On Aug 1, 2020, at 04:20 , Mark Tinka <mark.tinka@seacom.com> wrote:
On 1/Aug/20 02:17, Sabri Berisha wrote:
I'm not sure if you read their entire Mea Culpa, but they did indicate that the root cause of this issue was the provisioning of a legacy filter that they are no longer using. So effectively, that makes it a human error.
We're going to a point where a single error is no longer causing outages, something very similar to my favorite analogy: avation. Pretty much every major air disaster was caused by a combination of factors. Pretty much every major outage these days is caused by a combination of factors.
The manual provisioning of an inadequate filter, combined with an automation error on the side of a customer (which by itself was probably caused by a combination of factors), caused this issue.
We learn from every outage. And instead of radio silence, they fessed up and fixed the issue. Have a look at the ASRS program :)
What I meant by "TOTALLY avoidable" is that "this particular plane crash" has happened in the exact same way, for the exact same reasons, over and over again.
That’s also true of Asiana 214. (Root cause: 5 pilots failed to pay attention to the approach) https://www.ntsb.gov/investigations/AccidentReports/Reports/AAR1401.pdf (The full report probably only interests pilots, but the executive summary on pages xi - xv is a good read). Worth noting, contrary to the public perception of airline accidents, despite the near total destruction of the airframe in this incident, 288 of 291 passengers and all of the crew survived. Of the 307 people on board, only 49 suffered serious injuries. (serious is defined as an injury requiring >48 hours of hospitalization within 7 days of the accident in which the injury was sustained). (49CFR§830.2) For those that find 5 pages of type TL;DR, the key findings are in the first paragraph after the last bullet point on page xv.
Aviation learns from mistakes that don't generally recur in the exact same way for the exact same reasons.
Aviation makes a strong effort in this area, perhaps stronger than any other human endeavor, especially when you’re talking about the fraction of Aviation known in the US as “Part 121 Scheduled Air Carrier Services”. However, as noted above, there are exceptions. In fact, there are striking parallels between Asiana 214 and this incident. The tools to avoid the accident in question automatically were available to the pilots, but they failed to turn them on (autothrottle). The tools to avoid this incident were available to Telia, but they failed to turn them on. Owen