
The Differences Between the Plane Crash in Tapei and the Miracle on Hudson - BIackSwan
http://nautil.us/issue/23/dominoes/fear-in-the-cockpit
======
danielvf
It's hard to imagine how safe US passenger airlines have become. From the
start of 2002 to now, there have been only 115 airliner fatalities in the US.
That's 8.7 deaths per year. That's one death per 68,965,517,241 airline
passenger miles flown.

It's an incredible human achievement.

I make a hobby of reading through NTSB avaition an maritime accident reports.
It's a fascinating look at how to create almost failure free systems out of
mechanical things that break and humans that do stupid things.

~~~
mikeash
An interesting facet of this is that even though the death rate is extremely
low, the authorities still want to get it to zero. And it's becoming _really
hard_ , because failures are no longer happening often enough to be able to
analyze them properly.

~~~
csours
I'm sure it is more difficult, but you should be able to measure significant
non-fatal events.

For instance hospitals (and some industries) measure sentinel events [1][2].
Sentinel events cause death or serious permanent injury, or events that
_could_ cause death or serious permanent injury.

1:
[http://en.wikipedia.org/wiki/Sentinel_event](http://en.wikipedia.org/wiki/Sentinel_event)

2: I couldn't find a reference for industry, but I know they are recorded
because I went through the training.

~~~
mikeyouse
The US instituted what's called the 'Aviation Safety Reporting System' in the
mid-1970s, which is a program administered by NASA. Any airline employee can
file confidential reports about near-misses or other safety issues to an
independent party, which then analyzes and aggregates the info to make safety
changes.

I think it's a large part of why the US airline industry has become so much
safer over time. Having a lower-bound number for altitude overshoots or
communication problems is immensely useful for policy.

[http://en.wikipedia.org/wiki/Aviation_Safety_Reporting_Syste...](http://en.wikipedia.org/wiki/Aviation_Safety_Reporting_System)

~~~
cmurf
The general ASRS reporting form can be filled out by almost anyone, not just
an airline employee. Most typically it's pilots, including general aviation
pilots.

------
ppod
I think this is a bit of an unfair comparison. Sullenberger had 3000 feet at
time of engine loss and Transasia had a max altitude of 1050 feet, and lost
the first engine at around 3-500 feet. Yes it was their own fault but no
engines at 1000 feet is a different story than 3000, and you could even argue
that single engine failure just after takeoff requires more taxing immediate
action - possibly especially in a turboprop where I think you have to feather.

Also, as the article mentions, the river is much less suitable for ditching
than the Hudson.

*edit apart from the comparison, I think it's a pretty good article.

~~~
CPLX
It is an unfair comparison but not in the way you suggest. Sullenberger was
going to have some sort of plane crash, he didn't have any good options, he
was over Manhattan without the ability to reach a runway by glide and no
engine power.

By contrast the Taipei flight has a perfectly good working engine and should
have had no problem reaching a runway and landing with minor drama at worst.

There is no question that losing an engine in a twin prop plane on takeoff is
among the more gnarly problems you can have but there is absolutely no reason
the plane had to depart from controlled flight.

It is pilot error that caused the deaths of dozens of passengers, period.
Without said error that plane would have been able to land at an airport and
taxi back to a gate.

(Source - I have a pilots license)

~~~
cpncrunch
Although it happened on takeoff, they were at about 1000ft, so it's not an
immediate "do or die" moment. They should have been trained to calmly identify
the failed engine before feathering it. Many high-time pilots say that the
first thing you should do when an engine fails in cruise flight is _absolutely
nothing_. You need to relax and calmly assess the situation. Although they
weren't in cruise, they certainly had enough altitude to be able to take 10
seconds to calm down and properly identify the problem.

------
probabilistic
> What’s the difference between Sullenberger, who was able to innovate
> solutions in the face of imminent death, and Liao, who apparently panicked
> and shut down the wrong engine?

They mentioned Sullenberger's experience, but he also had more than twice the
altitude when he lost engine power. Still an emergency, but he had a bit more
time to think about it.

~~~
mikeash
That's just the thing, though: Liao had all the time in the world to think
about it. There was no imminent danger, until he created it. Losing an engine
on takeoff is a bona fide emergency, but the only immediate actions you need
to take are to keep the airplane straight and keep your speed up. For
everything else, you can take your time and analyze.

Sully, on the other hand, had a minute or two before he was going to run out
of altitude, no matter what he did. Every moment counted there, in a way that
it definitely didn't count in the Taipei crash (until the pilot made it that
way).

------
dankohn1
This video [0] of a bird strike on a 757 always makes my heart beat faster.

For the first time, I just counted the timing. Bird strike is at ~10 seconds.
Pilot waits until ~20 seconds to call "Mayday". Only at ~32 seconds does he
shut down the damaged engine.

If the Taipei pilot had taken the same time to get his bearings before acting,
everyone might have survived.

In terms of the value of training, I love how cooly the air traffic controller
responds to the Mayday.

[0]
[https://www.youtube.com/watch?v=9KhZwsYtNDE](https://www.youtube.com/watch?v=9KhZwsYtNDE)

------
js2
I'm glad the article touched on experience, as there is compelling evidence
that it is a critical factor in safety:

[http://philip.greenspun.com/flying/foreign-airline-
safety](http://philip.greenspun.com/flying/foreign-airline-safety)

~~~
rwallace
It is indeed, but according to the article, the Taipei pilot had five thousand
hours of flight experience. If five thousand hours of experience is not
sufficient answer, it's time to reevaluate the question.

~~~
mikeash
There's more to experience than just time. Variety counts for a lot as well.
Sully, for example, had glider experience, which was certainly helpful when
his Airbus suddenly became a glider.

There's a saying in aviation that one pilot may have a thousand hours of
experience, while another pilot may merely have a hundred hours of experience
repeated ten times.

~~~
neurotech1
I would agree.

Capt. Sully is known for being involved in aviation safety before Flight 1549
put him on the front page. It was like decades of training and experience, was
leading up to that one day in January 2009 when Flight 1549 was able to land
safely in the Hudson.

Some career pilots have very little stick-and-rudder (& thrust lever)
experience, and fly on autopilot for thousands of hours. Shutting down the
wrong engine is either very poor piloting, or a systemic training issue.

~~~
mikeash
I'm not sure about it being poor piloting or bad training to shut down the
wrong engine. My kind of flying involves no engines at all (I'm a glider
pilot), but my understanding is that shutting down the wrong engine after an
engine failure in a multi-engine airplane is a somewhat common mistake.
Experienced pilots do make basic mistakes, sometimes even more often than
inexperienced pilots, because they let their guard down.

I believe the true failure here wasn't shutting down the wrong engine, but
trying to shut down the bad engine _at all_ while still so low. Shutting down
a failed engine is not a priority. It can windmill and tear itself to shreds
for a little bit while you keep the airplane flying, get to a safe altitude,
and figure out what to do. Multi-engine pilots I've talked to about this have
said that it's standard procedure not to shut down a bad engine below a
certain altitude, precisely so you're not screwed if you go for the wrong one
by accident.

A common cause of aviation accidents is a pilot responding to an emergency by
making it worse. A safety class I went through recently presented a case where
a pilot thought he was low on fuel, decided to land at a nearby airport,
botched the landing by coming in high, fast, and downwind, and crashed off the
end of the runway. Turned out the fuel gauge was faulty. There's a famous C-5
crash that's similar to this Taipei crash, in which an engine failed, the
pilot shut down the opposite engine by mistake, and then botched the landing
because he flew as if he still had three engines instead of two. A semi-
frequent cause of glider crashes is a pilot failing to lock their canopy which
then comes open in flight, and the pilot tries to fix it instead of flying the
airplane. They key isn't to ensure you do the right thing fast, but to make
sure you prioritize and don't do _anything_ fast that isn't immediately
necessary. Engines fail? Find a spot to land, right now. _One_ engine fails?
Keep climbing and breathe, _then_ take your time to decide what to do next.

~~~
neurotech1
For turboprop aircraft, if the engine is producing power (eg. oil leak) then
keep it running until at a safe altitude. If the engine isn't producing power,
then the prop may need to be feathered to keep the aircraft climbing.

Certified passenger turboprop aircraft (ATR-72 included) should be able to
maintain altitude, without feathering the failed engine.

I was thinking of British Midlands flight 92, where an experienced crew that
were new to the 737-400 misread the vibration instruments, and shut down the
wrong engine, at altitude. Poor training on the -400 differences was a major
factor.

Experienced pilots do screw up occasionally, but good CRM usually avoids a
mistake snowballing into a fatal crash.

In a Cessna 150, I had the window come open on takeoff. Same aircraft, same
instructor, same thing happened to my dad years before. He told my dad to "Fly
the plane".. I knew not to close the window until at a safe altitude. He just
smirked a little.

~~~
foldr
>where an experienced crew that were new to the 737-400 misread the vibration
instruments,

That's not quite what happened. The vibration instruments on earlier models
were known to be unreliable, so the pilot tried to figure out which engine had
failed using other indications (I forget which).

------
JulianMorrison
It makes me wonder if there's any medical way
([http://en.wikipedia.org/wiki/Transcranial_magnetic_stimulati...](http://en.wikipedia.org/wiki/Transcranial_magnetic_stimulation)
?) to jam the fight-or-flight mechanism, and force human pilots to stay cool
as a cucumber?

~~~
rasz_pl
There is - experience in critical situations of similar nature. Experience
makes it less severe and more manageable. Couple personal examples.

I did teakwondo and kickboxing. When I was starting Teakwondo (~16 year old)
first sparrings were dominated by fear and anxiety. I didnt know how to act,
what to expect, I was physically shaking. Fast forward few months and I was in
control, anxiety turned into excitement, fear into caution. My body and mind
learned to use that sudden adrenaline injection to my advantage. Two years
later I moved to kickboxing. Its very different sport, more violent, faster
and can be significantly more painful in the ring, nonetheless my experience
from teakwondo translated perfectly. Since then I had couple of dangerous
situations on the street (drunk idiots, football fans etc) and again I was in
control of my body and reactions, my previous experience of being punched
repeatedly in the face inside the ring helped me stay calm :)

Second example is virtual. Eve Online is a space themed MMO. Everything you
own in the game has to be earned or paid for with real money, and all losses
are persistent and final. Someone kills your ship worth two months of heavy
missioning? its GONE forever. This design choice makes Eve Online the only
computer game inducing real fight-or-flight reaction that I know of(outside
tournaments/leagues). Losses can be as small as 10 minutes of your time
(couple of cents), and as severe as $1000 blink mission ship you spend whole
last year to build. First PVP fights in Eve were exactly the same as my first
sparring 10 years before :) heart pounding, hands shaking, sphincter gripped
tight etc :) and mistakes ending in expensive wrecks. It took some time and
experience to fully take control of the situation.

Can write something about bike riding(crashing), but it will be the same story
again :)

I wonder if pilots with military background, trained in battle sims in high
pressure situations, are significantly better at handling emergency. My own
experience makes me think definitely yes.

~~~
athenot
Motorcycle riders have the same issue. On a sportbike, if you enter a turn and
your radius is not tight enough you will exit pavement before the road/track
straightens.

Human instinct is to slow down, but on a bike this will have the effect of
widening your turn radius—totally counterproductive. To tighten the turn
radius, you need to accelerate and lean in (which you can do unless you're
already dragging a knee).

~~~
codyb
I'm sure there are a million examples but I find snowboarding very similar. If
you're going too fast the instinct is to lean back but that makes it extremely
hard to turn into the mountain, but if you lean forward you can take the
weight off the back foot and whip it over to turn into the mountain and weave
some of the speed off.

Or when you're on ice and you really want to turn but just have to keep going
straight until you hit a patch where you'll get some grip from the mountain
cover.

~~~
erobbins
yeah, I learned this very quickly when I started skiing.. lean back when you
feel like you're going too fast and it's out of control time. I overcame that
instinct very quickly!

------
humanarity
Trying to explain aircraft accidents is hampered because the sample size is so
small (literally anecdotal they are so infrequent), so making "inferences"
about general rules from this is really unlikely to work. However, the
psychological and social utility of explaining disasters to create the
illusion of control is something which works. Also the investigations by the
FAA and other bodies create reforms which improve safety. It somehow makes it
easier to deal with if tragedies can be "resolved" by understanding what
caused them, I guess it's part of the way that communities deal with tragedy.
The ancients explained it by inventing elemental gods. We explain it with
"rigorous investigations". I suppose because we're wired to try to learn from
things which are dangerous, because that might help us survive.

Also, as tragic and sad as the crash in Taipei is, the swerve of that little
yellow car in the dashcam still, and imagining the occupants' reactions as a
they swerved to avoid the plane that was crossing in front of them, is quite
priceless.

~~~
kiba
Our 'rigorous' investigation resulted in safer airline travel.

Our ancestors' attempt to explain it by inventing elemental gods and pleasing
them...does nothing.

~~~
humanarity
Exactly correct. It does result in safer travel, and worship of idols probably
does not result in this! So there's a mix of tangible and intangible utility.
:)

The entire public discourse of investigation, of which the actual result
producing investigation is just a part, serves a narrative purpose akin to the
ancients' gods. To some extent there's a spectacle of rigorous investigation
and explanation in public discourse, and to that extent it's like worship for
harvest. It makes us feel things are getting better when perhaps there are
areas where we have little control. So there's a social utility and an
engineering utility. That's the thesis anyway! Maybe it's all social or all
engineering, tho I think each of those less likely than providing both.

------
andyzweb
[http://en.wikipedia.org/wiki/Crew_resource_management](http://en.wikipedia.org/wiki/Crew_resource_management)

------
kiesel
I wonder why it wasn't possible to restart the mistakenly shut down engine.
The article states that in first seconds after the shutdown, the pilots were
unaware of their mistake. They then noticed the plane stopped climbing and
actually went down even when pulling up the nose (which is counterproductive
in that situation).

How long would it take to restart an engine and gain speed again?

~~~
kjs3
You can't always restart a turboprop in flight. You need enough air moving
over the blades (e.g. you have to be moving fast enough). How much airflow
depends on the engine; every one is different. If you've got the airflow, it
doesn't usually take very long but spooling up turboprops to the point where
you're generating lift isn't instantaneous. More importantly you have to
identify the issue, figure a remediation plan, and execute before you hit the
ground. It's how much time you have before you hit the ground that's generally
the limiting factor.

------
bsder
Proof, yet again, that computers should be flying planes.

Humans are absolutely terrible at two kinds of tasks: 1) boring, rote tasks
that require continuous attention for long periods of time and 2) high-stress,
quick decision bursts.

Which pretty much describes flying a plane.

~~~
melling
Can a computer land in the Hudson? To generalize, how does the computer decide
where to land?

~~~
parados
> Can a computer land in the Hudson?

Well it did. One of the (probably lifesaving) actions that Sullenberger did
was to deploy the RAT which meant electrical power was maintained. This was
not a checklist item, merely something he though useful. This meant the
computers were still firmly in control when the aircraft ditched and the stall
protection they gave certainly helped the ditching.

Interestingly after the accident the NTSB and Airbus made a number of ditching
simulations and it showed just how hard it was for pilots to achieve the
correct entry mandated by the ditching certification (minimum speed, -1 degree
approach). However one pilot, an Airbus test pilot, managed to do much better
than this by levelling out at high speed and very low using the radar
altimeter. He the allowed the speed to decay until the aircraft touched the
'water'. This unusual proceedure probably couldn't be done by many pilots but
it could be done by a computer.

~~~
neurotech1
RAT is automatic. APU was started manually which allowed full electrical power
and flight envelope protection.

