WorldWide Drilling Resource

For want of a Nail . . . by Britt Storkson Owner, P2FlowLLC The moral of the story in the box is: Something of great importance may depend on an apparently trivial detail. It’s triv- ial until it causes a major problem. On July 6, 2013, Asiana Airlines’ Flight 214 came into San Francisco (California) air- port too low and too slow, hit a concrete seawall, and skidded down the runway. In an article Pilots in Crash Were Confused About Control Systems, Experts Say (Matthew L. Wald, New York Times online, December 11, 2013) it states: “The pilots of the Asiana jumbo jet that crashed in San Francisco on July 6 were deeply confused about the plane’s automated control systems, and that is a common prob- lem among airline pilots, according to experts who testified Wednesday in a National Transportation Safety Board hearing on the crash.” If they were confused about the airplane control systems, why were they flying the plane in the first place? The article goes on to say: “The captain and the supervising pilot in the Asiana crash - in which a Boeing 777 hit a sea wall short of the runway, killing three passengers - said they thought a system that is used to control the plane’s airspeed was run- ning, although it was not.” Often, pilots rely too much on the automation systems. Again quoting from the article: “Government studies as far back as 1996 show a heavy reliance on automation that pilots often do not understand, witnesses said. One common prob- lem is what they call “mode error,” in which pilots become confused about what automated cockpit controls will do in a certain situation. The problem is akin to hav- ing trouble with the buttons on a remote control unit for a home entertainment sys- tem, but with greater consequences.” The author explains the automated airplane control systems of the Boeing 777 and the Airbus A320 - two very similar aircraft are also very similar in terms of what their automation will do - but not exactly the same. And that’s the rub. I’ve been confused when trying to figure out the “pay stations” which are almost everywhere nowadays. As far as the functional objective, they all do exactly the same thing - take your money and record your transaction. No problem there. Where the problems come in is the particular sequence of operations, which again accomplishes the same objective, but does so in many different ways depending on who made the machine. Some require you to sign something, others don’t. Often, one must operate two or more keyboards, keypads, or touch screens to get the job done. Not terribly “intuitive.” Now, if the average person gets confused by the simple action of paying for a purchase using an automated system, imagine the problems airline pilots would encounter using a far more complex and critical control system such as an autopi- lot. Years ago when watching cartoons as a kid, I remember one of a plane going down and about to crash. In this episode, someone thought to activate the autopi- lot. When the autopilot button was pressed, a robot came out, strapped on a para- chute, and jumped out of the plane. While this was a corny illustration of somebody’s idea of an autopilot, it illus- trates the fact the automation equipment has nothing to lose - but we humans have much to lose if an operator, such as an airline pilot, does not fully understand the computer controls he/she is using. Automation controls, if we use them, should serve us. We should not serve them. Britt Britt Storkson may be contacted via e-mail to michele@worldwidedrillingresource.com 29 WorldWide Drilling Resource ® SEPTEMBER 2018 “For want of a nail the shoe was lost, For want of a shoe the horse was lost, For want of a horse the rider was lost, For want of a rider the battle was lost, For want of a battle the kingdom was lost, And all for the want of a horseshoe nail.”