Originally Posted by
alf5071h
However, this point might be refuted in the differences between previous events and AF447.
All crews encountered adverse conditions; some initially reacted as AF447, but at a later point transitioned to a successful outcome. Why; what attributes, skills, behaviour, etc, led them to revert to appropriate actions whereas AF447 did not.
As far as is known all crews had ‘identical’ (acceptable) ‘average ability’ based on training, checking, normal operations, etc (but I am prepared to debate that). Thus the key issue is the ability to switch between alternative courses of action, which in turn involves awareness / understanding, knowledge of procedures, and ability to recall them (including cognitive resource).
The latter point includes surprise which appears to dominate in AF447 and other LoC events; thus how do crews use their skills when subject to surprise?
This line of argument can be applied to other ice crystal (non) events in A330s. We do not know how many other crews have been confronted by ice crystal conditions, but either due to less severe weather or appropriate change of track, they did not suffer an adverse event. Again what led crews to take these courses of action. It appears that this involves similar qualities of ‘skill’ (judgement) within the overall flying process as required in the incidents, but were used at an earlier time. Thus key issues are when to change the course of action and what mental abilities are required to understand the situation and choose the correct action.
The above concentrates on mental skills with all the problems of influences, bias, training, knowledge, and constraints of human factors.
Outwardly this involves TEM and Time; Avoid (detect and react a threat), Detect and react to an error (revise the course of action), Mitigate (recover), before the situation degenerates to an accident – the importance of timely thoughts.
… does the above challenge the assumption that average crews have sufficient skill for all reasonable situations (what is reasonable); if not then how are these aspects to be taught, checked, practiced, and then how can we ensure that they will be used.
Automation Surprise is often misunderstood. It is not surprise every time automation that you depend upon fails, it is the initial surprise for that particular failure. Once that particular failure has surprised you once, you do not suffer from the same impact again. This makes it hard for human factors testing as you can only catch people out once so it is difficult to do comparisons of behavioral changes in slightly altered situations with the same crew.
So it may be that in the other cases the particular training or experiences of the crews had put at least one of them through a very similar loss of pressure instruments and a drop into Alternate Law at height - or they just had pilots who reacted to their automation surprise differently.
By its very nature, 'Surprise' leads to indeterminate responses from the human 'subject' and can lead to cognitive tunneling on inappropriate actions such as trying to follow a failed FD as that 'always works' and disregarding other disagreeing valid inputs.
Once that surprise has happened and the responses corrected then it will not happen again. Unfortunately, in some cases the results of the first surprise are such that there is no second chance.