PPRuNe Forums - View Single Post - AF 447 Thread No. 12
View Single Post
Old 18th Aug 2014, 11:51
  #274 (permalink)  
roulishollandais
 
Join Date: Jun 2011
Location: france
Posts: 760
Likes: 0
Received 0 Likes on 0 Posts
Hello PJ2,

Apologize for my late answer to you post #307. You were doing an acurate description of evolution of pilots' knowledge, functions and actual work.

-Intuitive knowledge of new generation helps to learn but not to overcome every aerodynamic situation like degenerating dutch rolls (I'm seeing that USAF decided to fight them forever if possible) or actual stalls in limited airliners and intuitive knowledge does not protect against the drift of airworthyness due to abusive complexity to manage in some mishap cockpits.

The younger generation of pilots and engineers and managers grew up with software : but we know (at least some of us in IT know) that software grew bad, accepting many bugs appearing in subit countrywide pans of electricity, trains, files with mistakes and losses, subprimes, and money scandals (list is unlimited).
I want to point strongly the fact that software's quality is mostly bad and generally accepts an uncomputed rate of reliability and what it means in real life for victims of accidents.

- The description of the both point of view of management teams and pilots (and pilots'unions) points an ordinary human behaviour : to be safer we set two (or more) levels of responsibility to double the verifications, but quickly, to avoid competition for exemple, every "responsible" man/organisation watches only the half of the chain... and a little later the verifications are no more doubled but divided by two, and if an accident happens you will no more find any "reponsible" person.

Exemple 1 about that responsibility dilution :
After the Ariane 501 crash and his wonderful J.L.Lions report, the engineer Ducrocq commented :"Everyone was responsible, so nobody is responsible" ; final cost was 8 billions French Franks ; in the 12 pages report I noted 99 mistakes had been done, from around 80 types of failures, not far of all the failures you can do in software...

Exemple 2 : In the 1992 Air Inter Ste Odile crash I discovered that the height of the mountain the Bloss on the official Instrument approach chart was false. The 2710 FT summit (IGN) of the Bloss against which the wreckage was found at 2620 FT (BEA report) was inside a highest level line of 2500 FT. It appeared to me that the mistakes was years old, and around 7-8 organisations had shared the responsibility of drawing, publishing, using that chart during these years. More, in the same highest line level of 2500 FT was the very popular well known statue of Ste Odile seen by any and many ATCs every day for departure or arrival (depending of the wind) inside of the arrival or departure cone, but no ATC asked himself how that statue could figure inside the 2500 FT line of their IAC which was the always present before their eyes on their table, main tool. (764m Mont Sainte-Odile ? Wikipédia ).
Happily that official VORTAC approach procedure respected the margins.
The BEA did not strickly lie about that -so that the most of you discover these facts now!- but wrote few very difficult understandable sentences if any about theses differences and read the report without noting the faulty height.

Not only that, Air France drawed their own charts (with ATLAS). Surely they used the wrong chart, rectified the height, but deleted the ICAO level lines, and deleted the mention "FAF" as they did on all their approach charts (1992) before that accident. Again more than 10 organisations drawed, published and used the chart without the "FAF" position ; that loss allowed the plane to descend at 1340 FT after 9 NM to STR VOR instead waiting at 3660 FT until 7NM to STR. Experts said nothing, BEA no-commented turning around again too. Two derogations had been given (BEA report) to draw and use a CDA and everyone forgot it was a VOR-DME (or VORTAC) approach. The expert Belotti said me he ignored the PROMIN ICAO and French law's rule of 15% obstacle clearance and had honesty to no more came to the trial...
Since that trial the list of persons who signed the crash reports (around 15 in that crash) is no more public...

We need to have multiple levels of verifications and cross-checks for some critical points, it is important to don't transform them in crash swisscheeze.

PJ2 we are used to read how seriously you are studying hard the folders where you were and still are involved, and in connection with others in the safety chain, which happily is more than 99.9 or 99.99 ;-) or "enviously low". I wanted to say that, despite working together as you are doing, management and pilots are not in a common balance. The latter pay with their lifes the mistakes -as do the passengers-.

And my obligation, being aware of the high unvisible criticity of flying softwares (which may be analogic too) is to move the eventual danger flag existing in that world, decreasing -in my conviction- the safety level under its possibility.

Going in that new world doesn't allow to leave historical airworthyness in abusive complexity that brain is not sure to masterize in the short minutes, or seconds or less allowed for decision in flight.

Thanks for your always appreciated very professional posts.

Last edited by roulishollandais; 18th Aug 2014 at 17:21. Reason: altitudes bloss and ste-odile, swisscheese, spelling, highest
roulishollandais is offline