project and program management? If we could track key indicators as these projects rolled along, we would then have more meaningful data to use in preventing project and program failure. What are key indicators? The perceived quality of the processes being used. If this system works so well for saving lives, why not use the MAT to start preventing program failure rates for being so high? What's worse than not having somebody or some thing there to save the day? Having something available and not realizing you are even in trouble until it is too late.
3 Comments
Leave a comment
It's a shame that FAA rules don't apply there. They have a supplemental oxygen rule (FAR 91.211) that requires pilot, co-pilot, etc. to be continuously on oxygen above 14,000 ft. I think they trade off oxygen duty during the flight. So high-altitude flight is even safer in the U.S., and such a rule probably would have prevented this horrific story: http://www.heraldsun.news.com.au/common/story_page/0,5478,16274492%255E663,00.html
Great article, It would be a great use of the mat program. The more I learn about it, the more I see its value.
Thanks for the comments!
Yes. The FAA rules do not apply here, although I believe it has more to do with where the plane is owned rather than where it is flying. International airspace regulations are a whole world of hassle beyond just flying. For instance, there are special courses that U.S. pilots need to take (if they are smart) on flying to the Bahamas, or to Europe. The U.S. is one of the few places where the average Joe can fly. Most places you have to be VERY rich and have connections.
As for the MAT, I appreciate the thoughts. As a pilot, I know how critical perceived danger and risk is in preventing failure. Comparing that risk and danger during the mission with the end result is the only way to act safer next time those perceptions occur.