Since the beginning of flying, aviation learns (often too late) from mistakes. There are some questions rising from the recent debacles at Haneda Airport of an Airbus A350-900 crashing into a Coast Guard aircraft and the Boeing 737-Max9 loosing a dummy door in-flight, that I find noteworthy to share. I will not mention the airlines, considering them victims.
Neither will pour blame over Boeing only again, at Haneda it was an Airbus raising questions. In my humble opinion, think the entire industry has an issue relating to “safety first” recently. And I am afraid, the “commercial focus” on the cost of safety hasn’t ended with the Boeing 737Max debacle with an amok running flight system driving two fully loaded aircraft into the ground just before the Pandemic.
Haneda (Airbus)
An Airbus A350-900 aircraft crashed into a small Japan Coast Guard Dash-8 aircraft at Tokyo Haneda airport, killing all people aboard the Dash-8. No fatalities aboard the Airbus A350-900. Which in hindsight is a miracle to many experts I heard talking the last days.
- Airbus Fire Sensors
“After the aircraft came to a stop the cockpit crew was not aware of any fire, however, flight attendants reported fire from the aircraft. The purser went to the cockpit and reported the fire and received instruction to evacuate. Evacuation thus began with the two front exits (left and right) closest to the cockpit. Of the other 6 emergency exits 5 were already in fire, only the left aft exit was still usable. The Intercom malfunctioned, communication from the aft aircraft with the cockpit was thus impossible. As result the aft flight attendants gave up receiving instructions from the cockpit and opened the emergency exit on their own initiative” (Source). Later information says there was a several minutes of delay because of missing or misinformation between cockpit and cabin. So why was the communication malfunctioning in that situation? Why were the pilots unaware? Even Haneda Tower should have informed them instantly of that danger! Why haven’t they? And … and why does the crew have to get approval from the flight deck to evacuate when the aircraft is burst into flames and mortal danger imminent? - Airbus Evac Procedures
Good thing first: The captain [reported only later] was the last one to leave the aircraft. 18 minutes after the aircraft came to a stop. (Source). Wait a minute … 18 Minutes??
Given he aircraft burned out and was on fire rather instantly after the collision, what the heck have those passengers been thinking or doing? I’ve seen my first flight attendant training back in 1989, the emergency training a major part of the training courses. The shouts, day and night in the training center echoing in my ears: “Move it, move it. Get out of my way!”. But 18 minutes? Especially with the issue of 5 out of 8 emergency exits blocked by fire when the purser went to the cockpit to get evac approval?! I believe both Boeing and the airline must have to review the procedures urgently.
Side note. I find it rather telling that there is a lot, a big lot of footage (images, video) of the A350-900, but virtually none of the smaller Dash-8 suffering all the fatalities. At least, I didn’t see or find any? A nice example of “biased news reporting”?
Portland (Boeing)
Above Portland, Oregon (USA), a Boeing 737-Max9 lost a “door plug” in-flight, by sheer luck, not causing any fatality. That this can end far more tragic is burned into my mind, remembering the Aloha Airlines 737 loosing its entire roof shortly after I’ve been there and flying Aloha. A flight attendant being ejected by the decompression. And given the picture, it makes one wonder on the miracle the entire aircraft didn’t break up. One of the many “near-misses” in my life to date. (Wikipedia)
Following the two fatal disasters of 2018+2019 forcing the lengthy grounding and near-bankruptcy of Boeing, the new accident now “naturally” raises the question about the quality of Boeing engineering. In my humble opinion, it does raise the question especially about their constant claim of “Safety First”! With subject matter experts claiming loose screws having caused the door to come apart. What was that about four-eye principle on aircraft construction and all major maintenance?
The door was later found in a teacher’s back yard in Portland Oregon. Just like a phone from the aircraft, the pieces “sailed down”, aerodynamically similar to a Frisbee and landed almost unharmed.
Added 08Feb24: According to preliminary media reporting, there were bolts not just not fastened but missing. Say what??
Is the 737 MAX safe?
Fact: I will neither voluntarily fly, nor allow my immediate family to fly a 737 Max anytime soon. In my humble opinion (IMHO), that aircraft has been misconstructed from the outset and should be shelved for good. It only flies and is approved IMHO for commercial reasons; if it’d be grounded for good, the losses for Boeing can very well proof fatal. To me, it seems the door plug again was a “quick and dirty” solution. On the other end, I won’t “actively” avoid the aircraft, flying was and remains the most secure transport in the world. Just that any incident instantly receives scrutinous media coverage. But yes, booking flights, I usually happen to look at details – and given the choice, avoiding the MAX will be a clear decision making factor for me.
The new incident brings up feedback that I got during the 2019 grounding media uproar. Questions why the “better” Boeing 757 was shelved. It didn’t have the low profile causing engineering complications as there wasn’t enough space under the 737’s wing. Which led to the fatal idea of MCAS, later being the cause for the two fatal crashes killing 346 people. And commercial reasons leading not only to base that on a single sensor (instead of the originally planned three), false readings causing the misinformation of MCAS causing the crashes. But also to the secret implementation not shared with the pilots to avoid potential demand for an “expensive” full type-rating as a new aircraft.
Conclusions
Flight Safety is back to “reactive”. But aircraft engineering must be proactively focused on flight safety! As must be processes, just like the evacuation of aircraft under grim circumstances! Ever since the beginning of flight safety with the Comet-disasters back in the 1950s, aviation “reacted” to disasters. A lesson we also learned with aircraft deicing.
I truly believe that flight safety ain’t a luxury. Just like “service” or “sustainability” being only identified as “cost factors” by finance-focused aviation managers. The recent “cases” are just more examples where things went awry and off track. There are enough cases, not just old, but rather recent, when airlines in distress started to save on the aircraft safety and maintenance. Usually reducing it to the rule-book, “encouraging” their maintenance staff to “look the other way” and to delay parts replacement in questionable situations. Or to have supervisors “sign off” as the additional pair of eyes but in fact reducing it to a single pair of eyes on the job! To safe cost.
Boeing engineers are well advised to return to spend a few more screws and bolts on securing a door plug and to demand four-eye-principle on their construction.
Airbus better finds out, what too so long to evacuate the aircraft.
All else is to be looked at when the incident reports come out. And media is well advised to not just jump the incident, but also report on the final findings. Not 1:1 copying the press release, but questioning them. I think that would be good for (shareholder-value-focused) “managers” to not stray from “Safety First”. As in the end, it’s a trust thing.
Food for Thought
Comments welcome…
Last week, I had a lengthy phone call with an airport manager in the U.S. Snow-Belt, asking me about ideas, how to break up the silo thinking that keeps all his ideas about a common airport operations center as a basis for some A-CDM-style development from moving forward. Next winter approaching, he’s worried about repeating the past years’ experience of unnecessary delays. “The airline always knows better” he complained to me. If we offer them solution, it’s not theirs, so it’s being turned down. Communication is faulty and in crisis, everyone works on their own. #talkthetalk
Now give me a break. When I read this “promo” on LinkedIn, is it just me, seeing the fault in it?
Our vision for what was to be Cytric, that we wanted to follow, a vision not existing now, 25 years later, was to enter the home address, the destination address and the system would provide you the best travel options for you to get to the airport using car, rail, taxi, whatever, fly towards your destination and again take rail, taxi, rental car, whatever, to get to where you needed to go.
Speaking about Business Travel Management, we don’t need data typists any more. In the good old days, travel agents were the experts, knowing how to get the traveler from A to B, halfway (or all) around the world… Then came the GDS and the travel agents became data interfaces to the big data accessed through travel computers being connected with mighty servers. Something we call cloud computing today, using “dummy terminals”. Using codes like AN19DECFRAMIA and SS1B1M2 to search for and book a flight. Or similar complicated tools to book a rail ticket.
It is why I believe we need regional aviation and we need more of it. Smaller aircraft, connecting secondary cities, offering quick and direct connection. Hubs are good for the global networks. And as I kept and keep emphasizing. Regional airports must not look out, how to get their locals out to the world. But to 
As I approached it back in 2016/17 and shared the learning curve at 
An older 
Our main problem is that our Powers-That-Be still consider themselves in a competition. Data is value, so put it in siloes. Where OpenStreetMap enabled mapping solutions, aviation data is still locked away. It takes two months until IATA publishes passenger data, after four months those numbers happen to differ substantially.
Where aviation in the 1960s to -80s was a pacemaker in global eCommerce, it is now limping behind. Can tell stories about replies from industry bodies when I informed them about factual mistakes in their data. And their ignorance shown by neither directing the report to their PTBs, nor updating the faulty information. Instead of working together to develop the aviation of the future, we have conservative forces in play that hinder real development. Be that about A-CDM, data interfaces, data intelligence. We limp behind and instead of doing, we #talkthetalk.
Computer Literacy
Cloud Computing
Aircraft System Redundancy
Faith in The Computer
Fly by Wire, Drones and Air Taxis
A similar case is the automated drones as envisioned by Amazon, DHL and others, for automatic passenger delivery. As the air taxis, they will rely on a fully-automated flight planning and flight plan filing with the authorities’ computers. Simply to avoid in-air-collisions.
Back in the 90’s, I became the honorary member of the 
Speaking about Sales Managers ignorance to the cost of their airline’s operation, I found the fish stinks from the head first being a true proverb. I’ve met too many investors, airline managers, airport managers, not understanding the cost involved. Then they try to compete on the price with the large, established airlines. I have no idea, what those managers learned, I heavily doubt the quality of university education…
From Cobalt, Germany, Primera (alphabetical order), feedback said “disruption cost”, attributed i.e. to EU261 “passenger rights” to having been a major reason for their financial troubles. Still, most business plans, I was asked to have a look at last year failed to address that issue at all. Or they used “easyJet figures”, neglecting the fact that easyJet has a spare fleet to cover and minimize the effects of flight disruptions.
Carolin McCall understood “service” to be a difference maker. Since her leave, very quickly they dropped from my “role model” and preferred airline to “me too”. Taking over aircraft from Air Berlin with additional and “bulkier” seats, I suddenly experienced less leg space. Their airport manager at one of their hubs found himself quickly “obsolete”, the new paradigm being “cost savings”. In turn they seized my (half-sized) cabin bag due to “full overheads”. Aside the seat next to me being empty, there was more than enough space below the seat. Heard meanwhile from many frequent flyers they no longer wait if they have an aisle seat but make sure they have their seat and the cabin baggage with them. Would be indeed interesting to have some statistics how that impacts boarding time.
As mentioned above and before and again. I usually don’t believe in the survival of virtual airlines. A few leased aircraft of the same kind than their competitors, outsourced IT, ground handling, maintenance and other “services”, often even the call and service center (to “GSAs”). Then they believe to be competitive to the large players. If you operate in an un- or under-served market, you may be able to ask for the higher ticket prices required by your increased cost levels. Most airlines I see trying to take off or change their business to survive try to compete to the large network and low cost carriers, but without a secure market (using the same aircraft).
If you have subscribed to the 
P.S.: While I wrote this article, Germania, an airline that I know from the beginning of my career, who’s team I booked at 
Lesson learned from my research about Zürich delays: It very often is cheaper for the airline to cancel the flight to make sure the further aircraft “rotation” (planned flights for the remaining day/week) are not impacted. Especially if i.e. winter operations allow for “higher force” reasoning of the cancellation. While the airline can show goodwill and help the stranded passengers, in such situation they are not legally forced to add the legal, excessive passenger compensation for delays. It also in fact reduces the overall passenger upset. And Zürich can predict the delays!
BlueSwanDaily believes in the future of 
I myself worked out a “green” concept a few years ago, but we’re neither getting there… The project got grounded in the wake of Lehmann Brother’s and a world financial crisis and the original interested investors gone never took up speed again. [Update: The Korean 
Later I learned the same lesson from space shuttle Challenger, management ignoring their own experts warning them of the temperature being below safety specifications. Shuttle Columbia dying of a piece of foam worth a few cent perforating the heat shield. Of Concorde crashing from a “minor” piece of scrap metal.
Clear as can be, there is no “software panacea” either. In North America, the closest thing in my experience is 
![“Our Heads Are Round so our Thoughts Can Change Direction” [Francis Picabia]](https://foodforthought.barthel.eu/wp-content/uploads/2021/10/Picabia-Francis-Round-Heads.jpg)
While doing the research at late delair for the Zurich Airport case study, focusing on the impact of a contemporary deicing management, just that improvement in (IT-supported) process saved about 20 million in one winter alone there. For Swiss (about 50% of the flights). Now working on a financial summary that thanks to the acquisition of delair by SITA never made it “to market”, I spoke with the OCC (Operations Control Center) manager of Swiss in Zurich. Who confirmed what they all knew (and know), but their management remains blissfully ignorant about: It is all about rotations in an airline. The aircraft starts somewhere in the morning and flies to different places throughout the day. And a disruption or delay anywhere en-route is prone to impact the entire rotation. Worse, a late aircraft usually accumulates more delays as ground handling is also tightly scheduled without spare manpower to cover up for such situations. Then crews fall out of schedule as they have to have their rest times. And while the airline may reduce the financial damage by calling for higher force on a snow event in the morning, on the flights down the line, I am told they tend to pay. And passenger compensation often exceeds the value of a single ticket!
In 2014 I wrote 
And while the airlines benefit, I hear from the airports that they do not show any interest in A-CDM and A-CDM improvements. While they cut into the flesh on most airport’s fees, while they let them starve; while most airports need to invest heavily to compensate the losses from “aircraft handling” by doing their best to increase “non-aviation revenue”, while this is daily life today, airlines demand airports to invest into those technologies and development and process improvements, but are not willing to pay. Did Swiss pay a Penny (Rappen) for the improved deicing at their home airport? Make a guess.