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To sum it up
• True Chesley Sullenberger was a great pilot
• However he was not alone
• He had a network of engineers, designers,
computer programers, algorythms, hours of
flight simulations etc with him in the cockpit.
• This was great piloting via a team of
specialists, combined with years of learning
from tests and errors, but not a miracle and
well within the realms of possibility.
Remember: in the right Oxygen atmosphere even metals will burn.
Graham Allison’s three lenses for decison making
Team or crew
Organization or network
Malaysian Flight 370
• Cognitive biases
Trust in the machine
Windows of recovery
Squashing divergent views
• Are 99% of all aircraft accidents caused by
• Why is it easier to blame the pilot?
• No eventually it is closer to 50% and that includes
equipment and weather factors.
• But there is an obvious advantage treating pilots
as scapegoats since quite often they died in the
crash and there is little money at stake in blaming
them and much face to save for companies and
• However good companies like Toyota search out
lower ranked workers for their assestments
What happens if you ask a pilot?
• A Startlingly Simple Theory About the Missing Malaysia Airlines Jet BY CHRIS GOODFELLOW
• The pilot did all the right things. He was confronted by some major event
onboard that made him make an immediate turn to the closest, safest
• The loss of transponders and communications makes perfect sense in a fire. In the
case of a fire, the first response is to pull the main busses and restore circuits one
by one until you have isolated the bad one. Hence communications go silent.
• going to 45,000 feet in a hijack scenario doesn’t make any good sense
• let’s accept for a minute that the pilot may have ascended to 45,000 feet in a last-
ditch effort to quell a fire by seeking the lowest level of oxygen. That is an
acceptable scenario. At 45,000 feet, it would be tough to keep this aircraft stable,
as the flight envelope is very narrow and loss of control in a stall is entirely
possible. The aircraft is at the top of its operational ceiling. The reported rapid
rates of descent could have been generated by a stall, followed by a recovery at
25,000 feet. The pilot may even have been diving to extinguish flames.
Why wouldn’t Boeing want to mention Egyptair B772 at Cairo
on Jul 29th 2011, cockpit fire fueled at least in part by the
oxygen tanks in the cockpit?
Would you be able to function in this
With a hole and fire like this would
Flying higher really make sense?
Squashing divergent views
It is very hard for homogeneous and hierarchical organizations to accept outside views
• Exploration firm claims MH370 wreckage found in Bay of Begal
• The Adelaide-based GeoResonance said on Monday the possible wreckage was found in
the Bay of Bengal, 5,000km away from the current search location in the southern
Indian Ocean off Perth, with the company beginning its own search on March 10.
• We identified chemical elements and materials that make up a Boeing 777… these are
aluminium, titanium, copper, steel alloys and other materials," said Mr Kursa
• GeoResonance's search covered 2,000,000 sq km of the possible crash zone using
images obtained from satellites and aircraft, with company scientists focusing their
efforts north of MH370's last known location
• "The technology that we use was originally designed to find nuclear warheads and
submarines. Our team in Ukraine decided we should try and help," said the company
spokesman David Pope.
• The most recent acoustic signal (5th) detected by an Australian aircraft in the search Thursday is "unlikely to
be related to the aircraft black boxes," Australian chief search coordinator Angus Houston said in a statement
• So if the fifth is false because there was no possibility that the batteries lasted that long were the other four
just wishful thinking?
• From Oxygen, to fly by wire and blamestorming all appear to
have played roles.
• It seems that Malaysa Flight 370 is not so much a mystery as
just poor organization and communication.
• While the Bay of Bengal solution is unproven there is still no
reason to suspect that there would have been a logical
purpose in changing direction and flying towards open ocean.
• It would be nice to know what if any further investigation
occurs in the Bay of Bengal.