PPRuNe Forums - View Single Post - AF 447 Thread No. 12
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Old 16th Nov 2014, 16:16
  #765 (permalink)  
PJ2
 
Join Date: Mar 2003
Location: BC
Age: 76
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Hi gums;

The thread went this way because someone compared the AF447s crews' actions with SW111's.

Your post clarifies the difference between hindsight bias and understanding what actually went on in the cockpit of SW111.

I think it is important for some here to understand that the question itself, (Could they have made Halifax?), is natural enough and a good one to ask but that it is important to distinguish between the question and a creeping hindsight bias regarding the SW111 crew and their actions.

There really is no meaningful comparison between the two which can teach us something. But the opportunity to discuss why I think this is so can and does provide some lessons.

First, the Canadian TSB's Report into the Swissair 111 accident is one of the finest investigative reports ever written. It sets a gold standard for how such reports should be done, and is well worth reading or re-reading.

Second, the Swissair crews' actions did not occur in a vacuum. There is a great deal of industry history behind the the actions the SW111 crew took. We can't even isolate the question without limiting ourselves to understanding the lessons that the accident ultimately had to teach the industry.

Some history...

From very early on (introduction of the jet transport in the late 50's), when smoke in the cockpit occurred, the drill was for "Smoke of Unknown Origin". After donning O2 masks etc., the "Smoke of Uknown Origin" drill for the DC8 and on other types was to troubleshoot, not land asap.

For the '8, we shut of one generator at a time to see if the smoke abated. The drill might take fifteen minutes. Then we'd do the air conditioning smoke drill if that didn't "work". Later, the drills were given a starting decision point regarding the "kind" of smoke...electrical or air conditioning, (essentially, was it arcing or oil sourced?...).

No crew ever thought to land the airplane first - or at least if they did and survived, it was certain that the first question asked would be, "Did you go through the smoke drill?". I know of at least one case where upon smelling smoke of unknown origin a crew did descend first and land. The company involved disciplined the captain for his actions - (gee, could it have had to do with embarrassing the company?). It turned out that the smoke was from one of the crewmember's cigarette butt that had dropped off and was smouldering on his seatbelt, (does anyone here remember when everyone smoked on board?!...even those in the "non-smoking" section?)...I can recall the cockpit blue with smoke while crossing the Atlantic - cigars, cigarettes, pipes. The nicotine stain was not only on many fingers, it was a long, brown streak along the fuselage behind the pressurization outlet door. Maintenance said many of the pressurization problems they had to deal with were with the sticking of these doors from the nicotine "goo" in the linkage...more history.

That was then and now is now. That needs to be understood by some, before coming to some conclusions. ;-)

Today, no crew in their "right minds" would hesitate to descend and land the airplane first. But that industry mentality only changed, and slowly, as a result of Swissair 111. The drill is to Land ASAP, while donning masks in the cockpit, (the masks are generally not deployed in the cabin), descending, and possibly troubleshooting on the way down.

You're absolutely right about "know the airplane", and that too has a history, and a sad one in my view. The value of "knowing", vice button-pushing automation has yet to be fully understood.

To return attention to AF447's crew and the thread topic, I think there is more in common between them and the crew of Colgan's Flight 3407 Q400 accident crew at Buffalo, N.Y. The First Officer was pretty new but, like all new pilots, hadn't been mentored into the profession but simply passed the checkrides and had the licenses. Mentoring is expensive, difficult to measure and therefore difficult to implement and sustain because the attitudes of airline managements at the time, partly driven by tremendous economic uncertainties and partly through ignorance, (no airline manager reads accident reports...it seems to be "against the religion"), considered the bare minimum qualification standards as acceptable. In both accidents, there are good reasons to say that this is not true.

Neither the F/O at Colgan nor the F/O's at Air France really "knew their stuff" and it wasn't entirely their fault. As I have written on the original threads, the Colgan F/O was "an innocent", earning US$16,000 a year, who's airline and who's captain in this case failed her in "bringing her along" in the profession. I don't think this is too broad a brush when it comes to adapting to the changes that have occurred to the profession since the early 70's. In many ways our knowledge of human factors is far better than then, but the citing of such factors in accident reports hasn't been able to change the industry.

The industry had shifted its attitudes towards pilots and pilot training and particularly the profession itself of which pilot associations were very slow to guard and sustain.

The pay and the status of "airline pilot" had plummeted (and is still there, where the industry put it), and people naturally respond to how they are treated. Sullenberger certainly understood the problem and said so to Congress soon after the Colgan accident, (but before AF447).

These days, how many, and how often do airline pilots hit the books in their free time? How many actually have the time to do so? How many regularly seek out and read accident reports? How many could carry on a discussion on basic aerodynamics, of high altitude flight, of the complexities of weather, of human factors and the realities of automation? How many are encouraged by "their elders" to do all this?

All this is in keeping with how a profession is defined - by expectations of self-governing behaviour, by a constant learning and by upholding standards in the face of those with different agendas and goals for your profession.

"Change is the only constant", is one way to assess how the commercial air transport industry treats flight crews; but the industry must also acknowledge that the principles of aviation, in terms of staying alive, do not change. I sense the industry has turned the corner on this but it has a long way to go, including attracting a steady stream of good candidates and teaching them well.

I think that is the historical lesson of AF447 and of Colgan. I think SW111's lessons are now well understood and already incorporated into the industry's and flight crews' collective mentality.

Sorry for the long post.
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