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Old 13th May 2014, 19:52   #1 (permalink)
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AF 447 Thread No. 12

Thread part -

This thread series started out of an earlier thread which starts here and finishes here.

Another, slower moving, thread on the subject and covering the period from the original thread, above, and the start of thread #4



Total posts to date 17634 .. with in excess of 2.7 million views overall.

Links to the various BEA reports are given below. If I have missed any of the useful papers, please PM me with the URL and I can include it.

(a) BEA site - French, English
- Report link page - French, English

(b) Interim Report (No, 1) Jul 2, 2009 - English

(c) Interim Report No. 2 Dec 17, 2009 - English
- Update Dec 17, 2009 - French, English

(d) Estimating the wreckage location Jun 30, 2010

(e) Wreckage search analysis Jan 20, 2011

(f) Briefing and associated update May 27, 2011
- Briefing - update French
- Briefing - update English
- Briefing - update German
- Briefing - update Portugese

(g) Interim Report No. 3 July 2011 - French, English

(h) Links to final report Jul 5, 2012 and associated documents.

Miscellaneous pertinent links -

(a) Airbus Operations Golden Rules
(b) ALPA FBW Primer
(c) C* and Civil Transports - Cranfield
(d) Longitudinal Flight Control Design - RAeS
(e) Longitudinal Stability: Effect of High Altitude and CG - Boeing
(f) pitot static system performance - USN (Pax River) FTM
(g) The Problem of Automation: Inappropriate Feedback and Interaction, Not Over-Automation. Donald A. Norman UCSD
(h) Upset Recovery - 16MB zip file
(i) Ironies of Automation. Lisanne Bainbridge UCL
(j) Cognitive Capability of Humans. Christopher Wickens Uni Illinois
(k) Trust in Automation: Designing for Appropriate Reliance John D. Lee, Katrina A. See; Human Factors, Vol. 46, 2004
(l) Training for New Technology. John Bent - Cathay Neil Krey's CRM site


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Another search engine approach tailored for AF447 can be found here.

NB This thread has been merged into the main AF 447 saga as thread No 12. Originally, I expected it not to develop a life of its own .. but I was grossly wrong ... isn't the first time and certainly won't be the last ... c'est la vie ... I'll tidy up the detail in this post over a coffee tomorrow .. JT
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Old 13th May 2014, 20:25   #2 (permalink)
 
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Any expert panel who says that the pilots are to blame, without looking into what and how the company behind acted to put the pilots in that position/situation, does not know anything about flight safety and aviation safety culture.

But hey, if everybody is happy when the dead pilots are blamed, then lets not learn anything from this and move on to the next event that will look more or less like this one.
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Old 13th May 2014, 20:42   #3 (permalink)
 
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That's an oversimplification of the article. What it says is (pardon Google Translate):

Quote:
The first three relate to the crew, they cite "lack of structured failure analysis" , "not understanding the situation" and "the division of labor in the cockpit that has not been applied rigorous " . But they also involve the airline, deploring a "lack of clear direction from Air France despite several similar cases after the icing of the pitot probes and thus a return to insufficient experience" .

They point also "inadequate pilot training in the application of the Unreliable IAS procedure" , required when probes have iced over, and the behavior of the aircraft during the loss of speed indications. They also mention the stress and fatigue of the crew, "the questionable attitude of the captain leaving the cockpit despite the questions asked by the first officer" .
So saying the panel "blames the crew" and leaves it at that is inaccurate. The airline comes in for censure, and the aircraft's behaviour is earmarked for review. This is all old news though, as this does not diverge significantly from the findings of the final report.

I note the "relatives" (read : SNPL) lawyer has been quoted as though the report and panel do blame the crew - but that's pretty much par for the course.

Last edited by DozyWannabe; 13th May 2014 at 20:56.
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Old 13th May 2014, 21:05   #4 (permalink)
 
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Winnerhofer, it appears that you are the one allocating blame.

My rough translation identifies the following significant aspects (as DW):-
“Inappropriate response of the crew”,
“Lack of structured failure analysis",
“Not understanding the situation"
“The division of labor in the cockpit."
“Inadequate pilot training in the application of the procedure unreliable IAS."

Modern views of human behavior do not allocate blame; instead they look for underlying contributions such as an inappropriate response which often results from a failure to understand the situation (awareness and training) and selection or application of procedures (training and reliance on humans to manage complex situations).
The report also considers the underlying technical failure and infers (my view) that the operational / regulatory approvals to continue based on refresher training also contributed.
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Old 15th May 2014, 08:57   #5 (permalink)
 
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Initially it was a technical malfunction. What led to a situation where proper pilot reaction was needed. This was not given. And to be honest the reaction needed was very basic and easy, but still not given. This is considered pilot error and you can not deny that pilots are not to blame at all. BUT not proper training and human factors are definitly important causations.


It is quite obvious why the outcome of both reports are so different. one was done by BEA (frensh authority for safety). For them it is important that people keep on flying AIR FRANCE. The other is done on request by airbus. Need more to say!!!


One thing is indeed really worrying:
(As Winnerhofer said And do not forget that we had a BEA report w
ith recommendations for aviation safety. These recommendations have unfortunately not been implemented: it's really dramatic, we must address this problem.
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Old 15th May 2014, 15:45   #6 (permalink)
 
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Does anybody know the Air France A330 IAS and UAS procedures today 16.May 2014 ?
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Old 15th May 2014, 20:41   #7 (permalink)
 
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Quote:
Originally Posted by DutchOne View Post
It is quite obvious why the outcome of both reports are so different. one was done by BEA (frensh authority for safety). For them it is important that people keep on flying AIR FRANCE. The other is done on request by airbus. Need more to say!!!
With respect, I don't think the BEA are particularly bothered one way or another regarding AF's business fortunes - their remit is to investigate accidents and incidents, usually to French-registered aircraft, and make recommendations to prevent them from happening again. Same with Airbus - they don't want their aircraft to have continuing issues.

All the old "cover-up" rubbish is just that - complete rubbish.
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Old 15th May 2014, 23:48   #8 (permalink)
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.. and, should the thread descend into witch hunts and conspiracy circular thoughts .. it will be despatched to a more appropriate forum ...
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Old 16th May 2014, 06:45   #9 (permalink)
 
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It is clear that both the Pilot Flying and the Pilot Not Flying were completely out of their depth in interpreting and correcting the situation.

The big question is, is that typical of Air France pilots (in which case the Airline and/or regulator is primarily to blame), or was it an aberration?

Were Air France pilots properly trained to set attitude and thrust when faced with an airspeed issue?

If not, are they now?
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Old 16th May 2014, 14:32   #10 (permalink)
 
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Changes after AF447

As a colleague of mine use to say , in this field the improvements are often written in blood. Maybe it is worth to try here to review what changes was eventually written in the blood of AF447 228 souls.. (industrywide!) . Certainly many of the posters and followers of this forum are interested, and after all it is muchmore important for the industry than “witch hunts and conspiracy circularthoughts” .

In the immediate aftermath of disaster there were of coursechanges in training programs, an AD that imposed the change of pitots, even a change of the the UAS procedure and more .. And later there were perhaps other, introduced more orless quietly.
For example in 5 years it was time for more software updates, butdoes someone know whether Airbus did changed the marvelous pieces of logicwhich allowed FD to step in by itself in a changed mode after a clear condition of “FD- off; AP - off”, or the THS to run to thenose-up limit in the same time with SW, or SW to be disabled in a full stalledplane, at FL >100, with a full working AOA vane?
And such other maybe... - things surfaced in this tragedy and and that would be a shame for the industry to remain unchanged…
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Old 16th May 2014, 17:42   #11 (permalink)
 
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Quote:
.. and, should the thread descend into witch hunts and conspiracy circular thoughts .. it will be despatched to a more appropriate forum ...
And in what forum?
I do not see in PPRuNe a forum section dedicated to the policy
Because it comes well political watered with some economic drops
BEA depends administratively on the French Ministry of Transport
The French state is a shareholder in Air France
Conclusion? conflict of interest ... simple as that
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Old 16th May 2014, 18:23   #12 (permalink)
 
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Does anyone know how many of the senior management of Air France, the BEA, Airbus and the DGAC went to the same Grandes Ecoles ... ?
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Old 16th May 2014, 18:38   #13 (permalink)
 
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IMHO, the only crumb of comfort to be drawn from this otherwise unmitigated tragedy is that every thinking student and practitioner of aeronautics has found something to learn from it. I imagine that may also apply to those concerned with deep-sea search operations.

However, one might have expected the BEA recommendations on flight-recorder ULBs to have been addressed, amended (if necessary), and implemented in time for MH370.
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Old 16th May 2014, 21:57   #14 (permalink)

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The mystery to me is why the the PF and PNF did not action the UAS (or any other) procedures on AP dropout.

With no SA whatsoever they pulled up into a stall, lost the plot comprehensively and fell into the sea.

It is hard to understand, and I still haven't seen any kind of explanation that makes sense.

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Old 16th May 2014, 22:14   #15 (permalink)
 
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Mac,

Notwithstanding the inexplicable mishandling by the PF, the bigger mystery for me has always been the apparently deferential attitude of the older, more-experienced PNF, who seemed to decide that the only person who could rectify the situation was the absent captain.
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Old 16th May 2014, 22:46   #16 (permalink)

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Chris, d'ye know I've seen suchlike in the operating theatre on occasion.

A forceful and confident junior leading a mild and unassertive senior into dangerous situations out of the capabilities of both.

'Tis a question of personalities.

(and yes, I've sometimes been the old guy roused out of his bunk to try and fix things - the first step is to establish your absolute authority and take over completely)
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Old 16th May 2014, 23:29   #17 (permalink)
 
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" 'Tis a question of personalities."

Quite. AF447 is all about human factors, and in this case they are not confined to the cockpit - or the aeroplane on the night.

However, a captain called from his/her bunk has to be wary of premature takeover...
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Old 16th May 2014, 23:35   #18 (permalink)
 
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“…why the PF and PNF did not action the UAS…”
Perhaps they did, except that it was the memory drill required for after takeoff – nose up (15 deg?), as opposed to the more benign level flight case on the same page.
This action might have been influenced by an inappropriate emphasis on this part of drill during the mandated UAS refresher training; also this might identify a difference between the accident and other successfully recovered incidents, apart from many other human behaviours.

“…the apparently deferential attitude of the older, more-experienced PNF…”
Perhaps he too was struggling to understand the situation, and with rapidly evolving circumstances was mentally limited, including time dilation, which delayed alerting the Captain.

The lessons to be learnt from this accident are in the successful recoveries of previous events. Everyone is trying to find a cause and thus something to irradiate, yet if we can understand what previous crews did with success and incorporate/strengthen that in operations then perhaps we might avoid similar situations.

W.r.t. the many French agencies, I have worked with most of them during certification and safety-incident investigation. My experiences were of very dedicated, knowledgeable, impartial, and independent organisations and individuals, whose primary aim was safety.
In recent years investigative authorities tend to invite the aircraft and vendor manufacturers to take a much more active role in investigations as it is apparent that no one group can have a sufficiently deep understanding of systems design and operation.
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Old 17th May 2014, 00:06   #19 (permalink)
 
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Is it possible that the PNF had less visual feedback on what the PF was actually doing due to the little Airbus sidesticks rather than traditional joysticks? Surely for any pilot the sight of the PF hauling desperately back on the stick ad infinitum would have maybe aided in his diagnosis of the problem (not withstanding the immediate resounding of the stall alarm the one time that the PF stopped pulling back)?

From what I've read I don't think that they're wrong to blame the PF as his initial reaction to the cacaphony of alarms was all wrong given the situation. However, AF failed on the implementation of pitot tube technical diversity despite previous warning incidents, adequacy of their pilot training can be put in question, and some the Airbus alarms and systems really didn't help in the correction of the initial error.
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Old 17th May 2014, 11:56   #20 (permalink)
 
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Stall Warning logic modified

Quote:
Originally Posted by Winnerhofer
Let ze battle commence!
Same schools or not, Air France is saying that Judicial Airbus Counter Experts did not search Air France arguments. In consequence AF is asking annulation of that Airbus counter expertise on judicial procedure ground.

Air France pointed also that Algorithm of the Stall Warning has been modified after the accident by Industry.

The pilots' Union ALTER reminds that the origin of pilots' actions is the Pitot tubes misfunction, today modified. Thalès Pitot tubes were replaced by Goodrich sensors after the accident.
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