----------------------------------------------------------------------
Date: Thu, 17 Apr 86
13:27:24 EST
From: bzs@bu-cs (Barry
Shein)
To: risks@sri-csl
Subject: BU
joins the InterNet...
I may as well tell this anecdote before others do...
Boston University this
past week submitted their host table for inclusion in
the NIC table. Unfortunately,
there were a few entries in the table that
should never had made
it. The most interesting was a one character nickname
("A") for host BU-CS
(local convenience.)
Apparently a bug in the
4.2bsd program htable program which converts from
standard NIC format
to the format UNIX uses proceeded to fill your disk when
it hit this entry. I
suspect from the notes that some hosts must pick up the
table automatically
in the wee hours and do the conversion with a command
script so they came
in the next morning with a disk full of the string
"BUCSA". I was assured
by one site that he no longer needs any mnemonics to
remember our name. I
have no way of knowing numbers, but apparently some
number of machines went
down or were crippled.
In addition, there was
an entry for a machine type "3B2", htable broke on
that also although not
so dramatically, because the string started with a
digit. It seems the
next night or so htables were breaking again because
someone managed to put
a lower case letter into the table. (I have heard
this only second hand.)
I then fixed our host
table to avoid the troubles and ran it through htable
myself just to be sure
and it promptly deleted the first entry in my table.
Apparently it had to
have at least one blank line before the first entry,
again, without warning.
This is after almost
three years of the program being in production at
probably thousands of
sites. Don't trust any program over 30 (lines of code)?
-Barry Shein, Boston University
----------------------------------------------------------------------
----------------------------------------------------------------------
Date: 16-May-1986 1241
From: minow%pauper.DEC@decwrl.DEC.COM
(Martin Minow, DECtalk Engineering ML3-1/U47 223-9922)
To: risks@sri-csl.ARPA
Subject: A
late report on the Sheffield -- RFI
[PGN's SUMMARY
LIST OF HORROR STORIES CONTAINS THIS ON THE SHEFFIELD:
"Exocet missile
not on expected-missile list, detected as friend" (SEN 8 3)
[see Sheffield
sinking, reported in New Scientist 97, p. 353, 2/10/83];
Officially
denied by British Minister of Defence Peter Blaker
[New Scientist,
vol 97, page 502, 24 Feb 83]. Rather, sinking abetted by
defensive
equipment being turned off to reduce communication interference?]
From the Boston Globe, May 16, 1986:
Phone call jammed antimissile defenses
LONDON -- Electronic
antimissile defenses on the British frigate Sheffield,
sunk in the 1982 Falklands
conflict, were jammed during an Argentine attack
by a telephone call
from the captain to naval headquarters, the Defense
Ministry said yesterday.
Twenty crewmen were killed when the Sheffield was
sunk May 4, 1982, by
a French-made Exocet missile fired by an Argentine
plane. A Defense
Ministry spokesman, confirming a report in [the] London
Daily Mirror, said Commodore
James Salt, the Sheffield's captain, was making
"an urgent operational
call" to naval headquarters near London when the
missile hit. "The
electronic countermeasures equipment was affected by the
transmission.
Steps have been taken to avoid a repetition," the spokesman
said. Commodore
Salt now has a shore job as chief of staff to the fleet
commander-in-chief.
(AP)
----------------------------------------------------------------------
----------------------------------------------------------------------
Date: Fri, 16 May 86
17:13 PDT
From: <Dave-Platt%LADC@HI-MULTICS.ARPA>
To: Risks@SRI-CSL.ARPA
Subject: A
late report on the Sheffield -- RFI
[beginning of message duplicated the above] From Today's LA TIMES: [...]
The telephone
system's transmitter was on the same frequency as the homing
radar of the
French-built Exocet missile fired at the Sheffield, and the
transmission
prevented the Sheffield's electronic countermeasures equipment
from detecting
the missile's radar and taking evasive action.
The article implies that
this situation might have been avoided had the
Sheffield been equipped
with an uplink into the British satellite
communication system;
the article gives no details but I'd guess that such
an uplink would have
used a transmitter which was (a) less powerful, (b)
more directional, or
(c) on a completely different wavelength.
Does anyone have additional
information about the equipment in question?
[Dave Platt]
----------------------------------------------------------------------
----------------------------------------------------------------------
Date: Thu, 25 Sep 1986
21:23 EDT
From: Rob MacLachlan
<RAM@C.CS.CMU.EDU>
To: risks@CSL.SRI.COM
Subject: "Friendly"
missiles and computer error -- more on the Exocet
[We have
been around on this case in the past, with the "friendly" theory
having
been officially denied. This is the current item in my summary list:
!!$ Sheffield sunk during Falklands war, 20 killed. Call to London
jammed antimissile defenses. Exocet on same frequency.
[AP 16 May 86](SEN 11 3)
However,
there is enough new material in this message to go at it once
again!
But, please reread RISKS-2.53 before responding to this. PGN]
I
recently read a book about electronic warfare which had some
things to say about
the Falklands war incident of the sinking of the
Sheffield by an Exocet
missile. This has been attributed to a
"computer error" on
the part of a computer which "thought the missile
was friendly."
My conclusions are that:
1] Although a
system involving a computer didn't do what what one
might
like it to do, I don't think that the failure can reasonably
be
called a "computer error".
2] If the system
had functioned in an ideal fashion, it would
probably
have had no effect on the outcome.
The chronology is roughly as follows:
The Sheffield was one
of several ships on picket duty, preventing
anyone from sneaking
up on the fleet. It had all transmitters
(including radar) off
because it was communicating with a satellite.
Two Argentinan planes
were detected by another ship's radar. They
first appeared a few
miles out because they had previously been flying
too low to be detected.
The planes briefly activated their radars,
then turned around and
went home.
Two minutes later a lookout
on the Sheffield saw the missile's flare
approaching. Four
seconds later, the missile hit. The ship eventually
sank, since salvage
efforts were hindered by uncontrollable fires.
What actually happened
is that the planes popped up so that the could
acquire targets on their
radars, then launched Exocet missiles and
left. (The Exocet
is an example of a "Fire and Forget" weapon. Moral
or not, they work.)
The British didn't recognize that they had been
attacked, since they
believed that the Argentinans didn't know how to
use their Exocet missiles.
It is irrelevent that
the Sheffield had its radar off, since the
missile skims just above
the water, making it virtually undetectable
by radar. For
most of the flight, it proceeds by internal guidance,
emitting no telltale
radar signals. About 20 seconds before the end
of the flight, it turns
on a terminal homing radar which guides it
directly to the target.
The Sheffield was equipped with an ESM
receiver, whose main
purpose is to detect hostile radar transmissions.
The ESM receiver can
be preset to sound an alarm when any of a small
number of characteristic
radar signals are received. Evidently the
Exocet homing radar
was not among these presets, since there would
have been a warning
20 sec before impact. In any case, the ESM
receiver didn't "think
the missile was friendly", it just hadn't been
told it was hostile.
It should be noted that British ships which were
actually present in
the Falklands were equipped with a shipboard
version of the Exocet.
If the failure was as
deduced above, then the ESM receiver behaved
exactly as designed.
It is also hard to conceive of a design change
which would have changed
the outcome. The ESM receiver had no range
information, and thus
was incapable of concluding "anything coming
toward me is hostile",
even supposing the probably rather feeble
computer in the ESM
receiver were cable of such intelligence.
In any case, it is basically
irrelevant that the ESM receiver didn't
do what it might have
done, since by 20 seconds before impact it was
too late. The
Sheffield had no "active kill" capability effective
against a missile.
Its anti-aircraft guns were incapable of shooting
down a tiny target skimming
the water at near the speed of sound.
It is also poossible
to cause a missile to miss by jamming its radar,
but the Sheffield's
jamming equipment was old and oriented toward
jamming russian radars,
rather than smart western radars which
wheren't even designed
when the Sheffield was built. The Exocet has a
large bag of tricks
for defeating jammers, such as homing in on the
jamming signal.
In fact, the only effective
defense against the Exocet which was
available was chaff:
a rocket dispersed cloud of metalized plastic
threads which confuses
radars. To be effective, chaff must be
dispersed as soon as
possible, preferably before the attack starts.
After the Sheffield,
the British were familiar with the Argentinan
attack tactics, and
could launch chaff as soon as they detected the
aircraft on their radars.
This defense was mostly effective.
Ultimately the only significant
mistake was the belief that the
Argentinans wouldn't
use Exocet missiles. If this possibility was
seriously analysed,
then the original attack might have been
recognized. The
British were wrong, and ended up learning the hard
way. Surprise
conclusion: mistakes can be deadly; mistakes in war are
usually deadly.
I think that the most
significant "risk" revealed by this event is
tendency to attribute
the failure of any system which includes a
computer (such as the
British Navy) to "computer error".
----------------------------------------------------------------------
----------------------------------------------------------------------
From: Robert Stroud <robert%cheviot.newcastle.ac.uk@Cs.Ucl.AC.UK>
Date: Tue, 30 Sep 86
14:43:24 gmt
To: risks@csl.sri.com
Subject: Re:
"Friendly" missiles and computer error - more on the Exocet
There is a very interesting
BBC TV documentary in the Horizon series called
"In the wake of HMS
Sheffield" which is well worth seeing if you get the
chance. It discusses
the failures in technology during the Falklands war
and the lessons which
have been learnt from them, and includes interviews
with participants on
both sides.
Naturally the fate of
HMS Sheffield features prominently, and the chronology
given by Rob MacLachlan
matches the program in most respects. However, I'm
afraid it says nothing
about the Exocet homing signal being friendly - I was
specifically looking
out for this. Instead, according to the documentary, the
device which should
have detected the homing signal is situated next to the
satellite transmission
device and was simply swamped by the signal from a
telephone call to London
in progress at the time - this backs up Peter's
definitive account.
A couple of other points
from the documentary are worth mentioning. Chaff
was indeed effective
in helping one ship avoid an Exocet (I forget which one)
but it is by no means
fool proof. The fuse needs to be set manually on deck
and must be exact, taking
into account lots of factors like wind direction,
ship's course, distance
from missile, etc. If you get it wrong, the distraction
comes too early or too
late. There was a nice piece of computer graphics
showing the difference
half a second could make - needless to say, they are
working on an automatic
fuse!
The Argentinian planes
were able to avoid radar detection using a technique
called "pecking the
lobes". Basically they exploit the shape of the radar
cone and the curvature
of the earth by flying level until they detect
a radar signal, then
losing height and repeating the process. As Rob said,
they only need to rise
up high enough to be detected at the last minute
when they fire the Exocets
and turn for home - even this trace would only
be visible very briefly
on the radar display and could easily be missed.
Thereafter the Exocets
are silent until the last few seconds when they
lock onto the target
to make last minute course corrections.
This problem has been
dealt with by building radar devices that can be used
from helicopters several
thousand feet up so they can see further over the
horizon.
There was also a discussion
about whether it would be feasible to install
anti-missile weapons
in cargo ships such as the Atlantic Conveyor (sunk
twice by the Argentinians
with Exocets who mistook it for one of the aircraft
carriers). Apparently,
installing a weapon would be possible, but to be
effective it would need
all the command & control computer systems as well to
keep track of everything
else that was going on, and that would not be
feasible.
Robert Stroud, Computing Laboratory, University of Newcastle upon Tyne.
ARPA robert%cheviot.newcastle@cs.ucl.ac.uk
(or ucl-cs.ARPA)
UUCP ...!ukc!cheviot!robert
----------------------------------------------------------------------
----------------------------------------------------------------------
Date: Mon, 23 Jun 86
09:56:05 pdt
From: price@src.DEC.COM
(Chuck Price)
To: RISKS@SRI-CSL.ARPA
Subject: License
Plate Risks
I heard the following
tale on KCBS this morning. [I intersperse a few
details from the SF
Chron, 23 Jun 86. PGN]
It seems that this fellow
[Robert Barbour] desired personalized license
plates for his car.
Since he loved sailing, he applied for ``SAILING'' and
``BOATING'' as his first
two choices [seven years ago]. He couldn't think of
a third name of NAUTICAL
intent, so he wrote ``NO PLATE'' in as his third
choice.
You guessed it. He got ``NO PLATE''.
A week or so later, he
received his first parking ticket in the mail. This
was followed by more
and more tickets, from all over the state [2500 in
all!]. It seems
that when a police officer writes a parking ticket for a
car with no license
plates, he writes ``NO PLATE'' on the ticket.
Our friend took his problem
to the DMV, which informed him that he should
change his plates.
The DMV also changed
their procedures. They now instruct officers to write
the word ``NONE'' on
the unplated parking tickets.
Wonder who's gonna get those tickets now?
-chuck price
[Obviously some poor sap whose license plate says ``NONE''!]
----------------------------------------------------------------------
----------------------------------------------------------------------
Date: Mon 31 Jul 86 17:38:10
N
To: risks@sri-csl.arpa
From:
<MANSFIEL%DHDEMBL5.BITNET@WISCVM.ARPA>
Organisation:
European Molecular Biology Laboratory
Postal-address: Meyerhofstrasse
1, 6900 Heidelberg, W. Germany
Phone:
(6221)387-0 [switchboard]
Subject: Laserprinter
dangers
Increasingly, large and
"official" organisations such as motor vehicle tax
offices, insurance companies,
etc. are using laser printers to print the
bills and other requests
for money which are sent to customers. Whereas
previously pre-printed
letterheads (often with several and or coloured inks)
were used, now the laser
printer is relied on to print the letterhead
itself, so that plain
paper can be used.
It is probably only a
matter of time before some clever person prints off a
batch that looks fine
but that have the c.d.'s own account number (or some
other slightly safer
one) on them, sends them out, and gets lots of money.
There must be lots of
other forgery and swindling possibilities with laser
printers. Have
any frauds of this type have actually been committed?
[Most banks
no longer make blank deposit slips routinely available, after
various
episodes of people magnetically coding account numbers onto the
blanks
and leaving these slips in the stack of blanks. Spoofing of
letterheads
is of course relatively easy with laser printers, but also
with
many of the electronic mailers around the net. PGN]
----------------------------------------------------------------------
----------------------------------------------------------------------
Date: Fri, 22 Aug 86
13:05:57 CDT
Received: by banzai-inst
(1.1/STP) id AA03138; Fri, 22 Aug 86 13:05:57 CDT
To: risks@csl.sri.com
Subject: Report
from AAAI-86 [Really from Alan Wexelblat]
I just got back from
a week at AAAI-86. One thing that might interest
RISKS readers was the
booth run by Computer Professionals for Social
Responsibility (CPSR).
They were engaged in a valiant (but ineffectual)
effort to get the AI
mad-scientist types to realize what some of their
systems are going to
be doing (guiding tanks, cruise missiles, etc.).
They were handing out
some interesting stuff, including stickers that said
(superimposed over a
mushroom cloud): "It's 11 p.m. Do you know what your
expert system just inferred?"
They also had a series
of question-answer cards titled "It's Not Trivial."
Some of them deal with
things that have come up in RISKS before. [I left
them in for the sake
of our newer readers. PGN] They are:
Q1: How often do
attempts to remove program errors in fact introduce one
or more additional
errors?
A1: The probability
of such an occurance varies, but estimates range from
15 to 50 percent
(E.N. Adams, "Optimizing Preventing Service of
Software Products,"
_IBM Journal of Research and Development_,
Volume 28(1),
January 1984, page 8)
Q2: True or False:
Experience with large control programs (100,000 < x <
2,000,000 lines)
suggests that the chance of introducing a severe
error during the
correction of original errors is large enough that
only a small fraction
of the original errors should be corrected.
A2: True. (Adams, page 12)
Q3: What percentage
of federal support for academic Computer Science
research is funded
through the Department of Defense?
A3: About 60% in
1984. (Clark Thompson, "Federal Support of Academic
Research in Computer
Science," Computer Science Division, University
of California,
Berkeley, 1984)
Q4: What fraction
of the U.S. science budget is devoted to defense-related
R&D in the
Reagan 1985/86 budget?
A4: 72% ("Science
and the Citizen," _Scientific American_ 252:6 (June
1985), page 64)
Q5: The Space Shuttle
Ground Processing System, with over 1/2 million lines
of code, is one
of the largest real-time systems ever developed.
The stable release
version underwent 2177 hours of simulation
testing and the
280 hours of actual use during the third shuttle
mission.
How many critical, major, and minor errors were found
during testing?
During the mission?
A5:
Critical Major Minor
Testing 3 76 128
Mission 1 3 20
(Misra, "Software
Reliability Analysis," _IBM Sys. J. 1983, 22(3) )
Q6: How large would "Star Wars" software be?
A6: 6 to 10 million
lines of code, or 12 to 20 times the size of the Space
Shuttle Ground
Processing System. (Fletcher Report, Part 5, page 45)
The World Wide Military
Command and Control System (WWMCCS) is used by
civilian and military
authorities to communicate with U.S. military forces
in the field.
Q7: In November
1978, a power failure interrupted communications between
WWMCCS computers
in Washington, D.C. and Florida. When power was
restored, the
Washington computer was unable to reconnect to the
Florida computer.
Why?
A7: No one had
anticipated a need for the same computer (ie the one in
Washington) to
sign on twice. Human operators had to find a way to
bypass normal
operating procedures before being able to restore
communications.
(William Broad, "Computers and the U.S. Military
Don't Mix," _Science_
Volume 207, 14 March 1980, page 1183)
Q8: During a 1977
exercise in which WWMCCS was connected to the command and
control systems
of several regional American commands, what was the
average success
rate in message transmission?
A8: 38% (Broad, page 1184)
Q9: How much will
the average American household spend in taxes on the
military alone
in the coming year?
A9: $3,400 (Guide to the Military Budget, SANE)
[question 10 is unrelated to RISKS]
Q11: True or False?
Computer programs prepared independently from the same
specification
will fail independently.
A11: False. In
one experiment, 27 independently-prepared versions, each
with reliability
of more than 99%, were subjected to one million
test cases.
There were over 500 instances of two versions failing
on the same test
case. There were two test cases in which 8 of the
27 versions failed.
(Knight, Leveson and StJean, "A Large-Scale
Experiment in
N-Version Programming," Fault-Tolerant Computing
Systems Conference
15)
Q12: How, in a quintuply-redundant
computer system, did a software error
cause the first
Space Shuttle mission to be delayed 24 hours only
minutes before
launch?
A12: The error affected
the synchronization initialization among the 5
computers.
It was a 1-in-67 probability involving a queue that
wasn't empty when
it should have been and the modeling of past
and future time.
(J.R. Garman, "The Bug Heard 'Round the World,"
_Software Engineering
Notes_ Volume 6 #5, October 1981, pages 3-10)
Q13: How did a programming
punctuation error lead to the loss of a Mariner
probe to Venus?
A13: In a FORTRAN program,
DO 3 I = 1,3 was mistyped as DO 3 I = 1.3 which
was accepted by
the compiler as assigning 1.3 to the variable DO3I.
(_Annals of the
History of Computing_, 1984, 6(1), page 6)
Q14: Why did the splashdown
of the Gemini V orbiter miss its landing point
by 100 miles?
A14: Because its guidance
program ignored the motion of the earth around
the sun. (Joseph
Fox, _Software and its Development_, Prentice Hall,
1982, pages 187-188)
[Questions 15-17 are not RISKS related]
Q18: True or False?
The rising of the moon was once interpreted by the
Ballistic Missile
Early Warning System as a missile attack on the US.
A18: True, in 1960.
(J.C. Licklider, "Underestimates and Overexpectations,"
in _ABM: An Evaluation
of the Decision to Deploy and Anti-Ballistic
Missile_, Abram
Chayes and Jerome Wiesner (eds), Harper and Row,
1969, pages 122-123)
[question 19 is about the 1980 Arpanet collapse, which RISKS has discussed]
Q20: How did the Vancouver
Stock Exchange index gain 574.081 points while
the stock prices
were unchanged?
A20: The stock index
was calculated to four decimal places, but truncated
(not rounded)
to three. It was recomputed with each trade, some
3000 each day.
The result was a loss of an index point a day, or
20 points a month.
On Friday, November 25, 1983, the index stood
at 524.811.
After incorporating three weeks of work for consultants
from Toronto and
California computing the proper corrections for 22
months of compounded
error, the index began Monday morning at
1098.892, up 574.081.
(Toronto Star, 29 November 1983)
Q21: How did a programming
error cause the calculated ability of five
nuclear reactors
to withstand earthquakes to be overestimated, and
the plants to
be shut down temporarily?
A21: A program used in
their design used an arithmetic sum of variables when
it should have
used the sum of their absolute values. (Evars Witt,
"The Little Computer
and the Big Problem," AP Newswire, 16 March
1979. See
also Peter Neumann, "An Editorial on Software Correctness
and the Social
Process," _Software Engineering Notes_, Volume 4(2),
April 1979, page
3)
Q22: The U.S. spy ship
Liberty was attacked in Israeli waters on June 8,
1967. Why
was it there in spite of repeated orders from the U.S.
Navy to withdraw?
A22: In what a Congressional
committee later called "one of the most
incredible failures
of communications on the history of the
Department of
Defense," none of the three warnings sent by three
different communications
media ever reached the Liberty. (James
Bamford, _The
Puzzle Palace_, Penguin Books, 1983, page 283)
Q23: AEGIS is a battle
management system designed to track hundreds of
airborne objects
in a 300 km radius and allocate weapons sufficient
to destroy about
20 targets within the range of its defensive
missiles.
In its first operational test in April 1983, it was
presented with
a threat much smaller than its design limit: there
were never more
than three targets presented simultaneously. What
were the results?
A23: AEGIS failed to
shoot down six out of seventeen targets due to system
failures later
associated with faulty software. (Admiral James
Watkins, Chief
of Naval Operations and Vice Admiral Robert Walters,
Deputy Chief of
Naval Operations. Department of Defense
Authorization
for Appropriations for FY 1985. Hearings before the
Senate Committee
on Armed Services, pages 4337 and 4379.)
Well, this message is
long enough; I'll hold off on my personal commentaries.
People wanting more
information can either check this sources given or
contact CPSR at P.O.
Box 717, Palo Alto, CA 94301.
--Alan Wexelblat
ARPA: WEX@MCC.ARPA or
WEX@MCC.COM
UUCP: {ihnp4, seismo,
harvard, gatech, pyramid}!ut-sally!im4u!milano!wex
----------------------------------------------------------------------
----------------------------------------------------------------------
Date: Thu, 2 Oct 86 19:10:10
CDT
From: Bill Janssen <janssen@mcc.com>
Subject: Wrongful
eviction through computer error
To: risks@sri-csl.arpa
An interesting thing
happened to me last month. I got home on the 5th of
September to find an
eviction notice on my living room floor. Something
about not paying my
rent. Well, I gathered up the checks and went over to
the office. Turns
out the problem was that I had already paid for October,
as well as September,
and the apartment management folks had just switched
to a new computer system!
There must have been a line in it something like
if (last_month_paid_for
!= this_month
AND day == trigger_day_for_eviction)
issue_eviction_notice();
According to some of
the office staff, 11 other people had already
been in with similar
complaints.
Bill Janssen, MCC Software
Technology, 9430 Research Blvd, Austin, Texas 78759
UUCP: {ihnp4,seismo,harvard,gatech,pyramid}!ut-sally!im4u!milano!janssen
----------------------------------------------------------------------
----------------------------------------------------------------------
From: mnetor!spectrix!clewis@seismo.CSS.GOV
To: Neumann@csl.sri.com
Subject: [More
Aviation Hearsay?]
Date: Wed Oct
8 12:04:57 1986
ReSent-To: RISKS@CSL.SRI.COM
I understand and appreciate
your comments in the mod.risks about nth party/
hearsay stuff.
But, from the examples you gave, in case you are really
looking for some aviation
accidents partially due to obedience to the
"book", here are two
- both commercial accidents at Toronto International
(Now Pearson International).
Both from MOT (then DOT) accident
investigations:
About 15 years ago a
Air Canada DC-8 was coming in for a landing. At
60 feet above the runway,
the pilot asked the co-pilot to "arm" the spoilers.
The co-pilot goofed
and fired them. The aircraft dropped abruptly onto
the runway, pulling
about 4 G's on impact. At which point one of the
engine/pylon assembly
tore away from the wing - this was an aircraft
defect because the engines
were supposed to withstand this impact - a
6 G impact is supposed
to shear the mounting pins. Not aware of this
fact, the pilot performed
what the book told him to do - go around for
another try. He
only made it halfway around - the pylon had tore away
a portion of the fuel
tank and the aircraft caught fire and crashed in
a farmer's field killing
all aboard.
In retrospect, the pilot
should have stayed on the ground, contrary
to the book. Many
would have survived the fire on the ground. However,
it was difficult to
see how the flight crew could have realized that
the aircraft was damaged
as it was in the short time that they had to
decide. The spoiler
arming system was altered to make this more unlikely.
The second incident was
about 8 years ago - on a Air Canada DC-9 taking
off. During take
off one of the tires blew throwing rubber fragments
through one of the engines.
One of these fragments damaged a temperature
sensor in the engine,
causing an "engine fire" indication to come on in
the cockpit. The
pilot did what the book said, "abort takeoff", even
though he was beyond
the safe stopping point. The aircraft slid off the
end of the runway and
into the now infamous 50 foot deep gully between
the runway and the 401
highway. The fuselage broke in 2 places, causing
one death and several
broken bones and minor back injuries.
In retrospect, if the
pilot had not aborted takeoff, he would have been
able to take off successfully
and come around for reasonably safe landing,
saving the aircraft
and preventing any injuries. However, there was
absolutely no way that
they could have determined that the engine was not
on fire.
Results:
-
in spite of the findings, I seem to remember that the pilot was
suspended for some time.
-
Recommendations:
- filling in the gully - not done
- cutting grooves
in the runways for improved braking - not done yet,
but the
media is still pushing the MOT. (I'm neutral on this one,
the MOT
has some good reasons for not doing it)
- cleaning the
tarmac of burned rubber - only done once if I recall
correctly.
As a counter example, I offer you another:
It had become common
practise for twin-otter pilots to place the props
in full reverse pitch
while landing, instants before actually touching down.
This had the effect
of shortening the landing run considerably over the
already short runs (twin-otter
is STOL). However, due to a number of
accidents being traced
to pilots doing this too soon - eg: 50 feet up,
the aircraft manufacturer
then modified the aircraft so as to prevent
reverse pitch unless
the aircraft was actually on the ground.
(The above, however, is from a newspaper, and would bear closer research).
----------------------------------------------------------------------
----------------------------------------------------------------------
Date: Wed, 29 Oct 86
17:31:59 pst
From: Dave Benson <benson%wsu.csnet@CSNET-RELAY.ARPA>
To: risks%csl.sri.com@RELAY.CS.NET
Subject: The
software that worked too well
This story is nth hand,
thus to be classified as rumor. But it is
relevant to RISKS, so
I pass it on, if only as a parable.
SeaTac is the main Seattle-area
airport. Ordinarily aircraft landings are
from the north, and
this end of the runway is equipped with all the sensing
equipment necessary
to do ALS (Automatic Landing System) approaches.
The early 747 ALS worked
beautifully, and the first of these multi-centaton
aircraft set down exactly
at the spot in the center of the runway that the
ALS was heading for.
The second 747 set down there. The third 747 landed
on this part of the
runway. ... As did all the others.
After a while, SeaTac
personnel noticed that the concrete at this point at
the north end of the
ALS runway was breaking up under the repeated impact of
747 landings.
So the sofware was modified so that 3 miles out on the
approach, a random number
generator is consulted to choose a landing spot --
a little long, a little
short, a little to the left or a little to the right.
THE MORAL:
Don't assume
you understand the universe without actually experimenting.
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