Pattern 10 · Failure

Explainable Fault

When something goes wrong, the system names the actual fault in the operator's terms and points at what to do about it, instead of showing symptoms or a code. On the 777 a checklist icon sits beside the message.

The mechanism

fault occurs → record it

  1. 01Fault occursA sensor, link or subsystem fails
  2. 02Diagnose itFind the cause behind the symptoms
  3. 03 · Key momentName it in the operator's termsThe condition, not an error code
  4. 04Point at the responseThe procedure that goes with it
  5. 05Record itSo maintenance inherits the diagnosis

At 02: On JT610 the crew met the symptoms — stick shaker, airspeed and altitude disagreement, repeated nose-down trim — with nothing naming the miscalibrated angle-of-attack sensor behind them. The AOA DISAGREE alert was not working on that aircraft.

At 04: The 777's EICAS puts a checklist icon next to a message whenever an electronic checklist has to be completed, so the fault and its response arrive together.

On this page

Without / with the pattern

Anti-pattern: Symptoms Without a Cause

Fault occurs, then Symptoms only, then Wrong diagnosis

Symptoms Without a Cause: the crew gets the downstream effects and has to infer the fault under time pressure. On the flight before JT610 the captain attributed the trim behaviour to the speed trim system — a different system entirely.

With the pattern

Fault occurs, then Cause named, then Response to hand

The alert names the condition in terms the operator recognises and carries the procedure with it, so the diagnosis is not left to inference.

Sources

The useful detail in JT610 is that the alert meant to name the fault was not working on that aircraft, so the crew were left with a stick shaker, disagreeing airspeed and altitude, and trim that kept pushing the nose down.23 Symptoms are not a diagnosis. The previous day's captain had put the same behaviour down to the speed trim system,3 which is exactly what happens when a cluster of effects arrives without the cause attached: the crew reaches for the system that best explains what they can see.

There is a second cost, further downstream. Investigators noted that without the alert the crew could not document the faulty sensor, so it never reached maintenance.2 A fault that cannot be named cannot be reported, which means it cannot be fixed, which means the next crew meets it too. That is why the last step here is recording rather than displaying — naming the condition is what makes it transmissible. The 777's answer is the plainest version of the pattern: the message states the condition, and the icon beside it says there is a checklist to run.5

  1. Guidelines for Human-AI InteractionSaleema Amershi et al. · 2019Paper
  2. Lion Air MAX report finds Boeing, airline, pilots contributed to tragedyAirlineRatings · 2019Article
  3. Bjorn's Corner: Analysing the Lion Air JT610 crash, Part 3Leeham News · 2019Article
  4. People + AI Guidebook — Errors + Graceful FailureGoogle PAIRArticle
  5. 16.422 Human Supervisory Control of Automated Systems — alerting systemsMIT OpenCourseWare · 2004Talk