Incidents are gold. …if used correctly | by Vicente Aceituno Canal | The CISO’s lair | August 2023


…if used correctly

photo by CHUTTERSNAP on Unsplash

More than 50 people died when the plane crashed, including the pilots and children.

To summarize a long and sad story, here are the causes found by the commission of inquiry:

  • A critical engine component failed in flight.
  • The engine component was not yet required to be replaced under the old regulations, and there was a misunderstanding in the airline’s communication of the new regulations to engineers. If the regulation had been correctly communicated, the part would have been replaced.
  • Despite not knowing the new regulations, an engineer wanted to replace the component because it was different from equivalents, but his manager stopped him because the higher the maintenance savings, the higher his bonus would be.
  • A third, unrelated engineer, new to his job, sent letters to the board, administrators and the aviation safety regulator about the bonus policy, but received the response that There were no rules on the practice of bonuses and therefore nothing could be done.
  • When the component failed, the pilots did not make adequate decisions to land the plane quickly enough and actually compounded the effects of the component failure, causing pieces of the engine to fly in all directions , causing additional damage.
  • The pilots failed to make timely and adequate decisions because it was unclear who was in command. It was unclear who was in command due to national culture conflicting with crew resource management training.
  • It took pilots too long to determine which engine had failed, because engine telemetry was originally an optional feature on this type of aircraft.
  • The crew resource management training materials were sourced directly from another country, without any changes in the curriculum to account for national cultural differences, and were poorly translated.
  • The engine telemetry component was at the time of the accident mandatory in several countries, but not yet in the one where the airline operated. When the airline acquired the aircraft, it did not invest in any features that were not mandatory. The national aircraft regulator…
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