And the other engine is the one that is malfunctioning? Yes. It happened. This slideshow presents the sequence of events and the six cascades that led to the final crash. Mechanical failure, pilot error, and more all contributed to this event.
48 sems (new physical laws) and “fundamental misunderstanding” of capt. sul...Miguel Cabral Martín
48 - SEMS (New Physical Laws) and “FUNDAMENTAL MISUNDERSTANDING” OF CAPT. SULLY SULLENBERGER
This written is due the incorrect statements of Capt. Sully according with his publication:
https://www.linkedin.com/pulse/technology-cannot-replace-pilots-capt-sully-sullenberger
48 sems (new physical laws) and “fundamental misunderstanding” of capt. sul...Miguel Cabral Martín
48 - SEMS (New Physical Laws) and “FUNDAMENTAL MISUNDERSTANDING” OF CAPT. SULLY SULLENBERGER
This written is due the incorrect statements of Capt. Sully according with his publication:
https://www.linkedin.com/pulse/technology-cannot-replace-pilots-capt-sully-sullenberger
In 1994, the University of Texas Human Research Project and Delta Airline developed the Line Operations Safety Audit (LOSA) program. With time, the LOSA program evolved into what is now known as Threat and Error Management (TEM).
The TEM framework is an applied concept which emerged from the observations and surveys of actual flight operations. It considers the various issues that a flight crew may encounter as a result of internal and external factors.
This model explores the contributing factors of the threat to aviation safety and, in turn, allows for the unearthing of ways to mitigate them and maintain proper safety margins. Now recognized and adopted across continents, the TEM framework aims to educate flight personnel on managing threats and errors before they degenerate into serious incidents or accidents. It is important to note that TEM is also applicable to maintenance operations, cabin crew, and air traffic control.
Many aviation accidents, both commercial and private, are caused by defective equipment. If it can be shown that equipment failure or a defective plane component resulted in an aviation accident that caused injury or death, it may be possible to file a lawsuit against the liable parties. So to file your case contact http://alabama.attorney-group.com/airplane-accidents/
Human Factors Training: There's nothing that can't go wrong. This simple insight forms the foundation of human factors training for pilots. In special courses, pilots are prepared for any possible emergency situation and action strategies. Crews learn to analyze and evaluate their own behavior and that of those around them more effectively. Training leads to more efficient work processes, a functioning error management culture, and increased safety. This is a general prsentation and human factors management in aviation training.
CHC Safety & Quality Summit 2016 - Risk Culture in Commercial Air TransportCranfield University
This presentation was given at the 2016 CHC Safety & Quality Summit in Vancouver. The aim was to present an argument to introduce 'Risk Culture' as a new component of 'Safety Culture. This is an academic research which aims to explore what/how operational risk decisions are made by pilots and engineers and if such decisions are also acceptable at different levels including senior management.
In this research paper, I go over research related to the dangers in automation in the aviation domain and how it compares to the two most recent Boeing 737 Max accidents. (This article was written before the final NTSB report was released).
What Do You Do When The Pilots Shut Down The Wrong Engine?Bob Mayer
And the other engine is the one that is malfunctioning? Yes. It happened. This slideshow presents the sequence of events and the six cascades that led to the final crash. Mechanical failure, pilot error, and more all contributed to this event.
How Did A Flyable Plane Crash in Just Over Four Minutes?Bob Mayer
How does a flyable plane go from 30,000 feet to crash into the ocean in just over 4 minutes? Do not read this if you're getting ready to take a flight. A cascade of events, of which human error played a big role. The key is to learn from such an event so the lives lost were not in vain.
How Did A Flyable Plane Crash in Just Over Four Minutes?Bob Mayer
How does a flyable plane go from 30,000 feet to crash into the ocean in just over 4 minutes? Do not read this if you're getting ready to take a flight. A cascade of events, of which human error played a big role. The key is to learn from such an event so the lives lost were not in vain.
In 1994, the University of Texas Human Research Project and Delta Airline developed the Line Operations Safety Audit (LOSA) program. With time, the LOSA program evolved into what is now known as Threat and Error Management (TEM).
The TEM framework is an applied concept which emerged from the observations and surveys of actual flight operations. It considers the various issues that a flight crew may encounter as a result of internal and external factors.
This model explores the contributing factors of the threat to aviation safety and, in turn, allows for the unearthing of ways to mitigate them and maintain proper safety margins. Now recognized and adopted across continents, the TEM framework aims to educate flight personnel on managing threats and errors before they degenerate into serious incidents or accidents. It is important to note that TEM is also applicable to maintenance operations, cabin crew, and air traffic control.
Many aviation accidents, both commercial and private, are caused by defective equipment. If it can be shown that equipment failure or a defective plane component resulted in an aviation accident that caused injury or death, it may be possible to file a lawsuit against the liable parties. So to file your case contact http://alabama.attorney-group.com/airplane-accidents/
Human Factors Training: There's nothing that can't go wrong. This simple insight forms the foundation of human factors training for pilots. In special courses, pilots are prepared for any possible emergency situation and action strategies. Crews learn to analyze and evaluate their own behavior and that of those around them more effectively. Training leads to more efficient work processes, a functioning error management culture, and increased safety. This is a general prsentation and human factors management in aviation training.
CHC Safety & Quality Summit 2016 - Risk Culture in Commercial Air TransportCranfield University
This presentation was given at the 2016 CHC Safety & Quality Summit in Vancouver. The aim was to present an argument to introduce 'Risk Culture' as a new component of 'Safety Culture. This is an academic research which aims to explore what/how operational risk decisions are made by pilots and engineers and if such decisions are also acceptable at different levels including senior management.
In this research paper, I go over research related to the dangers in automation in the aviation domain and how it compares to the two most recent Boeing 737 Max accidents. (This article was written before the final NTSB report was released).
What Do You Do When The Pilots Shut Down The Wrong Engine?Bob Mayer
And the other engine is the one that is malfunctioning? Yes. It happened. This slideshow presents the sequence of events and the six cascades that led to the final crash. Mechanical failure, pilot error, and more all contributed to this event.
How Did A Flyable Plane Crash in Just Over Four Minutes?Bob Mayer
How does a flyable plane go from 30,000 feet to crash into the ocean in just over 4 minutes? Do not read this if you're getting ready to take a flight. A cascade of events, of which human error played a big role. The key is to learn from such an event so the lives lost were not in vain.
How Did A Flyable Plane Crash in Just Over Four Minutes?Bob Mayer
How does a flyable plane go from 30,000 feet to crash into the ocean in just over 4 minutes? Do not read this if you're getting ready to take a flight. A cascade of events, of which human error played a big role. The key is to learn from such an event so the lives lost were not in vain.
To Readers
This summary is an overview of the book (The Art of Clear Thinking: A Fighter Pilot’s Guide to Making Tough Decisions) written by (Hasard Lee). It is not meant to serve as a substitute for reading the actual book, but rather it's intended to give you a general idea of what the book is about and the main themes and ideas that it covers.
Explore the innovative world of trenchless pipe repair with our comprehensive guide, "The Benefits and Techniques of Trenchless Pipe Repair." This document delves into the modern methods of repairing underground pipes without the need for extensive excavation, highlighting the numerous advantages and the latest techniques used in the industry.
Learn about the cost savings, reduced environmental impact, and minimal disruption associated with trenchless technology. Discover detailed explanations of popular techniques such as pipe bursting, cured-in-place pipe (CIPP) lining, and directional drilling. Understand how these methods can be applied to various types of infrastructure, from residential plumbing to large-scale municipal systems.
Ideal for homeowners, contractors, engineers, and anyone interested in modern plumbing solutions, this guide provides valuable insights into why trenchless pipe repair is becoming the preferred choice for pipe rehabilitation. Stay informed about the latest advancements and best practices in the field.
Event Management System Vb Net Project Report.pdfKamal Acharya
In present era, the scopes of information technology growing with a very fast .We do not see any are untouched from this industry. The scope of information technology has become wider includes: Business and industry. Household Business, Communication, Education, Entertainment, Science, Medicine, Engineering, Distance Learning, Weather Forecasting. Carrier Searching and so on.
My project named “Event Management System” is software that store and maintained all events coordinated in college. It also helpful to print related reports. My project will help to record the events coordinated by faculties with their Name, Event subject, date & details in an efficient & effective ways.
In my system we have to make a system by which a user can record all events coordinated by a particular faculty. In our proposed system some more featured are added which differs it from the existing system such as security.
CFD Simulation of By-pass Flow in a HRSG module by R&R Consult.pptxR&R Consult
CFD analysis is incredibly effective at solving mysteries and improving the performance of complex systems!
Here's a great example: At a large natural gas-fired power plant, where they use waste heat to generate steam and energy, they were puzzled that their boiler wasn't producing as much steam as expected.
R&R and Tetra Engineering Group Inc. were asked to solve the issue with reduced steam production.
An inspection had shown that a significant amount of hot flue gas was bypassing the boiler tubes, where the heat was supposed to be transferred.
R&R Consult conducted a CFD analysis, which revealed that 6.3% of the flue gas was bypassing the boiler tubes without transferring heat. The analysis also showed that the flue gas was instead being directed along the sides of the boiler and between the modules that were supposed to capture the heat. This was the cause of the reduced performance.
Based on our results, Tetra Engineering installed covering plates to reduce the bypass flow. This improved the boiler's performance and increased electricity production.
It is always satisfying when we can help solve complex challenges like this. Do your systems also need a check-up or optimization? Give us a call!
Work done in cooperation with James Malloy and David Moelling from Tetra Engineering.
More examples of our work https://www.r-r-consult.dk/en/cases-en/
TECHNICAL TRAINING MANUAL GENERAL FAMILIARIZATION COURSEDuvanRamosGarzon1
AIRCRAFT GENERAL
The Single Aisle is the most advanced family aircraft in service today, with fly-by-wire flight controls.
The A318, A319, A320 and A321 are twin-engine subsonic medium range aircraft.
The family offers a choice of engines
About
Indigenized remote control interface card suitable for MAFI system CCR equipment. Compatible for IDM8000 CCR. Backplane mounted serial and TCP/Ethernet communication module for CCR remote access. IDM 8000 CCR remote control on serial and TCP protocol.
• Remote control: Parallel or serial interface.
• Compatible with MAFI CCR system.
• Compatible with IDM8000 CCR.
• Compatible with Backplane mount serial communication.
• Compatible with commercial and Defence aviation CCR system.
• Remote control system for accessing CCR and allied system over serial or TCP.
• Indigenized local Support/presence in India.
• Easy in configuration using DIP switches.
Technical Specifications
Indigenized remote control interface card suitable for MAFI system CCR equipment. Compatible for IDM8000 CCR. Backplane mounted serial and TCP/Ethernet communication module for CCR remote access. IDM 8000 CCR remote control on serial and TCP protocol.
Key Features
Indigenized remote control interface card suitable for MAFI system CCR equipment. Compatible for IDM8000 CCR. Backplane mounted serial and TCP/Ethernet communication module for CCR remote access. IDM 8000 CCR remote control on serial and TCP protocol.
• Remote control: Parallel or serial interface
• Compatible with MAFI CCR system
• Copatiable with IDM8000 CCR
• Compatible with Backplane mount serial communication.
• Compatible with commercial and Defence aviation CCR system.
• Remote control system for accessing CCR and allied system over serial or TCP.
• Indigenized local Support/presence in India.
Application
• Remote control: Parallel or serial interface.
• Compatible with MAFI CCR system.
• Compatible with IDM8000 CCR.
• Compatible with Backplane mount serial communication.
• Compatible with commercial and Defence aviation CCR system.
• Remote control system for accessing CCR and allied system over serial or TCP.
• Indigenized local Support/presence in India.
• Easy in configuration using DIP switches.
Hybrid optimization of pumped hydro system and solar- Engr. Abdul-Azeez.pdffxintegritypublishin
Advancements in technology unveil a myriad of electrical and electronic breakthroughs geared towards efficiently harnessing limited resources to meet human energy demands. The optimization of hybrid solar PV panels and pumped hydro energy supply systems plays a pivotal role in utilizing natural resources effectively. This initiative not only benefits humanity but also fosters environmental sustainability. The study investigated the design optimization of these hybrid systems, focusing on understanding solar radiation patterns, identifying geographical influences on solar radiation, formulating a mathematical model for system optimization, and determining the optimal configuration of PV panels and pumped hydro storage. Through a comparative analysis approach and eight weeks of data collection, the study addressed key research questions related to solar radiation patterns and optimal system design. The findings highlighted regions with heightened solar radiation levels, showcasing substantial potential for power generation and emphasizing the system's efficiency. Optimizing system design significantly boosted power generation, promoted renewable energy utilization, and enhanced energy storage capacity. The study underscored the benefits of optimizing hybrid solar PV panels and pumped hydro energy supply systems for sustainable energy usage. Optimizing the design of solar PV panels and pumped hydro energy supply systems as examined across diverse climatic conditions in a developing country, not only enhances power generation but also improves the integration of renewable energy sources and boosts energy storage capacities, particularly beneficial for less economically prosperous regions. Additionally, the study provides valuable insights for advancing energy research in economically viable areas. Recommendations included conducting site-specific assessments, utilizing advanced modeling tools, implementing regular maintenance protocols, and enhancing communication among system components.
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What Do You Do When The Pilots Shut Down The Wrong Engine?
1. The Kegworth Crash:
What happens when one of the 2
engines on your plane catches on
fire? And the pilots shut down the
wrong engine?
2. The Rule of Seven:
Every catastrophe has 7 events.
Six Cascade Events leading to the
final event, the catastrophe. At
least one of the Cascade Events
involves human error. Thus most
catastrophes can be avoided.
Anatomy of Catastrophe
3. Passenger when the pilots shut
down the right engine:
“We were thinking: ‘Why is he doing
that?’ because we saw flame coming
out of the left engine. But I was only
a bread man. What did I know?”
British Midlands Flt 92
The Danger of Trusting Experts.
4.
5. On 8 January 1989, a Boeing 737-
400 crashed just short of the
runway near Kegworth in the UK.
47 people were killed and 74
received serious injuries out of a
complement of 126 on board.
THE FACTS
6. 8 January 1989
7:52 pm: Flight BD092 takes off from Heathrow
en route to Belfast International.
8:05 pm: Flight 092 experiences severe vibration
and a smell of fire. Engine #2 is shut down.
8:20 pm: Power is increased to engine #1 at three
thousand feet on approach to Midland Airport.
At nine hundred feet engine #1 fails.
8:24 pm: Flight 092 crashes a quarter mile short
of Midland Airport runway.
THE TIMELINE
7. Engines were upgraded but not thoroughly
tested and the pilots were never trained on the
upgraded aircraft.
The 737-400 was an upgraded version of the
737. The pilots never had simulator training for
the 737-400, even though it was a different
version of the aircraft. The first time they faced
an emergency in this new model, it was real,
not a simulation.
Cascade 1
8. Lesson: Equipment has to be tested in the exact
environment in which it supposed to function. And
upgrades to an existing piece of equipment must be viewed
as essentially making the equipment brand new, requiring
all the testing required of such.
9. A blade broke in the left engine.
This is a purely mechanical failure. By itself,
it was not a catastrophe. The 737, and all
multi-engine jets, can operate on the other
engine.
Of course, this failure was compounded by
Cascade One, and, as you will see, became
part of the overall fatal Final Event.
Cascade 2
10. LESSON: Mechanical failures will happen.
Safety designs and equipment redundancy
prepare for this and very rarely do they cause
a final event by themselves. This is why we
must focus on those Cascade Events that are
human caused such as . . . Cacade 3.
11. The pilot shut down the wrong engine.
As soon as they felt the vibration and received the report that
smoke had begun to seep into the cabin, the pilot disengaged
the autopilot and asked the copilot which engine was the
problem. The copilot replied “It’s the le—no, the right one.”
What both pilots failed to realize is that they were relying on out
of date data and training. In the version of the 737 they were
used to, the left engine supplied air to the cockpit (where there
was little smoke) while the right supplied the cabin with air. If it
had been the left engine, there would have only been smoke in
the cockpit. But since there was smoke in the cabin? Ergo, the
smoky air in the cabin had to come from the right engine.
What they didn’t know was that in the upgraded 737-400, the
left engine feeds the flight deck and the after cabin, while the
right feeds the forward cabin.
Cascade 3
12. LESSON: Any time equipment is upgraded or changed; the operators need to
be thoroughly trained on all the changes. Even the tiniest change in details
can have enormous repercussions. Here, the pilots made their initial estimate
of the problem based on a previous version of the plane.
13. The shut down brought erroneous data in terms
of reduced smoke and vibration to the crew, who
were not trusting their instruments.
There was a gauge, which would have alerted
them to the correct engine with the problem
from the start. There is a vibration readout for
each engine on the video display and it indicated
that the left engine was maxed out at 5, thus the
source of the problem.
Cascade 4
14. LESSON: Trust instrument readings.
We often make wrong choices because we base the
decision on our experiences rather than real data. Pilots are
taught never to trust what they physically feel, but rather
always trust their instruments. Alarms, gauges, and
warnings are put in place for a reason. Feeling abnormal
vibration, assuming it was from the engines, wouldn’t it
have made sense for the pilot or co-pilot to check the
engine vibration readouts?
15. People in the passenger compartment saw the problem
in the left engine in terms of sparks and smoke, then
heard the captain announce shutting down the right
engine, but no one reported this disconnect to the
cockpit. They all assumed the experts knew what they
were doing.
By the time, the pilots realized their error, it was too
late.
Pilots in a cockpit don’t have a view of the plane. They
can see forward, not back.
Cascade 5
16. Lesson: Don’t assume experts have all the data or
know exactly what they’re doing. Don’t ever
completely give up control of your environment.
Report suspicious data when you see it. An average
person seeing, hearing, smelling, noticing
something that just doesn’t look right, and
reporting it has averted many catastrophes.
17. The review of data and instruments was interrupted by a
call from the tower and never resumed.
As per SOP in the event of a malfunction, the pilot began
to recheck all instruments and decisions. However, before
he could complete this, a transmission from the airport he
was heading toward gave him flight information for
landing. After the transmission, he didn’t resume his
checks and instead began to descend as per the
instructions. It is likely he would have discovered his error
in shutting down the wrong engine if he’d continued the
checks and seen the vibration meter.
Cascade 6
18. LESSON SOPs exist for a reason.
Beware interruptions when conducting critical tasks.
19. The plane crashed a quarter mile short of the runway.
Two miles from the runway, the left engine completely
disintegrated, sending pieces flying about. The fire warning
light finally went off, and for the first time the pilot realized
which engine really had the problem.
This meant, of course, that he still had a good engine; except
it wasn’t running. The pilot’s attempts to ‘windmill’, using
the air flowing through the engine to rotate the blades and
start the right engine, failed.
Just before crossing a major highway, the M1, the plane’s
tail struck the ground, but luckily, the aircraft bounced up,
over the highway, and then crashed on the far embankment.
It broke into three major sections.
Final Event
20. LESSON: Changes were made after this event.
The vibration readouts were made more visible. Crews are
encouraged to do more communication between cockpit and
cabin during an inflight emergency. Pilots must receive
simulator training on any upgraded version of an aircraft.
Since there were so many survivors of this impact,
researchers were able to do something unprecedented:
examine the position of passengers at the time of impact and
their injuries. They found that the crash position promulgated
at the time led to severe injuries. This led to the hands behind
head, leaning forward, feet back under the seat as far as
possible position we now see as the industry standard.
Final Event
21.
22. Seven Ways to Prevent Catastrophes
1. Have a Special Ops preparation mindset
2. Focus by utilizing both big picture & detail
thinkers
3. Conduct Special Forces Area Studies
4. Use the Special Forces CARVER formula
5. Have a “10th man”
6. Conduct After Action Reviews
7. Write and USE Standing Operating Procedures
(SOPs)
23. Are you interested in a presentation about various catastrophes
and how the cascade events could have been prevented?
Events covered range from human-machine interface, to
leadership, to communication, cost-cutting, engineering, group
think, perseverance, systematic failure, and more?
Catastrophes are cascade events culminating in disastrous
chaos. War is chaos. Special Forces is the most elite unit trained
for a variety of combat situations.
What makes Special Forces elite is our mindset and
preparation.
Are you interested in a presentation on how to use Special
Forces tactics, techniques and mental attitude to help your
organization anticipate and prevent potential catastrophes?
Please email bob@bobmayer.com
Summary
24. More Free Information
I constantly update free, downloadable
slideshows like this on my web site for
preparation and survival and other topics.
FREE SLIDESHOWS
Also, I conduct Area Study workshops for
those interested in properly preparing for
their specific circumstances.
25. The guide on the left is the complete preparation and survival
guide. The one on the right is a pocket-size manual with just the
survival portion. Useful in your Grab-n-Go bag, car and kitchen
drawer.
SURVIVAL GUIDES
26. The Book
"The best preparation guide available, bar none. A
must have for anyone concerned about man-
made and natural disasters. Mayer points out
that preparation is key and he walks the reader
through it, each section building on the one
before. From page one, I felt more prepared.
Get it!" Assembly Magazine.
27.
28. New York Times bestselling author, is a graduate of West Point and
former Green Beret. He’s had over 80 books published, including the
#1 bestselling series Green Berets, Time Patrol, Area 51, and Atlantis.
He’s sold over 5 million books. He was born in the Bronx and has
traveled the world. He’s lived on an island off the east coast, an island
off the west coast, in the Rocky Mountains, the Smoky Mountains and
other places, including time in East Asia studying martial arts.
He was an instructor and course developer/writer for years at the
JFK Special Warfare Center and School which trains Green Berets and
also runs the SERE school:
Survival, Evasion, Resistance and Escape.
www.bobmayer.com
Editor's Notes
Time 1:38 for Captain to come in
LOOPHOLE!
Cockpit Resource Management (CRM) was begun in 1979 as a result of a NASA workshop. One of the key elements was to make sure that co-pilots would be more responsive to warning/advising the pilot. In the case of Air France Flight 447, they didn’t even get to that stage, with two co-pilots, both of whom tried to control the plane. Instead of working together, they actually worked against each other.The situation got worse when the Captain entered the cockpit, with neither co-pilot filling him in on the sequence of events and vital readings which might have allowed the Captain to quickly assess the situation.