Análise do resultado da investigação sobre o caso do Air Astana 1388 ou: “o preço dos salários baixos em Portugal e da precarização laboral em empregos de altíssima responsabilidade”
by Couve_do_Lidl
Análise do resultado da investigação sobre o caso do Air Astana 1388 ou: “o preço dos salários baixos em Portugal e da precarização laboral em empregos de altíssima responsabilidade”
by Couve_do_Lidl
1 comment
Recomendo muito, mesmo muito, a leitura, sobretudo para quem tem interesse por engenharia ou aviação e/ou queira perceber o buraco bem fundo que estamos a cavar para este país, até nas nossas empresas estratégicas bem como nos órgãos mais tecnicamente exigentes do aparelho estatal.
Saliento uma das causas:
>The fact that this lack of knowledge was so widespread led investigators to conclude that the problem likely began on an organizational level. Although OGMA had been around for many years, it had recently begun to suffer from excessive staff turnover, resulting in a hemorrhaging of institutional experience. This effect was compounded by a lack of effective competency testing which could prove technicians’ breadth of knowledge. In addition to these, the GPIAAF also criticized OGMA for sloppy bookkeeping, with inconsistencies observed in inspection paperwork and work cards, suggesting an insufficiently rigorous adherence to proper procedures.
Bem como a falta de reconhecimento do problema pela OGMA, no estilo de gestão clássica portuguesa:
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>OGMA also added comments which included some useful information, particularly regarding the “green boxes” on the synoptic page, but by and large the company’s response came across as aggressive and unrepentant. OGMA was clearly unwilling to accept any responsibility for the incident, going so far as to claim that knowledge of proper aileron and spoiler movement was “irrelevant” as long as its technicians followed the manual, which it claimed they did. The company also sought to blame the pilots for the non-detection of the screwup, writing that the dispatch of the plane in an airworthy state was ultimately their responsibility, and that it should have been obvious to them that the ailerons were not responding correctly. OGMA in fact argued that the pilots probably didn’t perform the pre-flight control checks at all, and accused them of negligence. For its part, the GPIAAF argued that the control checks had likely become rote, leading to inattention and automatic behavior which led them to miss the fact that the synoptic page, which should have been open, showed the ailerons moving the wrong way. In any case, it was hard to believe that the pilots deserved much blame for an event which was made possible by Embraer’s poor design and OGMA’s poor maintenance practices.
Realço também as seguintes considerações sobre a qualidade do próprio relatório que o Gabinete de Prevenção e Investigação de Acidentes com Aeronaves produziu:
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>At this point it should be noted that the GPIAAF produced a final report which looked very slick and modern, but which was at times confusing and lacking in detail. The description of the events of the flight itself, as related in this article, had to be gleaned from a number of different, sometimes contradictory sources, so the exact order and timing of events should be taken with a grain of salt. Furthermore, most of the information about the maneuvers made by the airplane had to be inferred from a single, blurry chart reproduced in the report without context, so all stated altitudes, speeds, and descent rates come with significant error bars. This is information that one would normally find in a final report, but it was conspicuously absent.
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>Furthermore, the final report did not describe the exact sequence of events on the workshop floor which led to the reversal of the aileron cables; made claims about the quality of OGMA’s organization and safety culture without backing them up with specific examples; and exhibited numerous instances of ambiguous or improper English translation. Most of these issues were explicitly called out by Air Astana in its comments on the report, only for the airline’s suggestions to be rejected. In fact, despite the GPIAAF’s insistence that its report contained sufficient detail, this article was only able to achieve its present level of clarity thanks to additional information contained in Air Astana’s comments.
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Bónus: a horripilante gravação da interação com o ATC de Lisboa, nomeadamente na parte em que a tripulação pede indicações para o Atlântico para morrer no mar
[https://youtu.be/kIc8Rr-cKd8?si=aEcqCo5Or8plFkv3&t=254](https://www.youtube.com/watch?v=kIc8Rr-cKd8)