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Old 20th Dec 2016, 06:34
  #332 (permalink)  
Capn Bloggs
 
Join Date: Mar 2002
Location: Seat 1A
Posts: 8,547
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Killed by Automation...

What a tragedy; I dread to think what must have been going through those two pilot's minds for the 90 seconds it took to spear into the ground.

In my mind the cause of this is clear: the inability of the captain to resolve the dud attitude indication because of a lack of basic IF flying skill caused by the automation policies of the regulators and probably the company. If the simulation is correct, he was pushing and trimming nose down with the speed on (and eventually through) the barber-pole, and altitude plunging. He didn't have the brainspace to "Say hang on, there might be something strange going on here, what's the Standby showing?".

Additionally, the FO didn't have the confidence to say "look at my PFD, look at the Standby, your PFD is wrong!"

I was bitterly disappointed with the report; the emphasis on the standard calls is completely misguided. Aeroplanes do not fly by mouth, they fly by hands-on. Adding yet another layer of verbal diarrhoea is not going to fix what is a fundamental problem that is easy to fix. Hardly any mention was made of the failure of the crew to fly the aeroplane, nor of the automation policies of the regulator and the company, nor of specific simulator training/practice (or lack thereof) in basic IF.

"Startle effect" has been mentioned. It is difficult to train for this. However, in my view, the major defence is being able to recognise an abnormal attitude without being overwhelmed. This can only be done, in large part, by being skilled in basic IF, so that all your brain space is not consumed by the shock, with some brain space available to step back and "Say hang on, what is really going on here? How can we be 30° nose-up with the speed increasing and altitude descending like a lead balloon?". Spare brain space will also allow a pilot to receive inputs from the other pilot instead of load-shedding all external information.

I suppose we can only be thankful that that aeroplane wasn't full of people...

Towerdog:

Last edited by Capn Bloggs; 20th Dec 2016 at 11:40.
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