PPRuNe Forums - View Single Post - AF 447 Thread No. 6
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Old 30th Aug 2011, 23:33
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JD-EE
 
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Olr Carthusian

Most likely their training did fail them, very badly and fatally. In addition the displays lead to confusion. And data that might have resolved that confusion was either not presented to them at all (AoA) or was presented on a display that was not a part of their usual instrument scan - pure inertially derived speed, attitude, and so forth.

The primary cause of the whole chain of events was PF pulling NU on the stick when he should have very carefully stabilized roll without touching pitch. After that he seems to have become fixated on the concept of the plane going too fast rather than that it was actually stalled. He had no experience in training or real life with the situation into which he was thrust. And communications between crew members never cleared up the situation. Contributions by PNF were ignored. PNF tried to take over. PF grabbed back control and the plane and its freight died.

  1. Communications were inadequate to absent.
  2. Cockpit Resource Management was sloppy.
  3. Data was inadequate.
  4. Training was inadequate.

That set of inadequacies teamed up as a perfect storm of inadequacies to send AF447 and its passengers to the bottom of the ocean.

I say inadequacies rather than other words because on the whole all three factors are sufficient that the vast majority of flights take place uneventfully. And I suspect fixing even one of the problems might have saved AF447. All four should probably be fixed for best results. (Fix 4 and both 1 and 2 should end up repaired in the process. Fixing 3 is a major change to get it right. But they should be able to at least show an icon if a plane in a stall to get the message across through a non-verbal channel as well as the verbal warnings.)
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