AF 447 Thread No. 10

[PJ2]

Lyman;

Thanks for your comments. With equal respect, may I re-iterate what has been a consistent and largely unchallenged theme since the first few days after the recordings were made public last year and stated by the BEA: - that standard cockpit discipline broke down, SOPs were not executed and CRM was essentially non-existent. Taking control of the aircraft and announcing that, is in itself not a sign of continuing required actions but it is a good start. What immediately ensured however was anything but standard or expected.

At the risk of repeating these things for others, the industry's long-term experience and fundamental principles place these qualities at the very top of airline transport operations as conducted by airlines and their pilots. There is no equivocating on this point - recognizing human factors very early on, these principles are in very large measure what has made this industry so safe over the past three decades.

"By the book" is precisely how airliners are flown, regardless of flight regime, emergency or abnormal. The captain is always free to deviate from such principles and standard procedures but there must be very clear reasons for doing so and only after such deviation is communicated to the other pilot(s) so that everyone knows and can assist.

The only exceptions to this process are extreme emergencies and over the years such circumstances have been well thought out and written into the Emergency and Abnormal SOPs, Memory items and QRH checklists. The rejected takeoff, the GPWS response, the stall warning are a few examples. Most other emergencies must be done "with dispatch" but not haste. The rapid depressurization and emergency descent is one such emergency.

Within very narrow boundaries, the processes are the same throughout the industry: First, ensure the stability and control of the aircraft, ensure the flight path is safe and communicate with other crew members your commands and intentions. Then call for the drills, ECAM actions, EICAS drill or abnormal checklist as the case may be. Fly the airplane while the PM does the work; confirm all non-reversible drill or checklist items before actioning.

So serious is this last item considered to be that in many companies, merely lifting a switch-guard on a switch which controls an irreversible change to aircraft systems, (eg generator disconnect, hydraulic pump shut-down), before confirming that switch with the other pilot, usually ends in the ride being assessed as a failure.

While perfection in SOPs and CRM ops cannot be expected especially under time compression or duress, these procedures are in place to ensure that the threat to the aircraft is minimized, that situational awareness is heightened, that crew coordination is enhanced and problem-solving behaviours thereby, and that actions are taken in a measured and therefore hopefully accurate manner.

None of this behaviour is demonstrated in the recordings. This isn't criticizing the crew...it is what it is and you can't put a blush on it. The PF launched on his own without announcing what the problem was, what he was doing and why, nor calling for any drills or ECAM actions. The PM tried to intervene and read the ECAM but made a mess of it while the PF continued his own course of action. When the PM used the take-over button and began flying the airplane the PF took control right back, neither announcing their actions but just doing it.

There are all manner of reasons, some which demand serious enquiry and response concerning why this kind of scenario unfolded as it did vice the expected procedures that airline transport pilots are trained to execute but that does not alter what actually went on in the first 40 seconds or so. The key in this accident is not determining what the THS did or did not do. Finding out why the crew acted as it did is the key to preventing future LOC and CFIT accidents. As I have offered, this is a performance accident.

Example of Emergency or Abnormal event crew response SOPs:

General Guidance - Standard Emergency and Abnormal Procedures

1. Initial Pilot Actions
A crew member detecting an existing or impending emergency or abnormal condition will immediately inform the other crew members.

Aural warnings will be silenced, and the master warning and/or master caution lights re-armed as soon as the cause has been determined.

Crew members should check circuit breakers and test lights when appropriate. Checking circuit breakers and testing lights is normal crew action and is not listed in the procedure unless there is a specific requirement.

2. Memorized Action Drills
The pilot not flying (PM) will complete from memory the items as directed by the AOM/QRH. In flight, before actuating a switch or control that could result in an irreversible action the PM must first indicate the switch or control and receive confirmation from the PF that the switch or control is the correct one.

On departure, the pilot flying (PF) will call for the appropriate drill at a minimum altitude of 400’ AGL, except as directed by the AOM/QRH.

On approach, the pilot flying (PF) will call for the appropriate drill. The drill should be completed by 1,000’ AGL, or as directed by the AOM/QRH.

Notwithstanding the two preceding paragraphs, prudent airmanship and good judgement will always be the guiding factors for the safest course of action.

3. Checklist Procedures
After the memorized drills have been completed and at a convenient time, the PF will call for the Checklist and Function, i.e. “CHECKLIST - ENGINE FIRE.”

The PM will read aloud all items on the applicable checklist and will call the action as it is checked or completed.

Upon completion of a checklist, the crewmember reading will announce “CHECKLIST COMPLETE”.



SHARING WORKLOAD DURING EMERGENCIES AND ABNORMALS

The general task sharing shown below applies to all procedures.

The pilot flying remains pilot flying throughout the procedure.

The PF (pilot flying) is responsible for:
– Thrust levers
– Control of flight path and airspeed
– Aircraft configuration (request configuration change)
– Navigation
– Communications

The PM (pilot monitoring) is responsible for:
– Monitoring and reading aloud the ECAM and checklists
– Performing required actions, or actions requested by the PF, if applicable,
– Using engine master switches, IR and guarded switches, with PF's confirmation.

REQUIRED MEMORY DRILL ITEMS

Pilots are expected to operate and execute their duties accurately and effectively in accordance with airline approved documents. Any deviation must take place only in the interest of safety and only if and when unusual circumstances dictate.

All pilots are expected to understand all policies, procedures, aircraft systems and operational requirements. In cases where these are identified in the AOM as a ‘Drill’, or in cases where these are not identified as such and are of a time-critical nature, the pilot must have the knowledge and apply the procedure without reference to any publication or material.

INITIATION OF EMERGENCY OR ABNORMAL PROCEDURES

Procedures are initiated on the pilot flying's command.

No action is taken (apart from cancelling audio warnings through the MASTER WARN light) until:
– the appropriate flight path is established,
– the aircraft is at least 400 feet above the runway if a failure occurs during take-off, approach or go-around.

In some emergency cases, provided the appropriate flight path is established, the pilot flying may initiate actions before this height.

INITIAL FAILURE INDICATION
When a failure initially occurs, the ECAM should be applied first.

This includes both the procedure and the entire STATUS review. Only after announcing "ECAM ACTIONS COMPLETED" should the PM refer to the corresponding QRH summary.



roullishollandais;

The way this system works is, these ACARS messages are not printed out on board the aircraft at the time they occur. They are transmitted to the airline's maintenance department in real time (timings as per early discussions on these messages), but are held in memory on the aircraft until the aircraft is parked at the gate, at which time a post-flight print-out occurs, which could and likely would include such ACARS messages. I have seen this many times.