Department of Near Miss: Too Much Info? – Conclusion

Qantas Flight 32 – Conclusion

(This five-part series begins with Part One HERE.)

Parallels for Fire Crews

 Abbreviations: Captain (PIC-pilot in charge), First Officer (FO), Second Officer (SO), Check Captain (CC), Supervising Check Captain (SCC), Electronic Centralized Aircraft Monitor (ECAM)

The ATSB interim report describes the flight deck ECAM outputs variously as "multiple", "numerous", and "extensive." They refer to "numerous other warnings and alerts" and "continuously sounding warnings." Indeed, the flight crew was faced with 17 different systems warnings, each with its’ own list of actions to be taken. It appears that taking actions based on ECAM instructions caused further changes in some systems, as well. Finally, even key actions such as the discharge of two fire extinguishing systems resulted in conflicting feedback from the ECAM. All of this had to be digested by the flight crew.

The issue of flight crews, civil and military, being overwhelmed with information and sensory outputs has been previously discussed since there is a limit to what the human mind can absorb. As they focused on the ECAM warnings and alerts, the QF-32 crew missed two opportunities to communicate with company resources. It is useful to note that despite this cascade of information that the SO and SCC "returned to the cabin on numerous occasions to visually assess the damage." We may have the data, but we still want to see it with our own eyes.

In this age of information, all professions, including firefighting, can fall prey to the tendency to be inundated with information that may or not be useful. In fact, consumers are generally not in control of the information technology being offered in today’s market. There is intense pressure on companies to constantly provide new hardware and software products and this generally means products that are faster and which provide more data. More and faster may not equate to useable or better. Even when high-volume data systems are extensively integrated their output can be overwhelming especially if the output requires action or must be prioritized.

Where technology is concerned, it is not uncommon for people to be judged on their "savvy" or "with-it-ness" based on the speed, capacity and features of their Smartphone or other handheld device. (God forbid that you don’t have one.) It is easy to see how the ubiquity of these devices and the intense focus on "apps" and speed can bleed over into the assumption that life-safety critical equipment should also be super fast and have a rich menu of features. In fact, the opposite is true. Systems to track or assess interior firefighting operations or personnel or those that monitor key apparatus or PPE functionality should be simple, direct and extremely reliable. Lots of fast data does not necessarily fulfill any of these goals most especially if interpretation is necessary in order to make a decision.

The QF-32 crew obviously got it right despite all of their many challenges for several key reasons:

-They elected to go for a stable environment over the big, fast play so they could fully understand their situation,

- They utilized all of their onboard crew resources to diagnose the problem, determine a solution, and to stay on top of a very fluid and complicated environment,

-Finally, they communicated effectively with each other and with the other crew and passengers.

Great lessons for us, all.

………. Eric Lamar

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