How
Organisations
Sabotage
Safety
Dr Sean Brady
Brady Heywood
Content Warning.
29 October 2018.
Soekarno-Hatta
International Airport.
Lion Air 610.
https://www.airdatanews.com/flight-jt610-final-report-points-nine-failures-that-caused-the-accident/
https://edition.cnn.com/2018/10/28/asia/lion-air-plane-crash-intl/index.html
6:20am, Departs.
https://pt.wikipedia.org/wiki/Voo_Lion_Air_6
20181029-0_B38M_PK-LQP_PRELIMINARY
https://www.airdatanews.com/organizations-and-experts-call-for-more-safety-redundancy-on-the-737-max/737-max-flight-deck/
https://www.cbsnews.com/news/lion-air-plane-crash-flight-jt-610-boeing-737-accident-indonesia-live-updates-today/
Bad Altitude.
Airspeed.
https://edition.cnn.com/2018/10/28/asia/lion-air-plane-crash-intl/index.html
“Flight Control
Problem”.
https://www.nytimes.com/interactive/2018/11/16/world/asia/lion-air-crash-cockpit.html
https://www.nytimes.com/interactive/2018/11/16/world/asia/lion-air-crash-cockpit.html
https://www.airdatanews.com/organizations-and-experts-call-for-more-safety-redundancy-on-the-737-max/737-max-flight-deck/
https://www.cbsnews.com/news/lion-air-plane-crash-flight-jt-610-boeing-737-accident-indonesia-live-updates-today/
https://www.nytimes.com/interactive/2018/11/16/world/asia/lion-air-crash-cockpit.html
https://www.nytimes.com/interactive/2018/11/16/world/asia/lion-air-crash-cockpit.html
https://www.nytimes.com/interactive/2018/11/16/world/asia/lion-air-crash-cockpit.html
http://www.cockpitcompanion.com/pd-b737-qrh-with-tabs.cfm
20181029-0_B38M_PK-LQP_PRELIMINARY
20181029-0_B38M_PK-LQP_PRELIMINARY
27,000 Ft
5,000 Ft
20181029-0_B38M_PK-LQP_PRELIMINARY
8 Minutes
21 Times
https://edition.cnn.com/2018/10/28/asia/lion-air-plane-crash-intl/index.html
https://www.nytimes.com/interactive/2018/11/16/world/asia/lion-air-crash-cockpit.html
https://www.nytimes.com/interactive/2018/11/16/world/asia/lion-air-crash-cockpit.html
https://www.nytimes.com/interactive/2018/11/16/world/asia/lion-air-crash-cockpit.html
https://www.nytimes.com/interactive/2018/11/16/world/asia/lion-air-crash-cockpit.html
“Sink Rate,
Sink Rate”.
https://www.nytimes.com/interactive/2018/11/16/world/asia/lion-air-crash-cockpit.html
“Terrain, Terrain”.
20181029-0_B38M_PK-LQP_PRELIMINARY
20181029-0_B38M_PK-LQP_PRELIMINARY
500 mph
https://www.bangkokpost.com/world/1567794/crashed-indonesia-lion-air-jet-fuselage-believed-found
https://www.bangkokpost.com/world/1567794/crashed-indonesia-lion-air-jet-fuselage-believed-found
189
https://edition.cnn.com/2018/10/28/asia/lion-air-plane-crash-intl/index.html
The Public Narrative.
The Private Narrative.
MCAS.
The Private Narrative.
https://aviationweek.com/air-transport/aircraft-propulsion/concerns-expressed-over-737-max-redundancy-manual-trim
How?
Cause = Effect.
https://www.bl.uk/collection-items/photograph-of-soldiers-walking-on-duckboard-third-battle-of-ypres
World War I.
https://www.nytimes.com/2015/04/20/opinion/the-assassination-of-archduke-franz-ferdinand-of-austria.html
‘Cause’ of World War I?
Complex Systems.
Complex Systems.
https://www.igismap.com/flight-routes-network-analysis/
https://hbr.org/2013/07/the-network-secrets-of-great-change-agents
Interactions.
Sports Teams.
Cause = Effect.
Cause ≠ Effect.
The Sand Pile Model.
Sand Piles.
https://medium.com/closer-consulting/beach-physics-for-economists-sand-piles-d1d34d8f80e5
Cause?
Cause:
Grain of Sand?
Cause:
Shape of the Hill?
A ‘Critical State’.
BP Texas City,
23 March 2005.
https://www.youtube.com/watch?v=goSEyGNfiPM
Pike River, Nov 2010.
TRIFR, LTIFR.
ESG.
Deepwater Horizon, April 2010.
United States Coast Guard
https://medium.com/closer-consulting/beach-physics-for-economists-sand-piles-d1d34d8f80e5
https://upload.wikimedia.org/wikipedia/commons/5/54/Boeing_full_logo_%28variant%29.svg
“We hire Engineers
“We hire Engineers
and
other people.”
“We hire Engineers
and
other people.”
https://en.wikipedia.org/wiki/File:Lufthansa_Airbus_A320neo_(D-AINC)_at_Frankfurt_Airport.jpg
Airbus A320neo.
https://en.wikipedia.org/wiki/File:South_African_Airlink_Boeing_737-200_Advanced_Smith.jpg
Boeing 737.
1/3
https://www.allaboutlean.com/boeing-management/
Pilot Training.
https://www.nytimes.com/interactive/2018/11/16/world/asia/lion-air-crash-cockpit.html
Early Wind Tunnel Tests.
https://www.nytimes.com/interactive/2018/11/16/world/asia/lion-air-crash-cockpit.html
Early Wind Tunnel Tests.
Mechanical
Solution?
Manoeuvring
Characteristics
Augmentation
System
Manoeuvring
Characteristics
Augmentation
System
https://www.seattletimes.com/business/indonesia-slams-boeing-737-max-design-before-releasing-report-on-lion-air-crash/
Pilot Training.
https://www.cbsnews.com/news/lion-air-plane-crash-flight-jt-610-boeing-737-accident-indonesia-live-updates-today/
Lion Air 610.
https://edition.cnn.com/2018/10/28/asia/lion-air-plane-crash-intl/index.html
The Public Narrative.
10 March 2019.
Addis Ababa Bole
International Airport.
Ethiopian Airlines Flight 302.
https://en.wikipedia.org/wiki/Ethiopian_Airlines_Flight_302#/media/File:Ethiopian_Airlines_ET-AVJ_takeoff_from_TLV_(46461974574).jpg
Ethiopian Airlines Flight 302.
https://theconversation.com/automated-control-system-caused-ethiopia-crash-flight-data-suggests-113688
Ethiopian Airlines Flight 302.
https://theconversation.com/automated-control-system-caused-ethiopia-crash-flight-data-suggests-113688
157
https://www.seattletimes.com/tag/lion-air-crash/
One Sensor?
MCAS.
https://www.nytimes.com/interactive/2018/11/16/world/asia/lion-air-crash-cockpit.html
Test Flights.
https://www.nytimes.com/interactive/2018/11/16/world/asia/lion-air-crash-cockpit.html
Plane Pitches Up Slow Speeds.
Pilot Training.
https://projects.seattletimes.com/2019/boeing-737-max-12-problems/
MCAS
Gets
Extended
Reliant on
one sensor
Manual?
https://edition.cnn.com/2018/10/28/asia/lion-air-plane-crash-intl/index.html
Lion Air 610.
Solution?
Ethiopian Airlines Flight 302.
https://en.wikipedia.org/wiki/Ethiopian_Airlines_Flight_302#/media/File:Ethiopian_Airlines_ET-AVJ_takeoff_from_TLV_(46461974574).jpg
Cause ≠ Effect.
https://www.nytimes.com/2015/04/20/opinion/the-assassination-of-archduke-franz-ferdinand-of-austria.html
‘Cause’ of World War I?
https://history.delaware.gov/world-war-i/
‘Cause’ of World War I?
https://history.delaware.gov/world-war-i/
‘Cause’ of World War I?
A ‘Critical State’.
https://medium.com/closer-consulting/beach-physics-for-economists-sand-piles-
d1d34d8f80e5
How
Organisations
Sabotage
Safety?

How organisations Sabotage Safety