Now that the BEA (the French authority that investigates airplane crashes) has completed its investigation into the crash of Air France Flight 447 off the coast of South America in June 2009, it is apparent that incorrect pilot reactions to alarms are what led to the crash. According to the report, the alarms that initiated the problems on Flight 447 indicated that three Pitot tubes (sensors that provide airspeed data to the airplane’s computers) had iced over and caused the autopilot to disengage.
The BEA report states: “The occurrence of the failure … completely surprised the crew of flight AF 447. The apparent difficulties in handling the airplane in turbulence at high altitude resulted in over-handling in roll and a sharp nose-up input by the pilot flying. The destabilization that resulted from the climbing flight path and changes in pitch attitude and vertical speed therefore added to the incorrect airspeed indications and ECAM [Electronic Centralized Aircraft Monitoring] messages that did not help any diagnosis. The crew, whose work was becoming disrupted, likely never realized they were facing a ‘simple’ loss of all three airspeed sources.”
Bottom line: More than 200 people died due to the incorrect reaction of operators to an alarm.
Granted, outside of the chemicals and oil & gas industries, most manufacturing/production malfunctions won’t cost scores of lives, as a commercial airplane crash will. But even non-life threatening production errors cost scores of cash.
Yet the issue of operators not being trained to properly respond to alarms and, in many cases, flat out ignoring alarms for years persists across industry. In an alarm management article I wrote this year for Automation World, 50 percent of respondents to a cross-industry survey indicated that their companies have no guiding philosophy or practice when it comes to alarm management. Based on these data, plus numerous accounts I heard from automation experts who work with clients in the field to improve operator training, it’s clear that a significant number of manufacturers (many of my sources say more than 50 percent) have operators who are unprepared to effectively deal with or understand their system alarms. Which means they are likely far less trained in proper alarm reaction than the pilots of Flight 447 were. And we all know how that ended.
On the upside, developing an effective alarm management process that includes proper operator response training is not difficult. It’s not cheap either, but it is far less expensive than an accident or production shutdowns. What it requires, first, is an acknowledgement of the issue from top management as well as operators, followed by the clear direction to operators and plant managers to devote the resources necessary to correcting production alarm issues through both system upgrades/corrections and thorough operator training. It must also be realized that this problem is not a one-time issue. It must be part of an ongoing cultural process at the company to stay on top of the issue as new workers come in, workers shift jobs and responsibilities, and new systems and equipment are deployed.
Another issue relevant to this discussion is addressed in an article which appeared on the IEEE Spectrum website. In this article, which also references the lessons to be learned by industry from Flight 447, the issue of the “automation paradox” is addressed. The author describes the “automation paradox” as: “The more reliable the automation, the less the human operator may be able to contribute to that [system’s] success. Consequently, operators are increasingly left out of the loop, at least until something unexpected happens. Then the operators need to get involved quickly and flawlessly.”
The core lesson for manufacturers is that, even with all the capabilities increasingly being afforded to us by automation technologies, most of us are still a long way from the lights-out factory (where little human intervention is required in the production process). Automation is a wonderful tool, but it is only a tool — and that means that it must be understood, manipulated, and reacted to by humans well trained in all aspects of the production process it controls.
Leaders relevant to this article: