CJ;
Originally Posted by ChristiaanJ #24
I do have the impression that too many people here are 'parsing' all the 'subtleties' of the English-language translation of the BEA report, trying to 'tease out' information which isn't really there, and isn't there in the original French either.
FWIW, I agree
CJ - it is a mistake to read too much into each word in an attempt to squeeze this or that interpretation, (
ours!), from it. Finding agreement when far more is known is going to be equally difficult as well.
Interesting post and link
Machinbird, thank you. I don't disagree that a form of cognitive overload may have occurred. In keeping with this discussion, I would like to broach a human factors aspect about which thus far nothing has been noted or asked. The observation concerns SOPs, CRM and cockpit discipline in the handling of this event.
The creation, implementation, training and checking of SOPs, CRM processes and their outcomes, cockpit discipline, are intended to avoid or delay cognitive overload, or cognitive dissonance.
While cockpit design, cockpit displays, ergonomics, and aircraft/system drill and checklist design will influence outcomes, a "Standard" way of accomplishing complex tasks under both time and operational pressures reduces the potential for error. I know very well that it doesn't always work that way despite best efforts.
I would like to preface this observation by stating that this is not just about "the crew", but it is a question which will arise in every airline pilot's mind because SOPs, CRM and cockpit discipline are heavily emphasized in recurrent training and line checking.
This is not about finding blame because that is not what the investigative process is about. The investigative process is about "finding things out" and must be free to ask all questions regardless of how uncomfortable they may be. In other words, the investigative process is unlike ordinary discussion in that when a question is asked, it does not imply anything other than a need to know.
So asking a question about training does not imply that "training is under suspicion" nor does asking questions about the crew's actions imply that such are under "special scrutiny".
I would like that distinction to be as clear as possible. This has nothing to do with complementing or criticizing the crew. The notions of "defending the crew" or "criticizing the crew" don't apply
in the investigative discourse. Criticizing or defending the aircraft may have a place in other venues and so may such an examination of the crew have a place, but that would be a legal, political, economic discourse, not the investigative discourse.
I make this distinction partly for the reason
CJ posted his comments on parsing language - the same words will mean different things, depending upon the discourse. "Investigate" means different things in politics and law than it does in safety work.
That said...
The question of SOPs and standard responses to abnormalities arises out of the almost-immediate response just after 02:10:05 by the PF to the autopilot and autothrust disconnect and the ECAM messages. We know that the BEA Update states that almost immediately there was a left and nose-up SS input and pitch increased beyond 10 degrees.
Abnormal and Emergency SOPs are created and trained to:
a) ensure control of the aircraft is firmly in hand and that stable flight was being maintained and to ensure the flight path (track and altitude) was being maintained as needed;
b) ensure that all crew members on deck were alerted to the problem, and to who was in control of the aircraft and who was to execute drills and/or checklists - ATC would be notified when there was time;
c) ensure that all crew actions are predictable and understood by all cockpit crew members and to avoid "individual variations" leading to unexpected responses and confusion.
This is the standard
Aviate, Navigate, Communicate rule that we have seen mentioned.
In terms of CRM and responding to abnormals and emergencies, no action, no drills, no checklists are started until the aircraft is under control and stable.
Most of the time that is a quick assessment and emergency drills are done without delay. For an abnormal such as this one, there is no hurry. The airplane was stable before the event and other than minor variations perhaps due to turbulence, would continue that way in the absence of input.
The pilot flying always initiates a drill or checklist by announcing the drill being executed or the requesting the appropriate checklist. This communication alerts everyone in the cockpit (usually just the two), to what is coming next and to prepare for response, as trained.
If a memorized drill (such as the Rapid Depressurization, Emergency Descent), the PNF monitors the drill for accuracy and correctness while the PF flies the manoeuver and where necessary calls out any deviations. If required (in a EGPWS manoeuvre for example or Stall Recovery), the PNF may call out primary parameters such as pitch, altitude, speed, rate of climb and so on. Here, such feedback would be of critical importance to help avoid "tunnel vision" and increase situational awareness for both crew members, and to help the PF who would be concentrating on flying the aircraft with a possibly-reduced scan.
As I have said, this wasn't an emergency such as a depressurization, an engine failure or fire or a GPWS event which requires timely, immediate action but it did have two memory components to the drill, (as shown in the BEA Interim Report #1), before the UAS QRH Checklist was to be called for. I have discussed this memorized drill and checklist a number of times on previous threads.
The next step in the SOPs for handling an abnormal is to execute and clear the ECAM messages. There are SOPs for this process. Once clearing all the ECAM messages is accomplished, the STATUS page is checked for equipment and capability lost. The ECAM is then cleared. Then, if still necessary, the "paper" checklist, (QRH) is called for by the PF and brought out by the PNF and referenced. Usually the QRH checklist most commonly used are the
Landing Config/Approach Spd/Landing Distance Following Failures and
Landing Distance Without Autobrake CONF 3 or CONFIG FULL checklists. These kinds of items might be delayed until closer to destination - I'm just using this as one example.
When all ECAM actions and Status reviews are complete and when the required QRH checklists are completed and when the aircraft is considered secured the process of communicating to ATC any problems with capability in terms of maintaining flight and navigation, then communicating with the Flight Attendants, then, where necessary, the company. Any diversions, changes in altitudes are considered at this time.
This is one example of how it's done and there will be variatons, slightly different priorities and more or less memorization of drills depending upon the airline.
The key point here is, this process must be thoroughly trained and checked during recurrent simulator and line checks. SOPs, CRM and cockpit discipline are for those times when things start come unglued in a hurry. The training focuses one and gives a structure to the inevitable initial chaos which can unfold rapidly as we have seen here; - at 02:08 they were talking about deviating to the left of course, and just over six minutes later they were gone.
The question of SOPs goes beyond the crew and must be asked "upstream" of just this crew. What support for these areas was there and how robustly was it carried out?
A more complete update from the BEA will hopefully shed some light on this aspect of this accident because it may be related to the reason for the pitch-up and stall.
The "
Airbus Golden Rules" came out a very long time ago - around 1998 IIRC. The later 2004 document discusses the above process in greater detail and is well worth examining.