How organisations Sabotage Safety. Presented by Dr Sean Brady

1. How
Organisations
Sabotage
Safety
Dr Sean Brady
Brady Heywood

4. Content Warning.

5. 29 October 2018.
Soekarno-Hatta
International Airport.

6. Lion Air 610.
https://www.airdatanews.com/flight-jt610-final-report-points-nine-failures-that-caused-the-accident/

7. https://edition.cnn.com/2018/10/28/asia/lion-air-plane-crash-intl/index.html

8. 6:20am, Departs.
https://pt.wikipedia.org/wiki/Voo_Lion_Air_6

9. 20181029-0_B38M_PK-LQP_PRELIMINARY

10. https://www.airdatanews.com/organizations-and-experts-call-for-more-safety-redundancy-on-the-737-max/737-max-flight-deck/

11. https://www.cbsnews.com/news/lion-air-plane-crash-flight-jt-610-boeing-737-accident-indonesia-live-updates-today/

12. Bad Altitude.
Airspeed.

13. https://edition.cnn.com/2018/10/28/asia/lion-air-plane-crash-intl/index.html

14. “Flight Control
Problem”.

15. https://www.nytimes.com/interactive/2018/11/16/world/asia/lion-air-crash-cockpit.html

16. https://www.nytimes.com/interactive/2018/11/16/world/asia/lion-air-crash-cockpit.html

17. https://www.airdatanews.com/organizations-and-experts-call-for-more-safety-redundancy-on-the-737-max/737-max-flight-deck/

18. https://www.cbsnews.com/news/lion-air-plane-crash-flight-jt-610-boeing-737-accident-indonesia-live-updates-today/

19. https://www.nytimes.com/interactive/2018/11/16/world/asia/lion-air-crash-cockpit.html

20. https://www.nytimes.com/interactive/2018/11/16/world/asia/lion-air-crash-cockpit.html

21. https://www.nytimes.com/interactive/2018/11/16/world/asia/lion-air-crash-cockpit.html

22. http://www.cockpitcompanion.com/pd-b737-qrh-with-tabs.cfm

23. 20181029-0_B38M_PK-LQP_PRELIMINARY

24. 20181029-0_B38M_PK-LQP_PRELIMINARY
27,000 Ft
5,000 Ft

25. 20181029-0_B38M_PK-LQP_PRELIMINARY
8 Minutes
21 Times

26. https://edition.cnn.com/2018/10/28/asia/lion-air-plane-crash-intl/index.html

27. https://www.nytimes.com/interactive/2018/11/16/world/asia/lion-air-crash-cockpit.html

28. https://www.nytimes.com/interactive/2018/11/16/world/asia/lion-air-crash-cockpit.html

29. https://www.nytimes.com/interactive/2018/11/16/world/asia/lion-air-crash-cockpit.html

30. https://www.nytimes.com/interactive/2018/11/16/world/asia/lion-air-crash-cockpit.html

31. “Sink Rate,
Sink Rate”.

32. https://www.nytimes.com/interactive/2018/11/16/world/asia/lion-air-crash-cockpit.html

33. “Terrain, Terrain”.

34. 20181029-0_B38M_PK-LQP_PRELIMINARY

35. 20181029-0_B38M_PK-LQP_PRELIMINARY
500 mph

36. https://www.bangkokpost.com/world/1567794/crashed-indonesia-lion-air-jet-fuselage-believed-found

37. https://www.bangkokpost.com/world/1567794/crashed-indonesia-lion-air-jet-fuselage-believed-found
189

38. https://edition.cnn.com/2018/10/28/asia/lion-air-plane-crash-intl/index.html
The Public Narrative.

39. The Private Narrative.
MCAS.

40. The Private Narrative.
https://aviationweek.com/air-transport/aircraft-propulsion/concerns-expressed-over-737-max-redundancy-manual-trim

41. How?

42. Cause = Effect.

43. https://www.bl.uk/collection-items/photograph-of-soldiers-walking-on-duckboard-third-battle-of-ypres
World War I.

44. https://www.nytimes.com/2015/04/20/opinion/the-assassination-of-archduke-franz-ferdinand-of-austria.html
‘Cause’ of World War I?

45. Complex Systems.

46. Complex Systems.
https://www.igismap.com/flight-routes-network-analysis/
https://hbr.org/2013/07/the-network-secrets-of-great-change-agents
Interactions.

47. Sports Teams.

48. Cause = Effect.

49. Cause ≠ Effect.

50. The Sand Pile Model.

51. Sand Piles.
https://medium.com/closer-consulting/beach-physics-for-economists-sand-piles-d1d34d8f80e5

52. Cause?

53. Cause:
Grain of Sand?

54. Cause:
Shape of the Hill?

55. A ‘Critical State’.

56. BP Texas City,
23 March 2005.

57. https://www.youtube.com/watch?v=goSEyGNfiPM

58. Pike River, Nov 2010.

59. TRIFR, LTIFR.

60. ESG.

61. Deepwater Horizon, April 2010.
United States Coast Guard

62. 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

63. “We hire Engineers

64. “We hire Engineers
and
other people.”

65. “We hire Engineers
and
other people.”

66. https://en.wikipedia.org/wiki/File:Lufthansa_Airbus_A320neo_(D-AINC)_at_Frankfurt_Airport.jpg
Airbus A320neo.

67. https://en.wikipedia.org/wiki/File:South_African_Airlink_Boeing_737-200_Advanced_Smith.jpg
Boeing 737.
1/3

68. https://www.allaboutlean.com/boeing-management/

69. Pilot Training.

70. https://www.nytimes.com/interactive/2018/11/16/world/asia/lion-air-crash-cockpit.html
Early Wind Tunnel Tests.

71. https://www.nytimes.com/interactive/2018/11/16/world/asia/lion-air-crash-cockpit.html
Early Wind Tunnel Tests.

72. Mechanical
Solution?

73. Manoeuvring
Characteristics
Augmentation
System

74. Manoeuvring
Characteristics
Augmentation
System

75. https://www.seattletimes.com/business/indonesia-slams-boeing-737-max-design-before-releasing-report-on-lion-air-crash/

76. Pilot Training.

77. https://www.cbsnews.com/news/lion-air-plane-crash-flight-jt-610-boeing-737-accident-indonesia-live-updates-today/
Lion Air 610.

78. https://edition.cnn.com/2018/10/28/asia/lion-air-plane-crash-intl/index.html
The Public Narrative.

79. 10 March 2019.
Addis Ababa Bole
International Airport.

80. Ethiopian Airlines Flight 302.
https://en.wikipedia.org/wiki/Ethiopian_Airlines_Flight_302#/media/File:Ethiopian_Airlines_ET-AVJ_takeoff_from_TLV_(46461974574).jpg

81. Ethiopian Airlines Flight 302.
https://theconversation.com/automated-control-system-caused-ethiopia-crash-flight-data-suggests-113688

82. Ethiopian Airlines Flight 302.
https://theconversation.com/automated-control-system-caused-ethiopia-crash-flight-data-suggests-113688
157

83. https://www.seattletimes.com/tag/lion-air-crash/

84. One Sensor?

85. MCAS.

86. https://www.nytimes.com/interactive/2018/11/16/world/asia/lion-air-crash-cockpit.html
Test Flights.

87. https://www.nytimes.com/interactive/2018/11/16/world/asia/lion-air-crash-cockpit.html
Plane Pitches Up Slow Speeds.

88. Pilot Training.

89. https://projects.seattletimes.com/2019/boeing-737-max-12-problems/
MCAS
Gets
Extended
Reliant on
one sensor

90. Manual?

91. https://edition.cnn.com/2018/10/28/asia/lion-air-plane-crash-intl/index.html
Lion Air 610.

92. Solution?

93. Ethiopian Airlines Flight 302.
https://en.wikipedia.org/wiki/Ethiopian_Airlines_Flight_302#/media/File:Ethiopian_Airlines_ET-AVJ_takeoff_from_TLV_(46461974574).jpg

94. Cause ≠ Effect.

95. https://www.nytimes.com/2015/04/20/opinion/the-assassination-of-archduke-franz-ferdinand-of-austria.html
‘Cause’ of World War I?

96. https://history.delaware.gov/world-war-i/
‘Cause’ of World War I?

97. https://history.delaware.gov/world-war-i/
‘Cause’ of World War I?

98. A ‘Critical State’.

99. https://medium.com/closer-consulting/beach-physics-for-economists-sand-piles-
d1d34d8f80e5
How
Organisations
Sabotage
Safety?